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I want to talk a little about 
using shockwave for nerve pain. 

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Shockwave isn't something that I
started out using for nerves. 

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It's when you're starting out, 
it's easier to to use for 

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plantar fasciitis, for Achilles 
tendonitis, for other types of 

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like 4 foot pain, things like 
that. 

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After you do that, that I found 
it was easier to use focus 

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shockwave for, for fractures for
example, works well. 

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And now as I've been having it 
do using it a little bit longer,

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I'm using it on nerve. 
So yesterday I, I did 2 neuromas

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that someone had in their 
forefoot where they're having 

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pain. 
So I, I used a dorsal approach. 

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I used to focus shockwave very 
low energy like .05. 

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And then today I had an 
interesting patient. 

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She's a 67 year old female. 
She came in and she had dorsal, 

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the intermediate dorsal 
cutaneous nerve pain. 

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So with palpation she had had, 
this is her second MRI and it 

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showed a little bit of scar 
tissue in that area. 

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I think she had a previous 
ganglion that popped and there's

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some kind of scar tissue. 
So we did radial all around the 

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dorsal midfoot ankle region and 
then did a shockwave focused 

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really low energy. 
I'm going to start with three. 

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So I'm going to explain a little
bit about my my protocol in 

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terms of how it's changed over 
time. 

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With Shockwave, I used to do 3 
sessions, then do a six week 

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follow up and then do another 
three sessions. 

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I did a little bit of coaching 
with Paul Habro and he 

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recommended and I do find this, 
it's nice to do 6 sessions now 

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because usually about the 5th 
week is where people start to 

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find an improvement. 
So I'm I'm present now when, 

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when patients are actually 
getting better and it's nice to 

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be there when they're when 
they're going around the corner.

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What I used to do is when I send
them to physical therapy. 

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These are getting better at 
physical therapy. 

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So my joke is that physical 
therapy got all the credit so 

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that that is some just some kind
of adaptations of how I'm using 

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shockwave at this time. 
Next patient was a 72 year old 

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man. 
He had a post up post op 

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bunionectomy with a hammer toe 
repair. 

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He asked me to do his nails so I
did nails his. 

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His bunion was still within the 
global period. 

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You know, one of the benefits of
of Mod Med that we switched to 

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is it it's really good at 
tracking global periods for 

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surgical procedures for let's 
say routine nail care. 

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So I think the billing component
of Mod Med is, is quite superior

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as I'm kind of getting deeper 
into it as compared to Athena. 

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He does also have some self paid
callus. 

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So he paid 75 for the callus. 
I did the nail to Bryman and 

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then just the post op we got the
X-rays. 

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Next was 80 year old female. 
She had a left fourth met stress

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fracture. 
So this one was a fracture code.

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She did a Cam boot and I'm going
to see her back in four weeks. 

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Next was a 49 year old female. 
She had a left. 

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This one had a fourth met 
fracture. 

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It's been about four months. 
It's it's not healed. 

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OK. 
And so for this one, we are 

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going to do shockwave. 
So I set up for focused only 

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shockwave. 
I, I tend to do when I'm doing 

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fracture care, I'm tending to do
4 shock waves When I'm doing 

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like soft tissue care, like 
plantar fasciitis, Achilles, 

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things like that, I'm doing 6. 
So I did 4 focused only. 

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So that was a good, that was a 
good patient because she did not

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respond to the other, other 
treatments. 

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Next was a 70 year old for 
bilateral plantar fasciitis. 

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So bilateral sessions, this is 
number 2 out of 6 for shockwave.

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Starting to get a little bit 
better. 

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Next was a 63 year old female 
for left arthritis midfoot, did 

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ultrasound guided cortisone 
injection. 

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So basically with ultrasound I 
go to the midfoot, follow the 

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metatarsals back to the met 
cuneiform or nvicular cuneiform 

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joints, whatever one is 
arthritic or they're swelling 

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around that you can see usually 
spurring on the ultrasound that 

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I do. 
I drop a little cortisone, I try

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to do like 1 CC in each of the 
joints that are painful for this

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patient. 
I did an X-ray for her as well. 

