Podiatry

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Podiatry () or podiatric medicine ( or ) is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of disorders of the foot, ankle and lower extremity. The term podiatry came into use in the early 20th century in the United States and is now used worldwide, including countries such as the United Kingdom and Australia.

Podiatry is practiced as a specialty in many countries, while in many English-speaking countries, the older title of chiropodist may be used by some clinicians (not to be confused with chiropractic, which is unrelated). In Australia, graduates of recognised academic programs can register through the Podiatry Board of Australia as a "podiatrist', and those with additional recognised training may also receive endorsement to prescribe or administer restricted medications, and/or seek specialist registration as a 'podiatric surgeon'. In many non-English-speaking countries of Europe, the title used may be podologist or podólogo. The level and scope of the practice of podiatry vary among countries.

According to the American Association of Colleges of Podiatric Medicine, a Doctor of Podiatric Medicine (DPM) is a medical specialist who diagnoses and treats conditions affecting the foot, ankle, and structures of the leg. The US podiatric medical school curriculum includes lower extremity anatomy, general human anatomy, physiology, general medicine, physical assessment, biochemistry, neurobiology, pathophysiology, genetics and embryology, microbiology, histology, pharmacology, women's health, physical rehabilitation, sports medicine, research, ethics and jurisprudence, biomechanics, general principles of orthopedic surgery, and foot and ankle surgery.

US trained podiatrists rotate through major areas of medicine during residency, including emergency medicine, orthopedic surgery, general surgery, anesthesia, radiology, pathology, infectious disease, endocrinology, sports medicine, physical therapy, biomechanics, geriatrics, internal medicine, critical care, cardiology, vascular surgery, psychiatric and behavioral health, neurology, pediatrics, dermatology, pain management, wound care and primary care.

Video Podiatry

History

The professional care of feet was in existence in ancient Egypt as evidenced by bas-relief carvings at the entrance to Ankmahor's tomb dating from about 2400 BC where work on hands and feet is depicted.

Corns and calluses were described by Hippocrates who recognized the need to physically reduce hard skin, followed by removal of the cause. He invented skin scrapers for this purpose and these were the original scalpels.

Until the turn of the 20th century, chiropodists--now known as podiatrists--were separate from organized medicine. They were independently licensed physicians who treated the feet, ankles and related leg structures. Lewis Durlacher was one of the first people to call for a protected profession.

There are records of the King of France employing a personal podiatrist, as did Napoleon. In the United States, President Abraham Lincoln suffered greatly with his feet and chose a chiropodist named Isachar Zacharie, who not only cared for the president's feet, but also was sent by President Lincoln on confidential missions to confer with leaders of the Confederacy during the U.S. Civil War.

The first society of chiropodists, now known as podiatrists, was established in New York in 1895--and still operates there today as NYSPMA. The first school opened in 1911. One year later the British established a society at the London Foot Hospital and a school was added in 1919. In Australia professional associations appeared from 1924 onwards. The first American journal appeared in 1907, followed in 1912 by a UK journal. In 1939, the Australians introduced a training centre as well as a professional journal.

Podiatry is a high paying specialty and was listed by Forbes in 2007 as the 15th best paid profession in the United States. The median annual Podiatry salary in the US is $124,830 as of 2016 according to the US Bureau of Labor and Statistics

Maps Podiatry

Scope of practice

United States

Scope of practice varies from different demographic and geographic areas. In the United States there is varied scope on where reconstructive surgery is done. According to the California Board of Podiatric Medicine, Doctors of Podiatric Medicine (DPMs) are licensed under Section 2472 of the State Medical Practice Act. They diagnose and treat medical conditions affecting the foot, ankle and related structures (including the tendons that insert into the foot and the nonsurgical treatment of the muscles and tendons of the leg). Any procedure and modality is within the DPM scope if utilized to diagnose and treat foot, ankle or other podiatric conditions. In addition to performing foot and ankle surgeries. DPMs are trained and fully licensed to independently perform full-body history and physical (H&P) examinations in any setting for any patient. DPMs, many of whom develop expertise in the care and preservation of the diabetic foot, perform partial amputations of the foot as a limb-sparing technique as far as proximal with the Chopart's joint, to prevent greater loss of limb, ambulation, or life. While podiatrists may order and administer anesthesia and sedatives, the administration of general anesthesia may only be performed by an anesthesiologist or certified registered nurse anesthetist (CRNA). DPMs commonly administer intravenous (IV) sedation.

