Hi, Doctor Belton here. I'm going to do a staff training today, staff and doctors training about all the office procedures that we do and all the treatments that we do. I'm going to go over. It's kind of a comprehensive explanation, but I think many people just don't know exactly what the treatments are. This can be for the back office staff, so they know kind of what we're doing and also for the front office when people are checking out and they're getting
these procedures. So we're going to go over all of these procedures. They're in alphabetical order. So I'm going to put a link in a lot of these. There's going to be these little links where you can learn more if you want to. These are going to go to different Google patient education things that we do. So let's start out aspiration of assist. This is where there is a cyst in the in the foot. Usually it's coming from a joint or a tendon sheath. It looks like a big bulb on the skin.
It can be different places to aspirated or to take out the liquid prevent we we use anesthesia, so we anesthetize the area. Usually it's right on the top of the skin, right over it first, and usually one CC is enough. And then what we do is we take an 18 gauge needle with the same syringe or a bigger syringe, usually 3:00 to 5:00 or 10CC syringes and you pull out all the liquid that's in there and
that should deflate this. This can be sometimes done with ultrasound and then afterwards you apply compression, a 1-2 or three inch coban. 1 inch tends to be for toes, 3 inch tends to be for the foot and they'll keep that on there for repeating it once a day after they shower for two weeks and then usually do a two week follow up for this. That's what a a cyst removal.
How that is in the foot. There's a high chance of recurrence with cyst removals and if it doesn't resolve doing it like two or three times then then a lot of times we'll we'll we'll surgically remove the cysts, but even with surgery there's a high recurrence rate. Next thing would be biopsy of the skin. Many of our patients they have skin dermatitis or or athletes footer tiniapetus or eczema or other types of things that haven't resolved.
They may have tried something topically already like an like an antifungal cream. What we what we tend to do for skin is we do one CC of lidocaine with epinephrine. The reason for the epinephrine is because it it doesn't bleed as much. So you would just put a little bit of a little a little bit underneath. Usually you want to do the the edge of the of the area that you're going to biopsy and you do 2-2 punch, two 2mm punch biopsies. That's the easiest for most.
The reason 22 millimeters are done is because you are because you don't need to do a suture Many times with 3mm or 4mm you have to put it, you have to put a stitch in there. So it's just easier to do 2 of them and and they heal a little bit better and they give you two different parts of the of this area. You use it to identify any dermatitis athlete's foot rashes. You may try something topically before but if that doesn't work
then you can do this. I usually do a two week follow up or go over the results and you make sure everything heals normally. These heal pretty well. This is 1 type of a biopsy. We're going to go over a few other types of biopsies as well. This is a from a previous lecture talks about CPT codes. There's if we do two of them, you have to do an initial CPT and then the subsequent biopsy. Here are some reasons that we would do it and some of the
things we talked about before. It's usually a smaller part of a larger lesion. This is how you do it. You you kind of go down you punch it in there. Be careful when you're removing it from the plunger right here to not crush it. It goes in from formalin their full thickness. They're going to heal by what we call secondary intention, which means that he'll just be on
their own. If it's over 3mm then then you usually do a suture for pigmented lesions, which are like things we're worried about, Melanoma, you're going to do A larger biopsy can be used and you have to. You have to mark the position on the foot. So might take a picture. You might take a suture and put a suture in the biopsy site to determine what's anterior
posterior in what, what time. Usually like 12:00, three o'clock, whatever o'clock it is. If you're doing that, we also can use curitage that's using a curette. This is typically used between the the toes. So if there's a build up in there, white build up, it could be athlete's foot, could be another condition called erythrasma. And we test this with a woods lamp where you take that little, there's a little black or blue light that we have and it makes it fluorescent.
You scrape the surface and you can send off. There's no need for anesthesia, but it's it's difficult to get anything deep with that. So we just usually use this between the toes. There's another couple of options of doing shave biopsies. We do less shave biopsies. If there's a lesion we're removing, it's usually where we're cutting out a wart which shave doesn't usually get deep enough, but this could be for a little elevations in the skin. You can get the whole lesion out there.
