Hi, Doctor Felter here again. This is Part 2 in the procedures that we do in the office. This is a staff training course. I'm going to talk a little bit now about carry Flex. So carry flex is a procedure that we do in the office. It's used to help with detached or thickened toenails. So for example, if there's a thickened fungal toenail, it works very well for a thick and toenail. The ones that it works the best for are those toenails that only
have a little bit on the base. If they only have a little bit on the base and the rest of it's not, not present or detached or fungal works really well for that. Or a nail that has a a lot of they've had a previous like ingrown toenail procedure and it and it hasn't worked and the nail looks very narrow so it works very well for that. The process is you first grind down the nail with one of the
grinders. This is the only thing that we really grind in our practice are are the carry flex nails. You apply something called the bonding agent, which is a liquid that you put on the nail and then you you let that dry for about 30 seconds. Then you apply a coat of the carry flex, the carry flex, you apply it a light layer 1st and then you do the UV light for like 30 seconds just to harden it up a little bit and then you do it another piece.
And then once you're done you then you do 2 minutes. OK, so 2 minutes is when you do the final amount. So you tend to do a layer over then like initial layer. And then the reason you use the the UV light is so it doesn't it's too flexible it it moves around, it's kind of like watery ish. And then you apply it again until you're done. And then when you're done you you cure it for 2 minutes and then you buff the nail. Usually I buff it with a there's a a file that's in there to buff
it down. If it's really thick, you can use the Dremel again and then you do the sealant, there's a sealant on there. You do that for and then you cure it for 2 minutes and then the patient's all set with that. You have to remember to apply the the Cariflex a piece at a time and may not make it too thick. And then I always say for patients, they usually come in in the spring to do it, unless they're going on a vacation in
the winter. So if they want it in the winter, then they can come in in the winter, but usually they come in in the spring for it. And then it lasts about 3 months. What you'll find with the nails is that if the nail grows, if it doesn't grow out, it grows thick. And so if it grows thick, it's going to be, it's going to be lifted at the base of the nail.
So they may come in to have a change just because it lifts up in the back because a lot of these thickened Toen nails instead of growing long, they'll grow thicker, OK. So it's something that patients really enjoy and works really well for their, for their nails. With our office, they tend to buy the kit and they keep the kit we charge usually increased price for the first nail and then less for the additional
nails. This is an example of Lunila Laser. Lunila, we've had a couple of different types of lasers in our office. We have the Qterra laser, which is the one that we typically use for warts and we have a Remy laser and we also have a Luna laser. So the Luna is the one that's a box and you put your foot in the box and you and you turn it on. Now if you look at these pictures, these are the nails
that it works better for. So what what what's the difference between this and a lot of the other ones we see, these are normal thickness nails that are a little bit lytic at the end. So lytic means it's detached. OK, see how it's detached and there's some fungus underneath the tip. But if you notice all of these nails, they're they're not very thick. The challenge with laser, laser does not work very well with
very, very thick nails. It works OK with these nails that are a little bit lytic or detached and have a fungus in them. So that's the main key if you're looking at like what's the kind of the, the selection process for who does the laser, It would be those types of patients that have less thick nails. Otherwise, we're tending to do the oral medications. The topicals aren't all out effective, so once again works better.
For lytic nails. I recommend getting a nail sample prior to starting the the treatment. Oral medication versus laser, you have to have that conversation with the patient if you're wanting to prevent recurrence. There's two things that you can do certainly. I guess the main issue with patients I explains that the problem is is incomplete cure usually, and it's not really recurrence.
Incomplete cure is because they're they they don't take it long enough, especially like the oral medications. I like to have the until the nail is normalized, they're actually on something. So in terms of the the laser, one of the challenges is if when they're using it it's not totally grown out, there's a chance that it could regrow in that that's the incomplete cure component but it can also come back from the fungus that can live in their shoes.