Podiatrists are uniquely qualified among medical professionals to treat only diseases of the foot and ankle. Whether it is sports medicine, pediatrics, dermatology or diabetes, today's podiatrist can treat the many diverse facets of foot care. Podiatrists can be the first to identify systemic diseases in patients, such as diabetes and vascular disease. Today's podiatrists:

Perform surgery
Perform reconstructive surgery and microsurgeries
Administer sedation and anesthetics
Perform complete medical histories and physical examinations
Prescribe medications
Set fractures and treat sports-related injuries
Prescribe and fit orthotics, insoles, casts and prosthetics
Order and perform physical therapy
Take and interpret X-rays, ultrasound, MRI's and other imaging studies
Work as valued members of a community's health care team

Doctors of podiatric medicine receive medical education and training in podiatric medical colleges including four years of undergraduate education, four years of graduate education at one of nine podiatric medical colleges and up to four years of hospital-based residency training. All podiatric physicians and surgeons receive a DPM degree.

Australia

The Australian Podiatry Council has defined the scope of podiatry in Australia as: Podiatry deals with the prevention, diagnosis, treatment and rehabilitation of medical and surgical conditions of the feet and lower limbs. The conditions podiatrists treat include those resulting from bone and joint disorders such as arthritis and soft-tissue and muscular pathologies, as well as neurological and circulatory disease. Podiatrists are also able to diagnose and treat any complications of the above which affect the lower limb, including skin and nail disorders, corns, calluses and ingrown toenails. Foot injuries and infections gained through sport or other activities are also diagnosed and treated by podiatrists. A range of skills are employed by podiatrists. Direct consultations include a clinical history composition, physical examination, diagnosis, preparation of a treatment plan and provision of a range of therapies. Clinical assessment techniques aim to secure a diagnosis and prognosis and take into account clinical, medical and surgical history, footwear, occupational and lifestyle factors, and may incorporate the use of diagnostic equipment such as vascularscopes or radiology. Gait analysis will often be undertaken through visual or computerised means and might include range of motion studies, postural alignment evaluation or dynamic force and pressure studies. Clinical services require skilled use of sterilised instruments and appropriate infection control procedures, along with appropriate application of pharmacological agents, specialist wound dressings and a variety of physical therapies. Prescription foot orthoses (in-shoe devices) offer long-term solutions in the treatment and prevention of corns, callous and necrotic ulceration in their capacity to provide pressure redistribution. As a technique for providing consistent weightbearing realignment they are utilised in the treatment of acute and chronic foot conditions such as tendonitis, recurrent ankle sprain, chronic knee pain and stress fractures, to supplement and enhance clinical care. Foot health education regarding self care techniques and prevention of foot pathology is an important component of individual care but is also frequently implemented on a greater scale, either to specific target groups or as community projects. In order to facilitate enhanced clinical care, podiatrists establish and maintain collaborative relationships with other health care providers, often working within a site-based, multi-disciplinary team.

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Podiatric surgery

Podiatric surgery is a specialist field in the podiatry profession. Podiatric surgery is the surgical treatment of conditions affecting the foot, ankle and related lower extremity structures by accredited and qualified specialist podiatrists. Podiatric surgery is designed to ensure continued functionality of the foot and ankle areas. Patients who complain of joint and ligament problems, as well as those with congenital deformities, are offered a plethora of surgical solutions that fix bones, muscles, and joints. Certain podiatric surgeons specialize in minimally invasive surgery, while others perform full reconstructions.

Ingrown Toenail / Conservative Treatment / Podiatrist in Tijuana ...