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Now this patient also has a 
feeling of the legs feel like 

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wood and I tend to when they my 
patients say leg feels like 

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wood. 
I think of neuropathy and this 

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patient already is being treated
by another provider. 

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I don't focus too much on 
neuropathy. 

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This is a non diabetic kind of 
like a back pain type of 

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neuropathy. 
Next was a a 80 year old female.

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She had a left and her left 
foot. 

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She had pincer nails 1-2 and 
five and they were thickened as 

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well. 
So she was concerned about, 

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well, you know, should I treat 
my nail fungus and, and AT80I, 

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I, I have to look at these. 
And she was a, a very, you know,

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well kept 80 year old. 
And I said, you know, if you're 

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my, I said mom, But then I 
thought, if you're my grandma, I

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would, I wouldn't treat them. 
I would just come in and either 

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have me trim the nails or go to 
a nail salon to trim the nails. 

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She also in the past she had a 
flexor tonotomy on the 4th toe 

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and she was asking me, hey doc, 
why in the world did you even do

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that? 
And I think patients, they 

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forget why we why we do things 
and what was hurting her. 

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I said, do you remember you had 
a really bad callus at the tip 

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or I think it was an ulcer at 
the tip of the toe and that's 

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why we did the flexor tonotomy 
and it's looking great. 

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That one we did in the office. 
That's one of my favorite 

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procedures to do is a flexor 
tonotomy with a 18 gauge needle.

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Next was a 39 year old female. 
She had a right partial nail 

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evulsion. 
She had a painful ingrown 

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toenail on one side on the right
foot on the side of that nail 

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that was kind of chronic. 
And then on the left side she 

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had, she was concerned with nail
fungus. 

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And I and I reassured her, you 
know, that she was from the 

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Cameroon. 
She was a very tall patient with

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big feet, like a size 12 for a 
female and, and, and I said, Are

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you sure your shoes are big 
enough? 

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And she came in a sandal. 
So I couldn't really show her 

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that. 
But what I tend to do in the 

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practice is I, I take my, my, 
my, my sock, my shoes off 

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actually. 
And I and I take out my sock 

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liner and I usually wear lems in
the office and in the, in the 

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lems I show them like the 
indentation of my toes. 

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There's about a fingers breath 
where the indentation of my big 

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toe is and the front of the sock
liner. 

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And I and I just tell them, I 
say what I'd like you to do is 

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I'd like you to take out the 
sock liner in your shoe. 

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And if your toes go right to the
tip of the liner, it's probably 

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too small and that could be 
causing some of the toenail pain

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or toenail changes that you're 
having. 

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So that's a real easy test. 
I call that the the sock liner 

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test that I do with my patients.
Next was a 33 year old female. 

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She made an urgent care 
appointment for a possible 

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fracture of her 5th metatarsal 
base. 

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Now this was 1 I did a video on 
because I'm trying to get more 

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urgent care patients and this is
a prime one. 

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She went there, she got 
crutches, she got a Cam boot. 

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And when I looked at the X-ray, 
she she got to do X-rays. 

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She had a little like an ossicle
at the fifth met base and there 

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was no pain, there's no 
swelling. 

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And this was one that she could 
have saved a lot of Rev money 

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coming to see us. 
So I did a little video and I'm 

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going to put that on our urgent 
care page. 

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Just so you know, the urgent 
care page seems to be working 

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well. 
We have patients come in every 

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day and the nice thing on my 
schedule, it says urgent care. 

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So I can see if they've actually
come from from that. 

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Next patient was a 54 year old 
female for left second and third

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met met cuneiform arthritis and 
she also had some sinus tarsi 

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pain and she she wasn't really 
interested in doing cortisone. 

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She actually wanted orthotics. 
So I scanned her for orthotics 

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that was orthotic #1 and I'm 
going to see her back in 

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basically about two months. 
So with orthotics, what I do is 

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I, I see them back in three 
weeks for my staff does to pick 

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them up and they get my little, 
they get little piece of paper 

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with the offering the second 
pair of orthotics and the break 

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in schedule and then I see them 
six weeks after that. 

