The Evaluation and Management of Common Neurologic Disorders in Primary Care Podiatry Practice: A Practical Review and Update

See Agenda at the following link: https://t8pze98ab.cc.rs6.net/tn.jsp?f=001UqKpMZHfMom90u3xqqP5Z0GUE0QZgLMXMMRV7CGv-pMsZkso-Z2ejmQn6M17spJYDkOE712qLOcJCqI6XDVCpVaBa8lcYyigEhHlY_PcEiRwjftZtcccWaZPeL7KjhANTnHdPewBmD1_CUWsEbLSO6x4536r5uI2QatNxZUiXjp2Sv4sKfo14Armn46g83SMa82zYE3zFp5A4y9MMp2LELoyd3BRsXW7uXm6r_4taWvZi9QjuN7RaSmyTHJ4wa9v&c=tD_8xDWcmYh_aQfBgxSE92GzV6Mqm6NRh2scR4jo3ijMtaKoisVJ4g==&ch=MVs_hnQFT3Idlxoc5jUI6XaEuQ5pyW9kzbtm3pPCJot_RTaYSYznGQ==

SESSION ONE; COMMON ENTRAPMENT NEUROPATHIES OF THE FOOT AND ANKLE: EVALUATION AND MANAGEMENT

8:00-9:00

POSTERIOR TARSAL TUNNEL SYNDROME: CAN WE PREDICT SUCCESS FROM FAILURE?

Posterior tarsal tunnel syndrome is a well-recognized nerve entrapment causing pain, paresthesia, and dysesthesia. Clinical understanding of tarsal tunnel has evolved significantly in recent years and continues to expand. Current guidelines for the evaluation and management of this entity will be reviewed and elucidated. The role of advanced diagnostic techniques, such as nerve conduction testing, electromyography, MRI, and diagnostic ultrasound will be discussed. Categorization of patients more or less likely to respond to non-operative or surgical management will be reviewed. Current recommended techniques for the non-operative or operative management of tarsal tunnel syndrome will be examined. Outcome studies following tarsal tunnel surgery will be reviewed for consideration of the attendee. Special consideration of the question of tarsal tunnel syndrome in the diabetic patient will be examined. CPT and ICD-10 considerations will be reviewed.

9:00-9:30

ANTERIOR TARSAL TUNNEL SYNDROME: COMMONLY ENCOUNTERED, UNCOMMONLY DIAGNOSED

Entrapment of the deep peroneal nerve may occur at the anterior ankle, dorsum of the foot, or at the MPJ joint. Dorsal foot pain, numbness, paresthesia, or dysesthesia, may result from this entrapment. Although not uncommon, anterior tarsal tunnel syndrome remains underdiagnosed and thus undertreated. In this discussion, the anatomical basis for anterior tarsal tunnel will be presented, together with a practical approach for the diagnosis and treatment of this clinical problem.

9:30-10:15

MORTON’S NEUROMA

Morton’s neuroma is a commonly diagnosed nerve entrapment in daily podiatry practice. Diagnostic protocols include history and physical examination. Is this sufficient for diagnosis? Are advanced imaging studies such as ultrasound or MRI required? What does the literature actually tell us about common protocols in management, such as local anesthetic, corticosteroid, alcohol injections? Is there a role for orthotic management? How do we address the issue of neurectomy vs. neurolysis? Dorsal vs. plantar incisions? Are less commonly utilized therapies such as ESWT, radiofrequency or cryosurgical nerve ablation techniques effective? What should our patients expect following neuroma surgery? What are the proper CPT and ICD-10 codes utilized in the management of Morton’s neuroma.

In this discussion, we will present for your review and consideration what actual RCT’s and objective studies tell us about the evaluation and management of this common nerve entrapment, to allow the practitioner to select more effective therapeutic interventions for the evaluation and treatment of Morton’s neuroma.

10:15-10:30 BREAK

SESSION TWO: NERVE INJURIES OF THE FOOT AND ANKLE ASSOCIATED WITH THE SURGICAL MANAGEMENT OF FOOT AND ANKLE DISORDERS

10:30-11:30

IATROGENIC NERVE INJURY OF THE FOOT AND ANKLE

Although uncommon, iatrogenic nerve injury may occur as the result of operative or even non-operative care of foot pathology. Treatment-associated nerve injury is a not uncommon basis for malpractice litigation. This session will review in detail the problem of iatrogenic nerve injury. Anatomical variations in nerve anatomy of the foot and ankle will be examined. Evaluation and testing of the podiatric patient for iatrogenic nerve injury will be reviewed. Documentation issues relevant to iatrogenic nerve injury will be presented. Diagnostic testing principles for the evaluation of a patient with potential iatrogenic nerve injuty will be elucidated. Theraputic interventions for the management of iatrogenic nerve injuries, from injection related to surgery related nerve injuries will be discussed. Malpractice consideration associated with iatrogenic nerve injury will be reviewed for consideration.