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Podiatric sports medicine

Sport podiatry, a sub-specialty of podiatric medicine, involves the expertise in diagnosis of foot and lower limb problems as well as treatments such as joint mobilisation, advanced biomechanical assessments, injection therapy such as Prolotherapy and PRP (Platelet-Rich-Plasma), soft-tissue manipulation and trigger point therapy, advanced functional orthotic therapy, exercise rehabilitation, exercise prescription [strength and conditioning] of the lower extremities and footwear prescription for the professional, elite, amateur and young athletes, as well as those who have sustained injuries in day-to-day life. Sports podiatry covers the following two areas:

foot and lower limb chronic overuse injuries
mechanical performance enhancement to minimise injury and to maximise efficiency

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Podopaediatrics

Podopaediatrics is a specialty of podiatric medicine that focuses on the treatment of medical lower limb issues in children. Proper podopaediatric care is important in the long term because unaddressed structural problems with the feet can worsen over time, eventually causing severe issues with gait and pain. By correcting early foot deformities many long term chronic mobility issues can be safely and effectively addressed, sparing a great deal of discomfort on the part of the patient, and future expenses. A number of different foot ailments can affect children from a variety of different backgrounds, these can include structural issues with the foot like flat footedness, or other, more general issues like ingrown toe nails or infections. A child's foot is more at risk compared with an adult. Biomechanical abnormalities as a child can cause long term damage, this is because the foot is more malleable. Children tend to have a high pain threshold as they are easily distracted and ill-fitting footwear is also an issue when it comes to children's foot health.

Podopaediatricians are specially trained to provide treatment to younger children. One of the requirements of becoming a podopaediatrician is that a practitioner completes the necessary qualifications after having graduated from a recognised podiatric medical school. Continuous Professional Development (CPD) courses outlined by regulatory bodies like the Health and Care Professions Council determine what practical experience and theoretical knowledge is needed for one to become a qualified podopaediatrician.

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Specific country practices

Australia

In Australia, podiatry is considered as an allied health profession, and is practised by individuals licensed by the Podiatry Board of Australia. The current issue is however though with the Podiatry associations in Australia believing that it is a profession distinct from allied health because it shares little in common with the allied health group, the evidence points to the fact that in the Health Insurance Act 1973, podiatry is one of three including dentistry and medicine as the providers of 'professional attention' as well as the only three professions that are able to administer injections and operate surgically on patients. Podiatry scope of practice also far outweighs all other allied health professions.

There are eight teaching centres (as well as Auckland University of Technology in New Zealand), with two levels of awards--bachelor's degree (pass and/or honours) such as the Bachelor of Podiatric Medicine offered by Charles Sturt University and University of Western Sydney, and the master-level postgraduate Doctor of Podiatric Medicine offered by the University of Western Australia and the Master of Podiatric Practice by La Trobe University.

In Australia there currently exist two levels of professional accreditation and professional privilege: General Podiatrist and the specialist - Podiatric Surgeon. There is current lobbying for other specialties to be recognised in Australia such as podopediatrics, diabetes, high risk, musculoskeletal and sports podiatry. Australian podiatrists are able to practise abroad with their qualifications recognised in some Commonwealth countries. Many general podiatrists in Australia do routinely use the title Doctor, Dr. compliant with advertising regulations, and appropriate for the professional standing. Dr is not a protected title and therefore its use is unrestricted in Australia, and may be used by any health professional regulated under AHPRA as per advertising guidelines. There are guidelines advertising for regulated health services were jointly developed by the National Boards under section 39 of the National Law. Section 133 of the National Law regulates advertising of regulated health services.

Registration and regulation

Australian Podiatrists must register with the Podiatry Board of Australia.[1] The Podiatry Board of Australia is responsible for regulation and recognition of Podiatrists and Podiatric Surgeons, and assessing foreign trained registrants in conjunction with the Australian & New Zealand Podiatry Accreditation Council (ANZPAC).

The Podiatry Board of Australia recognizes 3 pathways to attain specialist registration as a Podiatric Surgeon:

1. Fellowship of the Australasian College of Podiatric Surgeons

2. Doctor of Clinical Podiatry, University of Western Australia

3. Eligibility for Fellowship of the Australasian College of Podiatric Surgeons

The Board approved until 21 November 2019, the accredited Doctor of Clinical Podiatry program of study offered by the University of Western Australia as providing a qualification for the purpose of specialist registration as a podiatric surgeon