Usually we use the 15 blade, this is called a. It's like a flexible blade. I think we have some of these in the office that you can use as well. A nail biopsy. This is done right here. Here's an example of a 3mm biopsy that we did. This is after like a few months after because it's because it's growing out and it's it's used to evaluate Melanonokea. This is a black line in in the toe nail. If we're concerned about Melanoma, we will do a biopsy at
the at the nail base. You do a block of the toe, meaning you numb up the toe in the back just like you would do for an ingrown toenail. For nail biopsy we usually do a bigger one, so a 3mm one, but we don't need to do a suture and you're going to evaluate you do a two week follow up and usually this grows out well without injuring without injuring the the growth plate. With a nail biopsy it's that's normally for dark discoloration. Just a reminder, nail samples
aren't considered biopsies. So taking a sample for funguses in a biopsy, you're usually doing a toll block for that a nail sample. This is what we typically do in the office we used to evaluate nail fungus for discolored nails. What I tend to do is when the patients have their name on a little piece of paper, I just take that paper, stick it on the little plastic bag that we have in the bottom drawers and I take a little trimming.
That's why I would, I would trim distally here on the nail, put it in the plastic bag, put what toe it is and then and I would do the fill out the the biopsy within the within the medical record. So you always have to put it in the medical record what area you're doing and then that's sent out and I put their name on there from the from the little post it notes that we use it's this isn't considered a biopsy.
I tend to see patients back in two weeks where I would go over the results with them even even though many times we think it's fungus, a lot of times it can be due to trauma or to other things. So it's not always a fungus. That's the reason we take the nail sample and especially if I'm going to be putting someone on an oral medication, I like to use a nail sample. Very rarely we do this as well. This would be a needle aspiration. So we talked about a cyst before.
With a cyst you could, you could biopsy that so you could use imaging which would be ultrasound for soft tissue lipoma or a ganglion cyst. If you don't get anything then you would just flush out with the specimen jar. So let's say you try to pull something out of a soft tissue mask, but you can't get anything out. You can still take what's in there and you you kind of draw up the formalin and you push it back in and that could put in some of the content. So you can send that.
You have to create back pressure or a vacuum. You can see how it's pulled out with the fingers right here you're pulling it out. That's creating back pressure as you're pulling it. You go into different quadrants because many times these lesions are what we call lobulated. So there's different little chambers in them. So as you're pulling it out, you're pulling out for the
quadrants. If you don't see anything, once again you, you drop the fixative, which is the formalin, and you squirt it back in the specimen container. So that's what we do for, for these aspirations of soft tissue masses. OK, other procedures that we do, there's a procedure, we just call it a procedure, but it's brace dispensing. So that's done with the doctor. This is a visit with the doctor when we're dispensing the brace, the reason we do it with the doctor because we want to make
sure it fits. We'll make sure they have the right shoes. And we also bill the insurance at that visit. So we don't bill it when we order it. We bill the insurance when we dispense it and you need to make sure it fits well. Giving them shoe guidance is is the of the utmost importance. We give them a handout that has some information about shoes but typically they have to go up a half size and they they also may need to do an extra depth shoe or something similar.
These patients tend to be in like a an ortho feed or a doctor comfort shoe or a depth shoe or something that's a little bit bigger. One thing to remember, patients have a six week follow up and you have to be careful of any rubbing. So if there's any rubbing on the skin, you have to be careful. They should be seen that sooner. And they can get a new brace every five years unless their
foot changes. So if their foot gets more collapsed, it gets more swollen, increased deformity where things don't fit. Then you can evaluate something called same and similar and try to get a brace that's that's newer. This is an example of a Ritchie brace for a patient. We have to be careful that there's no rubbing with these. That's especially important. A patient is diabetic or neuropathic casting. This is something that we do frequently post operatively.
There's a little cast stand that we use, so all the materials should be prepared. It's done in the office. Sometimes patients might come in with a bivalve cast that just means it's cut down the side and then you put an ACE wrap around it. That's to allow for more swelling initially, but then when we put a cast on, we'll put it on and take it off every week to two depending on the amount
of swelling. If they have a lot of swelling, they'll take it off in a week because the swelling will come down with a cast and it'll it'll it'll piston, meaning it'll move up and down and that could cause irritation. Usually we use 3 rolls of cast material and we use the the cast and sometimes we put a little peg underneath it to help the patient. This is done by the doctor, but the setup is done done by the staff. Focused shockwave, they're two different types of shockwave.
We have in our in our Westboro office, we have the focused and the radial. I'll talk about all of them here. So the difference between focused and radio focused is electrical waves. It has very good bone penetration and it's used to speed up healings of fractures, stress fractures, areas that have bone marrow edema that's noted on an MRI. It can help with arthritis pain, but it doesn't restore the cartilage, so it can help with the swelling underneath the
bone, the bone marrow edema. It uses electrical pulses. It can be done by itself if it's purely a bone issue, but many times it's done with radial, radial shockwave and here is radial shockwave. This one has a little piece of metal that goes back and forth here and it creates these radial shock waves that penetrate into the skin. It's used to help areas of chronic or acute injury.
