What is podiatry?

Science and Profession

The human foot, which is located at the end of the lower leg and connected to the leg by the ankle, is a very complex structure. Feet are designed to optimize both balance and mobility. Each foot is composed of twenty-six bones, ligaments that connect and articulate these bones, blood vessels that provide nutrients and oxygen, sensory nerves, and a very thick covering of tough, strong skin. Heredity and a lack of proper foot care frequently result in painful calluses and corns, bunions, enlarged joints, and ingrown toenails. In addition, a variety of diseases, such as diabetes mellitus and cardiovascular problems, can lead to many other serious foot dysfunctions.

Podiatrists—more correctly called doctors of podiatric medicine—examine, diagnose, and treat dysfunctions of the foot as well as related problems associated with the ankle and the lower leg. The first record of a procedure associated with podiatric medicine describes the creation of plasters that were used to treat corns at the Greek city of Smyrna in 100 BCE. Although other records of podiatric treatments were found in antiquity and the Middle Ages, the modern science of podiatry arose from the activities of the fourteenth-century barber-surgeons of Europe.

In the United States, the first truly prominent modern podiatrist—then termed a chiropodist—was Isacher Zacharia, the foot doctor to President Abraham Lincoln, who published the first American podiatry text in 1862. Two other milestones in the history of American podiatry were the founding of the National Association of Chiropodists and the opening of the New York School of Chiropody, both in 1912.

In 1958, the National Association of Chiropodists was renamed the American Podiatric Medical Association. From the New York School of Chiropody, whose first curriculum required only one year of chiropodic training, arose today’s schools of podiatric medicine, which require a four-year study period and award to graduates the doctor of podiatric medicine (DPM) degree. This degree derives from a uniform curriculum that all schools follow.

To become a licensed DPM, it is first necessary to complete a four-year course of postgraduate study at a school of podiatric medicine. Admission to all American podiatry schools requires the completion of at least three years of a solid bachelor’s degree program, which must include a year each of biology, inorganic chemistry, and organic chemistry. Most podiatry school entrants have completed a bachelor’s degree. In addition, a solid grade-point average and good scores on the Medical College Admissions Test (MCAT) are required for admission.

The first two years of podiatric professional education use this background as a springboard for laboratory and lecture-hall training in anatomy, biochemistry, physiology, pharmacology, diagnostic radiology, and numerous other biomedical sciences. The third and fourth years of training are dedicated to the acquisition of clinical expertise by practicing podiatric medicine in college or community clinics, hospitals, and the offices of experienced, well-established podiatrists.

Upon graduation, the new DPM usually completes a hospital residency lasting three to four years. In the first year, clinical expertise is gained in podiatric orthopedics, biomechanics, and neurology. The first-year podiatry resident engages in supervised primary care, which involves observing, evaluating, and treating many dysfunctions of the feet, ankles, and lower legs. Minor podiatric surgery, such as the correction of a hammertoe, is also carried out during this training period. In the remaining residency years, the resident learns to carry out the more demanding aspects of podiatric surgery of the foot, ankle, and leg. During this time period, the podiatric resident becomes more independent and skilled.

Podiatric practitioners require licenses to practice. In the United States, these licenses are most often gained by passing state board examinations. Satisfactory scores on the separate tests given by the National Board of Podiatric Medical Examiners are also deemed satisfactory for podiatric licensing by many states. Renewal of podiatry licenses, however, requires that podiatrists undergo extensive continuing education aimed at keeping them at the cutting edge of the field.

Specialization is also possible for podiatrists. Podiatric specialists can be certified by the American Board of Podiatric Surgery, the American Board of Podiatric Medicine, or the American Board of Podiatric Public Health. Each of these podiatric specialty boards requires advanced clinical training, completion of written and oral examinations, and extensive experience in specific aspects of modern podiatric practice. Such board certification indicates that the individuals involved have met much higher standards than those required for licensing alone. Some podiatrists also belong to the American College of Foot and Ankle Surgery of the American Medical Association (AMA).

In modern practice, podiatric surgical procedures designed to prevent or correct podiatric deformities now supplant many of the more conventional methods that originally made up the expertise of most podiatric practitioners. In addition, numerous techniques that cause the improvement of the health and the function of the foot and the ankle, so as to preclude foot deformities, have become key aspects of the modern podiatric profession.

Diagnostic and Treatment Techniques

A thorough podiatric examination begins with the complete medical history of the patient, inspection of the patient’s gait, and careful examination of both feet, the ankles, and the lower legs. When these procedures point to the diagnosis of a particular podiatric problem, x-ray examination, muscle testing, and neurological consultation may be carried out to search for more subtle problems that the initial examination suggested but did not prove.

Once a clear, complete diagnosis has been obtained, a treatment regimen—including physical therapy, various surgical treatments, medications, and the use of podiatric (orthotic) appliances—is prescribed. Often, all aspects of treatment are carried out in the podiatrist’s office. Complex podiatric surgery, however, may require the use of a hospital surgical suite or its equivalent.