11:30-12:30

NERVE PAIN FOLLOWING SURGERY: IT IS NOT ALWAYS CRPS

Signs and symptoms of nerve pathology are not uncommon following surgery of the foot and ankle. While complex regional pain syndrome may occur as an undesired result of surgery, not infrequently CRPS-like entities may be present and be mistaken for CRPS. Post-surgical inflammatory neuropathy, post tourniquet syndrome, and transient regional osteoporosis are examples of post-surgical disorders which may present as a CRPS-like clinical presentation. This session will examine causes of nerve pain following surgery which may be mistaken for CRPS. The session will review these entities, diagnostic paradigms, and therapeutic interventions. Malpractice implications, which are significant in these patients, will also be discussed.

12:15-1:00 LUNCH BREAK

SESSION THREE: PSYCHOLOGICAL AND PSYCHIATRIC PROBLEMS COMPLICATING PODIATRY CARE

1:00-1:45

CATASTROPHIZING IN THE PODIATRY PATIENT

What factors do you consider in the evaluation of a patient for surgery? If a patient has a psychological risk factor, does this affect your treatment decision making? Catastrophizing is a cognitive distortion in which your patient assumes the worst possible conclusion, ie-they feel they are in a crisis. The patient dwells on the worst possible outcome, and expresses a concern that your non-operative or surgical therapy has failed or that they have a complication. Studies have demonstrated that a patient who tends toward catastrophization will have a worse post-operative outcome, and express dissatisfaction even in the presence of a normal clinical, laboratory, or radiographic examination. In this important session, we will review our current understanding of catastrophizing, recognizing the patient prone to this problem, and strategies to hopefully identify these patients. The session will further discuss management of the catastrophizing patient following non-operative and importantly operative care.

1:45-2:30

ANXIETY AND DEPRESSION

If a patient suffers from anxiety and/or depression, does this affect the ability of the patient to cope following surgery or response to non-operative care? How does the presence and severity of pre-operative anxiety and depression affect clinical outcome for the management of foot and ankle disorders? Is pre-operative anxiety and depression a predictor of negative surgical outcome, or is this a myth or presumption unsupported in the literature. This discussion will examine the important question of the role of anxiety and depression in the treatment of patients under care for foot and ankle pathology. From bunion surgery to calcaneal fractures, the role of anxiety and depression in patient satisfaction with care will be examined.

SESSION FOUR: SELECTED TOPICS OF CLINICAL IMPORTANCE IN THE EVALUATION AND CARE OF THE PODIATRIC MEDICAL AND SURGICAL PATIENT

2:30-3:15

SPINAL STENOSIS AND DOUBLE CRUSH SYNDROME

Double crush syndrome is not uncommon, but is frequently undiagnosed. Without appropriate evaluation and testing, double crush syndrome may result in an increased risk for poor outcome in the seemingly appropriate treatment a wide range of lower extremity nerve problems, such as intermetatarsal neuroma, tarsal tunnel, or diabetic neuropathy. Commonly encountered entities such as soleal sling syndrome, spinal stenosis, or peroneal nerve entrapment at the fibular neck may mimic or complicate more distal disease which we are treating. This session will review the clinical evaluation of patients for double crush syndrome. Special emphasis will include spinal stenosis and the role that spinal stenosis may play in causing or complicating lower extremity neurologic pathology. Review of dermatomal and myotomal anatomy and physiology will also be presented.

3:15-3:30 BREAK

3:30-4:15

COMPLEX REGIONAL PAIN SYNDROME

Complex regional pain syndrome is a known potential complication of foot and ankle surgery. This entity is responsible for some of the largest malpractice awards against podiatric physicians. Early recognition and referral of a patient with suspected CRPS is important. The signs and symptoms of CRPS, generally referenced as the Budapest criteria, are a diagnosis of exclusion, and may be encountered in a variety of other disorders. In this session, the problems in diagnosis and management of complex regional pain syndrome will be reviewed in detail, with suggested protocols for the diagnosis of this difficult and unfortunate disorder.

4:15-5:15 EVALUATION AND TESTING FOR DIABETIC SENSORY NEUROPATHY IN THE PRIMARY CARE PODIATRY OFFICE

The evaluation of the diabetic patient for signs and symptoms of sensory, motor, or autonomic neuropathy represents a growing demand in the primary care podiatry office. In this session we will review effective screening protocols for diabetic neuropathy and appropriate CPT and ICD-10 considerations. The addition of neuropathy management into “at risk” foot care protocols will also be presented.

5:15-6:00 QUESTION AND ANSWER SESSION

6:00 MEETING ADJOURNS