It can be used for chronic like chronic issues like plantar fasciitis, Achilles tendonitis, other types of tendons. It tends to work really well on on soft tissue and it's all can also can be used for acute things like an ankle sprains and things like that as well Hips the way I kind of explained it to patients is it helps he speed up the healing process by 50 by 50% and it's 82%. I know Doctor Savius is like 89% effective depends on what it is. Very very rarely is it
uneffected. It's not usually used in isolation, so you're doing other treatments as well. It's good for plantar fasciitis, Achilles tendon issues, swelling, ankle sprains, neuropathy, arthritis, not, not so successful for neuropathy and arthritis is the other things. Usually you do three to six sessions. The way I kind of explain to patients, if it's been over six months, I say they'll probably need 6 sessions. If it's under six months, they'll need 3.
Some of the doctors go right to four. It really depends. But some of these chronic issues that you need more time and it takes about six weeks before they see improvement. So the benefit of doing 6 sessions is that when they come in at the 6th one, they start to feel better. So what I what I tend to find is after they finish, I'll say you'll start have more good days than bad days. You can't have Motrin or similar medications for two days before and two days after.
And we tend to do weekly appointments. It's kind of like going to the gym. So you don't want to do it once a month because you're not going to see the benefit like going to the gym you should go every week because you're you're it's going to be tissue breakdown and tissue repair. So it can go up to two weeks, but usually it doesn't go beyond that. And it can even be sooner than weekly. It can be every two or three days as well.
If you want the effects of shockwave, a couple of the most important things that we tell patients. It stimulates circulation. OK, Micro circulation is important to healing. You don't really need to know these other things. Release of substance P just means there's reduced pain in the tissues. It stimulates growth factors like new growth of blood vessels, bone and cartilage, and it stimulates stem cells. So it recruits kind of the stem cells in that area.
So it's not injecting stem cells, but it recruits that. That's why it heals things that aren't healing. And for patients, a lot of times they're walking on their foot and they just never have a chance to heal or it keeps injuring it. So that's why we support it with like an orthotic or or a brace or a boot. And then we we use this treatment to help it heal faster. The shockwave process, initially we evaluate it usually with an ultrasound so we can see the
damaged tissue. We do three to six sessions. They're done weekly, they're 7 to 10 minutes, avoiding NSAID's a six week break. During this time there's a repairing of the tissue and this starts after six weeks. This is the time where I usually send them to physical therapy during that six week interval and then I've seen them back after six weeks and we see the improvement and if we want to, we can look at it with an ultrasound.
Again, with ultrasound, I tend to charge for the first ultrasound, but I don't tend to charge for the subsequent ones if they're paying out of pocket. But if insurance covers it, then I'll bill it and it takes about six months for everything to remodel. And so you just have to tell patients to be patient radial and focused We tend to do together. It helps to speed up the healing. We only have both of these in Westboro right now. It can also be done with pain
laser. There's also a pain laser that we have Remi pain laser. So we could do the all the combination talk a little bit about office visits just just
for simplicity. Sometimes we'll be putting this on the notes, but just for kind of staff training typically for established patients, there's new patient visits and established, so established or anyone that hasn't has been here and and new patients anyone hasn't seen this in, in more than three years, OK. If it's been less than three years, it's an established patient. I cannot keep it simple. A level 2 visit is is typically a quick follow up where you're not really going in depth that
much. This is very high level overview here, but it like a parenchia follow up matrix, follow up, infection follow up when everything is doing well. Level 3 visit is where we spend most of our time, Level 3 and level 4 for like a diabetic foot exam. Just a reminder for a diabetic foot exam, we tend to they put in the billing not diabetes but normally the condition that we're that we're looking at. So it let's say they have diabetes but they also have an ingrown toenail or or hammer toe
or something else like that. And when you need more treatment than and the current treatment is not that simple, let's say we order physical therapy, we order other types of treatment, we decide on shockwave, we decide on something else.
Level 4 is more complex or I kind of kind of keep it if I'm doing a prescription, so I'm doing a a a anti-inflammatory or antibiotic or something like that or renewing a prescription that's going to be a level 4. Or if you're doing like surgical discussion what you're tending to do prescriptions or planning to do prescriptions at that time. So just a simple overview of some of the billing things. A benign lesion excision, which is like removing a wart.