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Next patient was a 58 year old 
man. 

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He had left shark coat and he 
was going to be getting a crow 

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boot from one of my other 
colleagues and for some reason 

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he ended up on my schedule. 
He had a right second toe ulcer 

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and I had to bride at that. 
That was the morning afternoon. 

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There's a 43 year old female 
with left tibialis anterior pain

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at the insertion. 
She's #4 out of 6 for Shockwave.

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She brought in her little boy 
who I showed magic tricks. 

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Just so you know when when 
little kids come in, I tend to 

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show them magic tricks. 
If you want to see any of my 

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magic tricks, just ask me. 
My favorite 1 is where I take a 

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piece of gauze and I get close 
to them and I, and I ask them 

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what hands it and I kind of kind
of move my hand and say is it 

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the right or the left? 
And then I do it a couple times 

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and the last time I throw it 
right over their head and, and 

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they don't know that. 
And then I make it disappear. 

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But the problem is at the end of
the day, I have a whole bunch of

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gauze in the back of my, behind 
my, my chairs in my office. 

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OK, so she is doing much better.
She's already pleased. 

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She's back to walking, running. 
She's #4 out of 6 for this. 

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And this has been going on for 
her for over a year. 

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So she's getting better faster. 
Next was a 61 year old man who 

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had a right nail damage and I 
took a nail sample. 

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I don't think it is a fungus. 
He is super paranoid. 

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So I mostly just talked this 
patient off the Cliff. 

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He was a cash pay patient. 
He had mass health, which we 

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don't take in our office and he 
opted for for seeing us to, to 

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do this nail sample. 
I sent out to pathology for 

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evaluation. 
But I, I really don't think it 

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is. 
I think he's a little 

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overzealous here, worried about 
his feet. 

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Next was a 72 year old man, did 
a diabetic foot exam. 

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He had some maceration, so I 
kind of used tineopedus as the 

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diagnosis for that diabetic foot
exam. 

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When I do those foot exams, I 
try not to use diabetes. 

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I try to pick what other type of
pathology that they have. 

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Next was a 70 year old female 
and this patient had really bad 

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Aquinus really tight and so I 
did my Pelto special which is a 

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night splint foam rolling in 
morning stretch and they had a 

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little bit of FHL pain so 
proximal to the first met head 

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and also just some lateral foot 
pain and all due to that that 

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tightness that was the main 
issue. 

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Next was a 59 year old female. 
She had a a right second toe 

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with blood underneath it and she
was concerned of certainly a 

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Melanoma. 
I was able to trim back the 

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toenail and just show her that 
it was dried blood and she also 

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so just kind of calmed her down 
and she also had some 

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superficial article mycosis on 
both great toenails, mostly from

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taking off her nail Polish. 
So I explained about how to 

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buffer that down. 
I'm not going to see her back. 

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Next was a 21 year old female. 
She's status post a fibula 

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fracture. 
She's still having pain to the 

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sinus tarsi and to the lateral 
tailored Dome region. 

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So I'm going to order an MRI for
her. 

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Next was a 59 year old man for 
#4 out of 6 for plantar 

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fasciitis. 
Next one I'm not going to go in 

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or I'm just going to do all the 
shockwave here. 

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Next was a 33 year old man for 
#2 out of 6 for plantar 

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fasciitis for the right. 
And then there was a 47 year old

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man. 
He had bilateral Achilles 

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insertional. 
He's #3 out of 3 for shockwave. 

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So let me explain why he's only 
three out of three. 

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It's the reason. 
It's the reason. 

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The reason is, is because a few 
years ago he had shockwave and 

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he had three sessions. 
So I, I find a lot of times what

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patients want to do is what they
did last time. 

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00:12:08,360 --> 00:12:11,800
I think they even call this, we 
had a, we had a recent 

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00:12:11,800 --> 00:12:13,560
conference here in 
Massachusetts. 

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And I think it's, I think it's 
O'leary's law or Malley's law. 