So we have something called mycomist which is spray that can go in the shoes. We also have shoe ZAP, which is used to prevent recurrence, which is ultraviolet light that kills the fungus that's inside of the shoe. So patients are concerned about the shoes. I would just say that all fungal nail treatments take one year to see final results because a new nail needs to grow out. I say that Lamisil is about 80% effective, Luna is about 60%
based on the on the nail, right. If you have these really thickened toenails, Luna isn't going to penetrate enough and the topical are about 2020% effective and I'll require treatment to prevent recurrence. The other thing I use for recurrence to prevent recurrence is I use once they're totally better, using a topical antifungal once a week on the
skin and I do that. That would be like after it's totally gone and and that's only because many times the the the nail fungus can start from the skin fungus nail plate avulsion. This is an example of something that we do if someone has a a very painful ingrown toenail and they don't want to just take the sides out or if they have a very thick nail or if they have maybe blood underneath the nail, you can remove it. Here's an example of a nail that was kind of detached at the
base. Sometimes these these nails, they get injured at the base and they get kind of elevated and we'll call it boggy, which is like there's drainage in there and it's kind of detached and lifted. It's almost as if someone put something underneath there and it's kind of pulling it up and it was almost lifted up. What's holding it in most likely is just the edges. So for this we always numb it up.
The only reason we wouldn't numb it up if if someone is has neuropathy, but most of these patients we numb up. We don't use this type of a tourniquet. This is the old type of tourniquet for the picture I got. We usually use the little green ones that we put on the toes and then they'll stop the blood supply if you if you didn't know. That's why we put those on there.
So you you roll it, you roll it up on the toe and then as it as it as it rolls up it actually pushes the blood out and then this is the the nail base. It's used for a very loose nail also for something called the subungual hematoma, which is blood underneath the nail. It can be for a nail avulsion, which just means pulling off the nail. It can be total, meaning you take the whole nail off or partial, which is mean you just take off a side of the nail.
A lot of things like the the staff, sometimes you you're you're wondering well what's an I and D what's an avulsion for? For the staff purposes I'll explain the difference. But an avulsion if you take the whole thing off as a total nail avulsion, if you take an edge out, it's a partial nail avulsion because you're an impartial of the nail. Now if there's an infection in there, the same partial nail avulsion is called an incision and drainage.
And the reason it's called you're incising it and you're cutting it and you're draining out the infection that's usually in there. The the difference is if there is redness on the side, if there's pus things like that, that's that's considered an incision and drainage. The setup for for the staff is all really the same.
The only difference up is that if you're pulling totally the nail off, a lot of us like to use some adaptic because this can can when you pull up the bandage, you can stick the the gauze, little fibers get stuck in there and that's a challenge for them. And so our patients, they tend to soak before they take this off.
And if you're doing a total nail, we'll do that adaptic, apply sufficient triple antibiotic or a gauze or use adaptic to avoid it. If the bandage sticks, soak the toe prior to removing the bandage. This is something we tell all of our patients and we get a number of phone calls every year about that we talked about before
established patients. I'm going to talk a little bit about new patient office visits to keep it real simple for a new patient, if they come in, it's usually a quick visit where there's no real treatment done. So no X-rays done, no nothing. They just died some foot pain. I want to get looked at maybe an evaluation of an ingrown toenail without any treatment. Something like that would be a level 2. We don't do very many level twos.
We're usually doing something Level 3 would be a more complex condition if we get imaging which is X-rays or an ultrasound, taking a nail sample, doing a plan for the future plantar fasciitis, initial visit without a prescription, OK. And then level 4 would be things that are more intense surgical discussions, just giving
something that is an medication. We talked about these levels, these are billing levels and these are on on the billing tab that that we put in. But sometimes the front office staff, they need to know what level it is usual to will tell you, that's just kind of a reference for us. And there's this big billing sheet.
I'm not going to go into it, but it talks about like you have to how many conditions you need and problems and what documents you're looking at. I'm going to talk a little bit about Anifix. So Anifix is different than carry flex. So carry Flex is used for ugly toenails to cover them up. It's the cosmetic procedure. If they have a damaged nail that's never going to get better. They'll come in once a year or twice a year and we'll do that for them.
The onifix is used for ingrown toenails and it works better if the nail is flatter at the base. So with the base of the nail is this, this part's the base, so the base of the nail right here, if it's flatter here and then as it grows out, if it curves in, it works well. So let me give you an example. So if you look at this one, it looks like a a curly cue, right?