This is an example of a wart where we would numb it up with anesthetic, with epinephrine so there's no bleeding and then we would excise that. That could be anything else. Many times for excisions, we'll use in a Mira gel post op kit. Post op kits can be used not just on ingrown toenails, they can be used for like wart removals. They can be used for matrixectomies. They can be used for other wounds that aren't that deep. I tend to send anything we take out of the body like a lesion.
I'll tend to send a pathology. The only times I wouldn't, let's say they're like a self paid patient and they would have to pay for that pathology evaluation which can tend to be expensive and then we'll do a two week follow up for them. Here's an excision in nail and nail matrix which we call a nail matrixectomy. That's what this is called. It's used for chronic ingrown toenails. Someone has a chronic issue, they might have swelling on the side or they might just have callous buildup.
What we do is we take out the edge and we put a chemical which is in our office, sodium hydroxide and and then that doesn't grow back. It's used to remove the side of the nail or even the entire nail if they don't like it due to a fungal nail. The common complications are infection, which is quite rare. It's not really that common. So I always tell patients there's going to be redness, there's going to be swelling down at the base and they're a spicule can happen. This isn't a spicule.
So spicule is a piece of nail that grows back after a matrixectomy because it didn't work completely and you can remove that again and do another matrixectomy on there. We tend to do a two to three-week follow up when if you're less busy you can do 2-2 or four week. If you're busier you can do one at 3 weeks. OK. And then we also can have patient text us a number if they have concerns. This is an example of an exostectomy.
An exostectomy is an area of bone, usually it's between the 4th and 5th digits where it's kind of macerated and there's pain in there usually due to a bone spur. And the treatment for this certainly is spacers, wider shoes. But then if that doesn't work we we we shave down the bone. So you would shave down the bone on the side. We usually use a metallic marker when we get an X-ray for this to determine where the bone is.
And then you would put a, you would just make a little incision on top or at the tip and you would use the rasp to go in there and shave that down. And then that would kind of resolve that. You can't get it wet for two weeks because there's a stitch in there or a couple stitches and it's going to shave down the prominent bone. And we usually do a two week follow up whenever there's stitches and there might be a normal shoes or a surgical shoe after that example of a foreign body removal.
Once again this is if there's a non infected one such as like glass can be hair, a little Pebble, a needle. You may or may not need anesthesia depending. Consider anaesthesia with epinephrine so you can see it better. I tend to use we're getting X-rays once again like a metallic marker. You put a metallic marker because you can see if there's
anything underneath there. A lot of times you can't see it with an X-ray so you may have to do an ultrasound to help you see better and then tends to be a two week follow up. If there's an infection you would use an antibiotic. This is an infected foreign body or just an Abscess. This tends to be a little bit more difficult. You would have to open it up with an incision, so you'd have to numb that up as well. You would flush it out and you would give patients an antibiotic.
Many times we would take a culture as well. If we can't get all of it or if we want to know what type of antibiotic to guide that, if it's large or deep, you would put them in a surgical shoe and then you would use the the post op kit afterwards. Fracture Care is is just a tight, it's more of a billing thing, but when we see someone with a with a fracture you can do this. So with fracture Care it's, it's more of a billing issue.
So if there's a fracture in the foot or the metatarsal or somewhere else, it increases the billing initially. But then at the follow up visits you don't do office visits, you only do X-rays unless there's a new condition. So if we see something like a stress fracture or there's a fracture many times we'll we'll do this and then we'll do a two or four week depending for the follow up. And then if there's like a plantar fasciitis that develops something else then you could build that.
But normally you're you have a a longer what's called a global period in between this fracture care hardware removal. We don't do this that often in the office. Occasionally we'll take out a a little screw. We used to do it more, but this is an example of a little screw and you would do this with an X-ray and you would just put a a guide wire down there and pull out that screw. We don't do it all that often. You put a couple of sutures in
there. The most common ones we used to use were FRS but that tended to strip in the office so it made a little bit hard. There's osteo Med works a little bit easier because it has a different head of the of the screw. So occasionally we'll do that depending on patient's preference hematoma or incision and drainage of of of blood underneath the nail, it can be used to drain this hematoma. Sometimes the nail will come off and the entire nail can be evolved.