Education and training

Entry into undergraduate Podiatric Medicine degrees can be done so after the completion of a Year 12 Certificate with an Australian Tertiary Admissions Rank (ATAR). The cut-off scores from the Universities Admissions Centre (UAC) generally range from 70.00 - 95.00 dependent on the popularity and intake of each podiatric medical school. Prospective students can also be of mature age (21 & over) and they apply direct to the university instead of going through UAC. The UWA DPM degree have admission requirements that:

Completion of a UWA bachelor's degree or equivalent
A minimum GPA of 5.0 from the most recent three years (FTE) of valid study
Suitable GAMSAT score
There is no interview for the DPM (Applications are handled via the University)
English Language Competency

Australian podiatrists complete an undergraduate degree ranging from 3 to 4 years of education. The first 2 years of this program are generally focused on various biomedical science subjects including functional anatomy, microbiology, biochemistry, physiology, pathophysiology, pharmacology, evidence-based medicine, sociology and patient psychology, similar to the medical curriculum. The following one years will then be spent focusing on podiatry specific areas such as podiatric anatomy & biomechanics, human gait, podiatric orthopaedics or the non-surgical management of foot abnormalities, podopaediatrics, sports medicine, rheumatology, diabetes, vascular medicine, mental health, wound care, neuroscience & neurology, pharmacology, general medicine, general pathology, local and general anaesthesia, minor & major podiatric surgical procedural techniques such as partial and total nail avulsions, matricectomy, cryotherapy, wound debridement, enucleation, suturing, other cutaneous and electro-surgical procedures and theoretical understanding of procedures performed by orthopaedic and podiatric surgeons.

Australian podiatric surgeons are specialist podiatrists with further training in advanced medicine, advanced pharmacology, and training in foot surgery. Podiatrists wishing to pursue specialisation in podiatric surgery must meet the requirements for Fellowship with the Australasian College of Podiatric Surgeons. They first complete a degree of 4 years, which includes 2 years of didactic study and 2 years of clinical experience. Following this, a master's degree must be completed with focus on biomechanics, medicine, surgery, general surgery, advanced pharmacology, advanced medical imaging and clinical pathology. They then qualify for the status of Registrar with the Australasian College of Podiatric Surgeons. Following surgical training with a podiatric surgeon (3-5 years), rotations within other medical and surgeons' disciplines, overseas clinical rotations, and passing oral and written exams, Registrars may qualify for Fellowship status. Fellows are then given Commonwealth accreditation under the Health Insurance Act to be recognised as providers of professional attention, for the purposes of health insurance rebates.

Australian podiatric medical schools

There are currently nine universities in Australia (plus one in New Zealand) offering varying degrees of podiatric medicine from a Bachelor of Podiatry/Podiatric Medicine (BPod), a Masters of Podiatric Medicine (MPod) and the Doctor of Podiatric Medicine (DPM) (DPM is a master-level degree). All podiatry schools are accredited by the Australian and New Zealand Podiatry Accreditation Council (ANZPAC). ANZPAC is an independent body comprising members consisting of the Podiatry Registration Boards in Australia and New Zealand. The Board of Management comprises registered podiatrists (nominated by the Registration Boards), nominees from the professional associations (Australasian Podiatry Council and Podiatry New Zealand), nominees from the educational institutions offering podiatry programs and community representation. ANZPAC has been assigned the accreditation functions for the Podiatry Board of Australia under the National Registration and Accreditation Scheme for Health Professions. There are also two more podiatry schools currently being developed at the Australian Catholic University and the University of Ballarat. The following universities offering podiatry are:

University of Western Australia
Charles Sturt University
La Trobe University
University of Western Sydney
University of South Australia
University of Newcastle (Australia)
Queensland University of Technology
Central Queensland University
Southern Cross University
Auckland University of Technology (New Zealand)

Prescribing of Scheduled Medicines & referral rights

There is considerable variation between state laws regarding the prescribing rights of Australian podiatrists. While all registered podiatrists in each state or territory are able to utilize local anaesthesia for minor surgical techniques, some states allow suitably qualified podiatrists further privileges.