And it's flatter at the base. So if it's flatter at the base and you apply the the the anifix, as it grows out it stays on the nail and as the nail grows it slowly pushes out and it'll bend, then that it'll it'll untwist the nail at the tip. That's what it does. So you can see these examples here curved in 124 weeks later. OK six months later and then you know and that's how it looks and as it's slowly grows out and then it grows out a lot of times
we need to reapply these. I used to do it and then have people come back in three months. Now what I tend to do is I have them come back in when it falls off. So it might that might be longer period of time if there is enough space at the at the when they come back like let's say this, this has moved out here and there's enough room for another one. I sometimes put on two ANI fixes. It's applied to the base of the toenail. It trains the toenail to lift out the edges at the front.
Repeat it every three to six months when it falls off. If it falls off under two months, I apply it without any cost. So if this is something that's not covered by insurance, I usually do it for free. If it falls off again because I like to guarantee it, There's no restrictions both with carry flex and ANI fix that we talked about before. There's really no restrictions. Patients as well. Can I do, you can do anything
you want. There's a slight chance if you're a big runner, the carry flex and this the onifix could fall off. So if they if they if it falls off, I put it on again. I just charge an office visit or I let them know. If the office visit and if the nail is red infected and painful, we do an incision and drainage. That's where you numb it up and take out the edge with anaesthesia. If it's not successful then we'll either do a partial nail emulsion or we'll do a a matrixectomy.
So orthotic dispensing. This is not an office visit normally. Sometimes what we do in the office is let's say I'm seeing a patient for heel pain and they're doing orthotics, I might do a three-week follow up for them. So I kind of do it in a way that it'll the orthotics I hope will be come in. That's kind of how I do it. Usually it's done at the front desk, but if you set your follow up for for three weeks, usually the orthotics are in and you can dispense them to the patient.
They can make a dispensing visit if you want, but usually that builds an office visit. So some patients are are are concerned about the office visits, review shoe recommendations and make sure they're fitting well. I think that's key. Making sure they're fitting well in the shoe, making sure they're, they're, they know what shoes they can wear. You tend to want to do a shoe that has a sock liner that comes out.
The sock liner isn't the thing that has the name of the shoe and that pull that out and they put the orthotic in. A couple of modifications that we can do in the office, we can heat it up and we can drop down the arch. So if the arch is too high, we can do that. But a lot of times we can send it back with both forward motion and Northwest, which are the two labs we use. Forward motion is a little bit easier. You don't have to send the device with it.
You just kind of send back the orthotic and it works, works well and you say kind of what you want done, if you want it wider, if you want it longer or if you want the arch in a different place. It's always good to remind the patients, I know you give them the package, but it's good to let them know that there's a second pair for for $200 off. And the reason we do 2 pairs is because it just increases compliance of wearing the devices.
So they're going to get better results because they're wearing them more, because most people have like a workout shoe and an everyday shoe, and so they can just leave them in those. I tend to get the first pair first to make sure they're comfortable, there's no adjustments. And then I'll do the second pair as needed, Pad, net or vascular testing. So this is a test that we do in the office. The staff does, why do we do
this? Because our patients, most of them are elderly or have diabetes and those patients are at higher risk of developing PAD, which is peripheral arterial disease or clotting. The way I explained it to patients is that if you have let's say poor circulation to the legs, most people don't complain. Some might have what we call claudication, which is cramping in the legs, but for the most part our patients aren't complaining. But if you give, I'll give it an
analogy. So if you had poor circulation to the to the carotid artery which is in your neck that could lead to a stroke. OK people many times it's under not diagnosed can lead to a stroke. If you have it in your heart it could cause a heart attack or circulation. It's all all the circulatory
system. If you have it in your legs it's going to create a peripheral arterial disease which many times goes silent because the patients have neuropathy because they're just think their legs are tired. And that's why we do this test. It's it's an easy test.
It's a lot easier than checking other things because you can put these blood pressure cuffs on their on the legs, three blood pressure cuffs and then one on the toe And it it we do this for patients that are high risk, OK. What was considered high risk diabetes is always high risk, OK, because diabetes has a high higher prevalence of clogging the artery.