When or evolving a nail, we tend to put some nonstick dressing on top of it because it really hurts to pull it off if it sticks on there. And with these we also want to check many times with an X-ray to see if there's any fracture amnio injection. So amnio injections are used to help speed up healing of chronic tissue injury, very similar to where the shockwave is done, but it can be used in areas that
aren't typical for cortisone. So for example, the plantar fascia, you can use cortisone, but the Achilles tendon you can't and so this would be an area you could do it on the Achilles that's safe. I tend to immobilize the patients in a walking group for three to five days after I do an amnio just because it's it's kind of a not because of the procedure but because it's such an expensive treatment to put inside there. And I I typically use in
conjunction with shockwaves. So not by itself I will do let us say 3 shockwaves and at the second visit I will do amnio. Currently we are using right via flow and you can expand it 3 to 1. So what that means is if you have a, they come in at half CCS. So you would do half CCS of amnio and then you would do, I tend to do 1.5 CCS of saline and then a half CC of Marcaine. OK. So it expands into two CC's
total or about. Yeah. So I think it's one CC, Yeah, one CC is saline and half and a half CC of Markane for a little bit of numbing in there. The way I word it to patients is I say it helps stimulate your own stem cells to speed up healing and it's safer than cortisone. That's kind of how I, I word it. To the to the patients and meditations, they just they want what's best, right. That's what our patients
sometimes want. And so we can we can offer that we can offer Shockwave and and the amnio as well cortisone injections. We still use cortisone. It can be used for fascia tendon joints usually between 1:00 and 3:00 CCS. We pre drop here in the office 3 CCS for for our patients in case we need it. You might not have to use the whole thing like in certain joints that are smaller you can't use the whole thing.
Sometimes patients can develop it called a steroid flare reaction and I always tell them about that. It might get red, it might get swollen because it's a formed substance in your body that you're not used to. It's very effective for patients that have a gout flare up. Be careful if there's any signs of infection though. It's not typically done in the Achilles region and it's and also we don't usually use it and the MPJS.
So 1st and 2nd MPJ, third MPJ because it can cause weakening of the tissue and like hammer toe formation, sometimes I will do it if if I put them in a walking boot or if I just warn them and there's nothing else that they want. They don't want anything else or if they've tried other things, just be really careful you're going to because you could cause weakening or hammer toe or plantar plate tear or things like that. It's commonly done with ultrasound guidance and in our hands.
Now in the office we tend to do less cortisone because we have the shockwave treatment and we tend not. Every patients always ask this how many, how many injections can I have? We tend to do no more than three injections in any location per year. So they can have three in the knee, three in the back, three in the foot, like 3 in the heel, three in the big toe joint. They can have three anywhere. Sometimes you can do more, but you just have to be careful if you do too many of them.
Another area that we inject with cortisone is the neuroma and you evaluate for the molder sign. That's just where you squish the foot and it causes a clicking motion. Patients tend to say they have a a fullness feeling or they're walking on a bunched up sock. Injection can be done with an ultrasound and then you kind of inject that area, that little bulb that you can see right here, two to three CC's of
cortisone. If you're doing an ultrasound you tend not to use as much because you can get it directly into the area. So we say like a drop is the same as a gallon, if you can get it in the right spot you don't need as much and we tend to do a two week follow up for these neuroma injections, other tendons that can be injected as well. This is an example at the base of the fifth metatarsal where the injection or the insertion of the Pronius Brevis is. This is an ultrasound, you can
see the inflammation. It can be done in any painful tendon, but once again you have to be careful for tendon weakening. You might want to immobilize them in a walking boot or place an UNA boot around the area to rest it and typically done with ultrasound to see the area of damaged tissue and you have to discuss the risks of rupture. And also the other option would be the shockwave which we tend to do more so now than the cortisone.
Things that we don't do that often, but I just want to talk quickly about injection of scars. So some patients come in with really painful scars. We can inject those painful or keloid scars with cortisone. Don't do it all that much. There are other things that you can use like silicone tape, something called skarguard and other treatments include laser treatment which we'll talk about a little bit later that can reduce the thickness and the the
color in the area. And I kind of think of scars similar to a plantar fibromas which are those big lumps in the bottom of the foot. They're kind of treated the same way because they're proliferation of tissue keratomas or just callousing. We trim them with A-15 blade. If there's bleeding underneath it, you have to be aware because normally the bleeding makes it an ulcer, so that would be it.
And be careful between the toes. You could also have issues and recommend We tend to recommend a callus cream and a pumice, so patients are going to pumice in the shower and then use the callus cream after one with padding. And many times they'll do orthotics and things like that. And if there's fissure fissures skin, we'll use sleep and heel. So fissures are on the back. We'll use that sleep and heel callus cream and other things like that.