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Basically, if you did something 
one way for a patient in the 

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00:12:20,480 --> 00:12:24,560
past, let's say they had a 
McBride bunion like 30 years 

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ago, do a McBride, do a McBride 
today or do, do like whatever 

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the same procedure they had last
time, do it this time because 

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that's what they want, because 
that's what they know. 

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So he had three sessions before,
mostly I do 6 now, but I only 

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did 3 because of that. 
So and just a reminder, every 

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time I do my last shockwave 
session, I do an office visit 

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because I'm going to talk about 
what's next for the patient. 

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So whenever I'm doing 3, the 
last visit will do a Level 3 

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office visit. 
And then if I'm doing 6, the 

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last session I'm doing an 
office. 

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So usually, let's say the first 
visit I'm evaluating and I do 

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shockwave the first time. 
So I'll do an office visit and 

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then the last time I'll do an 
I'll do an office visit for 

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them. 
The ones in between, I don't do 

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an office visit every single 
time. 

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I know there are some people 
that, oh, I can do an office 

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visit every time. 
I don't think I'm really 

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changing my evaluation and 
management. 

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And the last patient was 
actually my MVP patient of the 

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day. 
This was a MVP's most valuable 

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patient. 
So let me explain this patient. 

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He had a right. 
He was. 

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So first of all, I tend to find 
my, my, some of my best patients

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are referred for mothers. 
So he came from another family 

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member, a 51 year old man with 
right cave, his foot very high 

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cave, his foot that kind of 
almost like pronates a little 

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bit even despite being The Cave 
is. 

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So he's overloading on the 
lateral foot, has lateral kind 

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of calluses on the right foot, 
and he has four foot calluses on

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the left foot. 
He has a severe Aquinas, which I

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think is causing a lot of that 
lateral foot pain that he's 

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having. 
So I did an orthotic for him and

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since he has bilateral Aquinas, 
I did bilateral night splints. 

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He's going to do foam rolling in
the morning stretch. 

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And so because of the bilateral 
light splints and he also got 

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scanned for orthotics. 
That's why he was considered my 

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my most valuable patient. 
So that was that was the day. 

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For those that are listening, I 
am working on putting together a

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six month challenge that you bet
you should be seeing some emails

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coming out. 
If you don't get my emails, you 

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can go to 
podiatrypracticemastery.com and 

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sign up for anything that I have
as a free download there and 

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you'll get those emails. 
But we're putting together a six

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month challenges for people that
wanted to get to their practice 

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over the $1,000,000 mark. 
And it's going to be a little 

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bit better for those that are 
around the 6 to 700,000. 

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That's how much you're producing
in a year. 

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Trying to get that to the 
million or past the $1,000,000 

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mark a little bit harder when 
you're just starting out because

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your, your main focus is going 
to be on marketing and producing

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content and stuff like that. 
Wanted to share a kind of a neat

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little tip I learned recently. 
I was like to share new tips. 

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I was talking to a gentleman and
I've been doing my these 

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podcasts for a while and I'm not
getting much traction on 

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LinkedIn with these and I'm not 
sure why. 

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So if you like this podcast and 
you listen to it, please just go

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wherever you're listening and 
review it. 

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I think that would help me. 
But in terms of LinkedIn, I send

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the post every day and I know 
probably a lot of, but I just 

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never looked at LinkedIn because
we're all way too busy. 

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But what he recommended is doing
some just regular posts on 

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LinkedIn and not doing just 
links because if you do a link 

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to like a podcast, a lot of 
times they, they don't show it 

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to as many people. 
So I'm, I've been doing that 

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and, and the easiest way is this
podcast I, I record on my phone.

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So I have a little transcript 
and then I just take the so on 

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your recording set with the new 
iPhone now it transcribes 

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everything. 
I just put that in chat sheet BT

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on my phone and it gives me like
3 LinkedIn like ideas or three 

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LinkedIn like topics. 
So I'm going to post those in 

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the description. 
So if you want to see what those

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are just so you can get an idea.
And then I then I post that on 

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LinkedIn. 
So it kind of gives some high 

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highlight ideas of the episode. 
Anyway, those are the things I'm

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working on. 
We'll talk more tomorrow. 

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Thanks.