So diabetics over the age of 50 and then nine diabetics over the age of 70, OK. Also for patients that have ulcers to evaluate the healing potential, if it's really urgent, sometimes we send this out to the vascular lab only because we tend to schedule these, you know, on Fridays or other days when when staff is available. So we we don't do them every single day.
We repeat them usually yearly because we want to see if there's any changes in the in the circulation and the results will come back as mild, moderate or severe. Most of them, ours come back mild and moderate. If it's mild to moderate, we usually evaluate it. We don't. Well, we just evaluate it again. We send the results to the doctor and then the following
year we'll see if it changes. If if there's a drastic change or if they have more symptoms, then we will refer them to a circulation Dr. OR called a vascular surgeon. It usually takes 30 minutes to do this procedure by the staff. They have to remember to bring in shorts or or they're going to put on a Johnny OR or something else like that. OK we we talked a little bit about I I just kind of bunched all these together only because what I was using was the the the
cash pay pricing kind of thing. But a paronychia is different than an Abscess which is different than assist I and D but I just want to explain they're all kind of infections. So a paronychia is an infection of an ingro and toenail. So an example of pus coming out the nail, this redness right here, you're going to either do the whole take the whole nail off or just take the edge of the nail and Abscess is is an infection usually in the in the skin.
And and then you would have to numb it up and and and and and cut through it to do a call in an I and D And then there's also a cyst I and D, which if there's a cyst not so much a ganglion cyst. But if there's like another type of a cyst in there that you would cut it and you would drain the fluid. So that would be that you can even an aspiration as well. It's used for an infected ingrown toenail where you remove the painful edge or you remove
the total total toenail. Used to drain out the prevalent Abscess or used to drain a ganglion cyst if it's not infected. We do not usually give antibiotics. This is a question that that differs us than a lot of the Eds or the urgent cares is they tend to give antibiotics for everything. Once you take out the nail and you and you have them soak it, you don't usually need an antibiotic. If there is a lot of redness you can do an antibiotic.
But for a lot of our patients we we do not do antibiotics. Remi laser for pain management, we we we do a little bit of this but not too much with this laser. So this has a pain setting on it and what you do is you you you move it back and forth on the area of pain kind of in a swooping motion kind of all around it. Kind of like we do a shockwave, you perform it on the pain setting, it usually takes 5 to 10 minutes and you do 6 treatments once a week or twice a week for three weeks.
And this can be done by staff, can be done by the doctors, it can be done in conjunction. So sometimes we're doing it in conjunction with with like Shockwave, you put the pain setting on and you check every two minutes until the pain is reduced. So the the determination if it's working is if the if the pain when you push is working, there's there's no pain. Like I said, it can be done with shockwave. Prior to the shockwave and your treatment is complete when the pain has reduced.
So what it does is it uses the laser light to heat up and it stimulates blood flow. All these treatments that we do kind of stimulate blood flow. This one stimulates shockwave, stimulates blood flow. Talk a little bit about routine care. I just want to explain a little bit about the difference. Routine care is a kind of a a difficult, challenging kind of animal in the office because some patients are covered, some are non covered. I'm going to explain the difference.
Routine care just means diabetic or non diabetic foot care. That and that usually entails trimming of the nails or debriding. So the difference trimming is when it's a thin nail. A normal nail we call it trimming. Debriding is where we trim down or cut down the thick nails. That's debriding. And then we also trim or or debride calluses, OK. There's just technical terms that we use. We usually in some reason, sometimes it's covered with insurance. And why would insurance cover
it? They're covering it for a patient that's considered high risk, OK. So someone that they could lead to an amputation. So not doing that care would lead to an amputation. Usually it's for thick fungal toenails that are derided, it's covered by insurance. Normal thickness nails usually are not unless they have what we call class findings.
So class findings are something that we would document in the physical exam findings and usually indicate something like a peripheral vascular disease, PVD. So like non palpable pulses, diabetes with proliferative vascular disease, diabetes with neuropathy or lack of sensation. So we would check with that little Sims, Weinstein, that little, little piece of plastic we push on there.