Recent legislative changes, allow registered podiatrists and podiatric surgeons with an endorsement of scheduled medicines in Victoria, Western Australia, Queensland, South Australia and New South Wales to prescribe relevant schedule 4 poisons. In states such as Western Australia and South Australia, podiatrists with Master's degrees in Podiatry, and extensive training in pharmacology are authorised to prescribe Schedule 2, 3, 4 or 8 medicines (Australian Health Practitioner Regulatory Agency). In Queensland, Fellows of the Australasian College of Podiatric Surgeons are authorised to prescribe a range of Schedule 4 and one Schedule 8 drug for the treatment of podiatric conditions. Currently endorsed podiatrists who have the ability to write prescriptions do not have those prescriptions qualify for the Pharmaceutical Benefits Scheme. There is also political lobbying for more Chronic Disease Management places from 5 to 12 visits a year to a podiatrist for chronic diseases such as diabetes and for PBS rights.

All podiatrists may refer patients for Medicare rebatable plain x-rays of the foot, leg, knee and femur, as well as ultrasound examination of soft tissue conditions of the foot. Podiatrists may refer patients for other radiology investigations such as CT, MRI or bone scans, however Medicare rebates do not currently exist for these examinations. Similarly, podiatrists may refer patients when needed to specialist medical practitioners, or for pathology testing, however similar exclusions in the Medicare Benefits Schedule prevent rebates being available to patients for these referrals.

Canada

In Canada, the definition and scope of the practice of podiatry varies provincially. For instance, in some provinces like British Columbia and Alberta, the standards are the same as in the United States where the Doctor of Podiatric Medicine (DPM) is the accepted qualification.

Quebec, too, has recently changed to the DPM level of training, although other academic designations may also register. Also in Quebec, in 2004, Université du Québec à Trois-Rivières started the first program of Podiatric Medicine in Canada based on the American definition of podiatry. In the prairie and Atlantic provinces, the standard was originally based on the British model now called podiatry (chiropody). That model of podiatry is currently the accepted model for most of the world including the United Kingdom, Australia and South Africa.

The province of Ontario has been registering Chiropodists since 1944, then introduced new legislation in 1991 (when the Ontario Government imposed a cap on Ontario trained chiropodists becoming podiatrists). If a registered podiatrist from outside of Ontario relocates to Ontario they are required to register with the province and practice as a chiropodist. Podiatrists who were practicing in Ontario previous to the imposed provincial cap were 'grandfathered' and allowed to keep the title of podiatrist as a subclass of chiropody. The scope of these 'grandfathered' (mostly American trained) podiatrists includes boney procedures of the forefoot and the ordering of x-rays in addition to the scope of the chiropodist.

In Ontario, podiatrists are required to have a "Doctor of Podiatric Medicine/DPM" degree (a post-baccalaureate, four-year degree), where the majority of chiropodists currently practicing hold a post-secondary advanced diploma in chiropody, requiring a baccalaureate degree in the sciences or in another field as a prerequisite before entering chiropody. Podiatrists may bill OHIP for their services; chiropodists were restricted in 1991 from billing OHIP. Podiatrists may "communicate a diagnosis" to their patients (or to their patients' representatives) and perform surgical procedures on the bones of the forefoot; chiropodists may do neither. Chiropodists perform soft tissue surgical procedures.

Chiropodists and podiatrists are regulated by the College of Chiropodists of Ontario, which had 594 chiropodists and 65 podiatrists registered as of 29 July 2015.

The only English-speaking Chiropody program in Canada, in which also has a working Chiropody Clinic on campus for students to treat patients under the supervision of licensed Chiropodists is The Michener Institute-affiliated with University Health Network, Toronto. According to The Michener Institute website, Chiropody is a branch of medical science that involves the assessment and management of foot and lower limb disorders. This includes the management of a wide variety of disorders, injuries, foot deformities, infections and local manifestations of systemic conditions. A Chiropodist is a primary care professional practicing in podiatric medicine in Ontario that specializes in assessment, management and prevention of diseases and disorders of the foot. An essential member of the inter professional healthcare team, the Chiropodist is skilled in assessing the needs of their patients and of managing both chronic and acute conditions affecting foot and lower limb function. As a primary care provider capable of independent clinical practice, these skills are often practiced independent of medical referral and medical supervision.