Among the podiatric problems most often seen are athlete’s foot, bunions, calluses, corns, ingrown toenails, hammertoes, heel spurs, traumatic injuries to the ankles or feet, plantar warts, and complaints associated with arthritis, cardiovascular disease, or diabetes mellitus. In many cases—especially those engendered by athletics, diabetes, or cardiovascular problems—the podiatrist will refer patients to other health practitioners, such as orthopedists, cardiologists, or endocrinologists. Increasingly, however, podiatrists and other specialists are beginning to work together as teams to solve such health problems.

Bunions are deformities of the big toes and their joints; they may or may not be painful, but they are almost always considered uncosmetic. When a bunion is not painful, it is usually treated by the use of an orthotic device that prevents further damage and pain. In cases where bunion pain is caused by inflammation, oral or injected anti-inflammatory drugs, such as corticosteroids, are often used for the shortest period of time needed to correct the problem. Such short-term treatment is made necessary by the potential health risks caused by this therapy, which include cardiovascular problems. In the most severe cases, surgery is used to remove the bunion. An incision is made near the bunion site, and a surgical burr is used to trim away the region of excess bone that is causing the problem. In cases where manipulative examination or x-rays show that the bunion problem is in the joint, much more complex surgery is required.

Corns and hammertoes may be considered together, as many corns are caused by hammertoes. Corns are not restricted to occurrence along with hammertoes, however, as they also arise spontaneously on any toe subject to inappropriate biomechanical stress. A corn, or heloma, is a skin protrusion or thickening atop or on the side of a toe. Corns can occur wherever a toe has been bent out of shape by a biomechanical problem or by a tight shoe. They can be quite painful. Hammertoe, a contracture of one of the toe joints, produces a toe malformation that makes wearing shoes painful and can lead to corns. Corns may be trimmed periodically or removed surgically. The treatment used by podiatrists depends on the severity of the problem. Similarly, hammertoes are corrected surgically. After treatment of these problems, it is important for the patient to wear shoes that fit appropriately, to use any corrective orthotic devices that are prescribed, and to follow closely the instructions given by the podiatrist. Failure to do so can counteract the results of the podiatric treatment.

Calluses, like corns, are buildups of tough, thickened skin. Unlike corns, they occur most often on the bottoms of the feet. Calluses form to protect the foot from undue stress resulting from uneven weight bearing by the bottom of the foot. Therefore, they will form again after removal wherever the causative mechanical stress recurs. When a callus becomes painful, the appropriate treatment regimen varies greatly from case to case. Often, an orthotic device is used to produce evenness of weight bearing by the foot. In other cases, the callus is trimmed. In the most extreme cases, minor surgery is used to correct the anatomical defect in the metatarsal bone that is causing the problem. Again, success in callus treatment is optimized by carefully following the directions of the podiatrist. In the most severe instances, up to three months of diminished physical activity is required to enable complete healing of the trimmed metatarsal bones. Calluses may also occur at the back of the heel, as a result of tight shoes and dermatologic problems. These calluses are usually handled by trimming and subsequent purchase of more appropriate shoes.

Heel spurs, Achilles tendonitis, ankle problems, dermatologic problems of the foot, and diabetic or cardiovascular complications may also be treated by podiatrists. Furthermore, it should be recognized that podiatrists will often repair damaged bones, muscles, and tendons surgically. They can also prescribe medications and treat fractures or sprains by applying casts and braces.

Perspective and Prospects

Many advances in podiatric medicine have occurred in recent years. Most encouraging is the improved ability of podiatrists to handle severe foot problems. This improvement is largely attributable to advances in the field and to more thorough training both in professional school and in postgraduate experiences. The increasing positive interaction of podiatrists and other health care professionals in the treatment of dermatologic, cardiovascular, and diabetic problems is another great step forward.

Bibliography

Alexander, Ivy L., ed. Podiatry Sourcebook. 2nd rev. ed. Detroit: Omnigraphics, 2007. Print.

Copeland, Glenn, and Stan Solomon. The Foot Doctor: Lifetime Relief for Your Aching Feet. Rev. ed. Toronto: Macmillan, 1996. Print.

Farr, J. Michael, ed. Enhanced Occupational Outlook Handbook. 7th ed. Indianapolis: JIST, 2009. Print.

Fink, Brett Ryan, and Mark S. Mizel. The Whole Foot. New York: Demos, 2012. Print.

Frowen, Paul, et al., eds. Neale’s Disorders of the Foot. 8th ed. New York: Churchill, 2010. Print.

Lippert, Frederick G., and Sigvard T. Hansen. Foot and Ankle Disorders: Tricks of the Trade. New York: Thieme, 2003. Print.

Rose, Jonathan D., and Vincent J. Martorana. The Foot Book. Baltimore: Johns Hopkins UP, 2011. Print.

Thordarson, David B., ed. Foot and Ankle. 2nd ed. Philadelphia: Lippincott, 2013. Print.

Van De Graaff, Kent M., and Stuart I. Fox. Concepts of Human Anatomy and Physiology. 5th ed. Dubuque: Brown, 2000. Print.