Foot and if they can't feel it, that kind of indicates neuropathy and then different circulation things like Raynaud's and and and different diseases. Regular callus trimming is usually not covered unless they have these class findings or they're high risk. So not not just everyone that wants their calluses trimmed can come into the office and have the calluses trimmed. They can do it, but they just have to pay. Now I want to explain a caveat here.
There is something that is not it's it's kind of a callous, but it's called a porokeratoma. Poro means pore like a sweat gland. Keratoma is callous. So these things we see a lot of times in the office, they they get confused for warts. It's a callous with a really
deep core in there. And then what we do is we trim off the upper callous, we cut out the center and then we put in one of those circular pads that we have the felt pads with a hole in it and then we put salicylic acid in the middle. When we do that, that's called lesion destruction.
So it's it's we use lesion destruction codes similar to a a wart, but the lesion destruction code is for anything that we're destroying, usually do it once, one time if you're seeing someone back like every three months to do poro keratomas that might turn into routine care, right. Because usually when you're doing this it after a couple of sessions it it should resolve OK. So that that's a kind of a a high level understanding of of
routine care. Let's talk about strapping of ankle, foot, hammer, toes and fractures. OK, Well, we don't do a lot of ankle strapping basically because of the time that it takes. Many times physical therapists will do ankle or this is called the Lodi strapping where you take tape and you tape it up the foot and this gives support to the arch. What are some ways that we kind of mimic this in the office? We do compression sleeves that kind of mimics it.
We'll do an over the counter arch support or do an orthotic. So these all help patients that tend to have like plantar fasciitis and other types of pain. OK, but we don't do a lot of strapping in the office fracture. Someone has a toe fracture. We do do this. This is a buddy taping. So you take Coban 1 inch, Coban tape the two toes together. You tend to tape the bigger toe to the the, I'm sorry, the the
fractured toe. You tape it to the to toe that's adjacent and bigger to it. Use one inch Coban and they just take it off from the shower and they put it on again. And you do that until they feel better along with the surgical shoe or walking boot. OK Then for hammer toes, there's different types of strapping. You can strap the toe down. That's for like a a hammer toe or what we call capsulitis or metatarsalgia that's in the in the front of the foot.
You kind of pull it down and that's going to make it feel better temporarily. Another thing that you can use is something called the boudin splint, which is right here. Boudin splint kind of pulls it down to. These are called considered strapping. So you could say you strapped it with this and then you can build, build those things, OK With these types of of treatments, laser scar treatment, we don't do this a
ton. But for some patients that have contracted scars or thick scars or elevated scars, here's an example. Before and after you can do this. I usually do four to six sessions. And in the in the medical record is the actual settings you put on the laser. I use the Qterra laser for this. It helps reduce stress and tension on the scar. So what I say is when you have a scar, everything is kind of confused in the in the in the
tissues. And then as you heat it up, it'll all kind of flatten out and make it a little bit more normal, OK? And it can reduce discoloration. I use this with in conjunction with like taping the skin. Putting tape on the skin reduces stress. There's silicone tape that can be used as well and there's also cortisone and injections and other things. Nail debridement just explaining the difference. This is a debridement. It's considered if there's very
thick nails. So if the nails over 3mm in thickness we consider that debriding of the nail. It's different than trimming. When we build it. We build it from 1:00 to 5:00 nails or 6 plus nails. I know it's funny but that's how we do it and it's covered usually every 61 days. If the nail is detached or the the nail bed is disappearing, what that means is let's say
this nail. If you cut this all the way back and there's only this little bit right here that's left, then you could apply that carry flex to it to make it look good if they if they wanted to for the summer. OK, this just going back, this would not be a good candidate for laser because it's so thick, right? If you had a thinner nail, it would be This was a better candidate for the oral medication. OK, nail trimming. These are just normal nails, you
just trim them. They're nails that are not thick. They tend not to be ingrown. If they're ingrown, then we would use an anaesthesia to numb it up when we numb it, when we numb it at the base of the nail ulcer debridement. I don't want to go everything into ulcers with you, but I just want to. These are some patients we typically see in the office, like an ulcer on the 5th Meta Head. Ulcers are graded. Most of the ulcers that we see in the office are grade one or grade 2.