Iran

There are no podiatric medical schools in Iran. The Ministry of Health and Medical Education (MoHME) reviews the dossier of podiatric applicants for medical registration according to the "Regulations on the Evaluation of the Educational Credentials of Foreign Graduates", updated on 12 Mordad 1388 AHS (3 August 2009 CE). Section 12-5: "The specific requirements for evaluation of education degrees in podiatry" stipulates that the podiatric degree from the United States will be registered as a professional doctorate in podiatric medicine, provided that the following are met:

Possession of a bachelor's degree
Successfully passing the MCAT
Completion of the podiatric curriculum and obtaining the Doctor of Podiatric Medicine (DPM) from an accredited school
If required by the home jurisdiction, completion of a one-year postgraduate training
Successfully passing of the relevant board examinations
An exception is made for those holding the [3-year undergraduate] Bachelor of Science (Podiatry) degree from accredited schools in the United Kingdom. After successful evaluation by the relevant commission, these degrees will be accepted at the bachelor's level (editorial note: the meaning of this exception is not clearly stated. It appears safe to assume that such bachelor's degrees do not qualify for medical registration and merely allow the holders to enroll in further educational programs).

New Zealand

Chiropody became a registered profession in New Zealand in 1969 with the requirement that all applicants take a recognized three-year course of training. Soon after the professional title was changed from Chiropody to Podiatry and The New Zealand School of Podiatry was established in 1970 at Petone under the direction of John Gallocher. Later the school moved to the Central Institute of Technology, Upper Hutt, Wellington. In 1976 the profession gained the legal right to use a local anaesthetic and began to introduce minor surgical ingrown toenail procedures as part of the scope of practice.

New Zealand podiatrists were granted the right of direct referral to radiologists for X-rays in 1984. Acknowledgement of podiatric expertise marked improved services to patients and eventually in 1989 suitably trained podiatrists were able to become licensed to take X-rays within their own practice. Diagnostic radiographic training is incorporated into the degree syllabus and on successful completion of the course, graduates register with the New Zealand National Radiation Laboratory.

In 1986, the profession undertook a needs analysis in conjunction with the Central Institute of Technology to identify competencies for podiatry in 2000. A Bachelor of Health Science was introduced in 1993. Auckland University of Technology is now the only provider of podiatry training in New Zealand.

United Kingdom

The scope of practice of UK podiatrists on registration after obtaining a degree in podiatry includes the use and supply of some prescription only medicines, injection therapy and non-invasive surgery e.g. performing partial or total nail resection and removal, with chemical destruction of the tissues. Podiatrists complete about 1,000 supervised clinical hours in the course of training which enables then to recognise systemic disease as it manifests in the foot and will refer on to the appropriate health care professional. Those in the NHS interface between the patients and multidisciplinary teams. The scope of practice of a podiatrist is varied ranging from simple skin care to invasive bone and joint surgery depending on education and training. In order to perform invasive foot surgery a UK podiatrist must undertake extensive postgraduate education and training, usually taking a minimum of 10 years to complete.

In a similar way to podiatrists in Australasia, UK podiatrists may continue their studies and qualify as podiatric surgeons. Due to recent changes in legislation, the professional titles 'chiropodist' and 'podiatrist' are now protected by law. In the UK there is no difference between the terms chiropodist and podiatrist. Those using protected titles must be registered with the Health and Care Professions Council (HCPC). Registration is normally only granted to those holding a bachelor's degree from one of 13 recognized schools of podiatry in the UK. Professional bodies recognised by the Health Professions Council are: The Society of Chiropodists and Podiatrists, The Alliance of Private Sector Practitioners (thealliancepsp.com ), The Institute of Chiropodists and Podiatrists and The British Chiropody and Podiatry Association.

The Royal Commission on the National Health Service in 1979 reported that about six and a half million NHS chiropody treatments were provided to just over one and a half million people in Great Britain in 1977, 19% more than three years earlier. Over 90% of patients receiving these treatments were aged 65 or over. At that time there were about 5,000 state registered chiropodists but only about two-thirds worked for the NHS. The Commission agreed with the suggestion of the Association of Chief Chiropody Officers for the introduction of more foot hygienists to undertake, under the direction of a registered chiropodist, "nail cutting and such simple foot-care and hygiene as a fit person should normally carry out for himself."