So a Grade 0 is nothing, OK? There's no ulcer, no symptoms. A Grade 1 ulcer is an ulcer. That's superficial, meaning it's just the top of the skin, kind of like a blister. This would be a Grade 1A, Grade 2 ulcer is going deeper. So it would go down to the tendon or ligament. And that, you know, you might think I'm not seeing the tendon ligament, not in this area, but if it's right out of toe, the tendon and ligament is really close By grade three, it goes
down to the bone. So if it probes down to the bone or you divide the tissue down to the bone, that would be a Grade 3 where you can see the bone or touch the bone, OK. And then grade 4 is where there's a lack of circulation, which is called gangrene. And then Grade 5 is really bad. We don't see that that much. There are different depths of
ulcers. The the grade of an ulcer it is how deep it goes, like if it probes to bone then you would call that grade three OK Or in our notes it says it goes down to bone. It doesn't really say grades, it says it goes down to bone or things like that. Where you debride the depth of debridement is different. So you might not debride the might not take the bone out but you'll you'll take the tissue lower lower down in there.
So it's different what it's superficial meaning when it's closer to the top of the skin kind of a this simple one like this we use a Mara gel, triple antibiotics or Betanine. We would use Betadine more if it's if it's if there's some dampness or maceration or like it looks like dish pan hands around it. If it's fibrotic or deeper we'll use like a collagen dressing or like a enzymatic debriser which there's one we call used called santal.
At times if it's fibrotic and if there's drainage as well we use this this this collagen. We have the the collagen in our in our office and you can't just do that, you have to offload it. So we'll try to put these people in off loading walking boots that peg assist with those little pegs that you pull out or you do faltered foam. So PEG assist and felted foam
are very similar. A felted foam is something that you do and that's why we like to do the PEG assist which makes a little bit easier for for taking those little plugs out. OK, You put that in a walking boot or a post op. And it's also good to evaluate circulation and verify that there's no bone infection with the X-rays. OK, Ultrasound guided cortisone injection. This is something we do quite a bit. Here's the ultrasound probe, Here's the injection.
This is looking at the fascia like a normal fascia right here. This is a thin fascia and it's especially helpful for smaller joints like the first MPJ or mid foot joints, which are the joints in the middle of the foot. Because they're so small, you can inject one to two CC's in each area. It's helpful for plantar fasciitis, tendons, posterior tibial tendon, peroneal tendon, The other areas that we also could do cortisone, we could also do shockwave in these areas.
So I tend to use ultrasound before shockwave and ultrasound helps find the area that's thickened. It's there's a dark area. It tends to be darker and thicker and you want to document this procedure that was done in in the notes and add it to the building and you save the ultrasound images prior to doing this. OK, this is a limited study of the ultrasound here. This is an example that I have from a presentation. You can see these examples right here.
But I tend to show like the ultrasound what it looks like normal and thickened and I give some normal values for males and females. So I kind of explained this it's it's the most common study in the office, that most common study in the office that looks only at the affected anatomy. You look at it in two angles, which is longitudinal transverse. It just means you switch the probe in two different angles to look at the planet fascia Achilles tendon, posterativia tendon.
Make sure the images are saved And once again if you want to look at some of my ultrasound images you can look here these those will be attached. This link will be attached ultrasound when building an injection. If we build a cortisone injection or aspiration or pulling out liquid and ultrasound, we use this category. It's less expensive than unlimited ultrasound. So limited ultrasound is where I
actually look. And we're building an ultrasound which is usually the $100 or insurance covers it. If we're doing just a guided injection, we just charge $50 or we can bill it if insurance will bill it. It's it's just to visualize just that one area where I'm doing the injection unaboot. Unaboot is used to help if someone has venous stasis ulcers or wounds on the on the lower
legs. Also, if they have a lot of swelling or if they have a sprain of their foot or sprain of the ankle, it's repeated weekly by the staff. If it's really bad for the ulcers, it's used to reduce ankle edema or swelling, tendonitis, foot instability. It can be used with a walking boot. You might have to take the top of The Walking boot off to fit it in there. You leave it on for three to five days and they can't shower or they would get a shower cover
as well. Wart treatment or Veruca Veruca treatment. So faroukas there's one to five 5 to 1415. Plus, this is the billing.