Podiatry

Overview
Podiatry, podiatric medicine or chiropody is a field of healthcare devoted to the study and treatment of disorders of the foot, ankle, and the knee, leg and hip (collectively known as the lower extremity). The range of disorders podiatry can address largely depends on the scope of practice laid down in national, state, and/or provincial jurisdiction. It is practiced by podiatrists, chiropodists and podiatric surgeons.

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 where work on hands and feet is depicted. Many Egyptologists believe tending feet probably spanned the whole of Egyptian civilization. The placement of carvings at the entrance of a tomb typically signified the profession of the buried individual and The Tomb of the Physician dates from 2400 BC.

Corns and calluses were described by Hippocrates who recognised 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. Aulus Cornelius Celsus, a Roman scientist and philosopher, was probably responsible for giving corns their name. Later Paul of Aegina (AD 615-690) defined a corn as "a white circular body like the head of a nail, forming in all parts of the body, but more especially on the soles of the feet and the toes. It may be removed in the course of some time by paring away the prominent part of it constantly with a scalpel or rubbing it down with pumice. The same thing can be done with a callus."

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, ankle and related leg structures. Lewis Durlacher was one of the first people to recognize the need for a protected profession. He tried to establish the first association of practitioners in 1854, although it would take another century to come to pass.

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 was established in New York in 1895 with the first school opening 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. The number of chiropodists increased markedly after the Great War then again after World War II. Increased numbers of ex-soldiers needing to be gainfully employed gave chiropody a boost and led to the need for registration in all English speaking countries. The study of the foot (i.e. podology), brought greater knowledge to the practice of foot care or podiatry.

Podiatrist
A podiatrist (, "poh-DYE-eh-trist") or foot doctor is a podiatric professional, a person devoted to the study and medical treatment of disorders of the foot, ankle and lower extremity. The term originated in the United States but has now become the accepted term in the English speaking world for all graduates of podiatric medical schools who have earned one of the following degrees: (D.P.M., D.P., B.Pod., Pod.B, or Pod.D.).

In other countries, such as the United Kingdom, Germany, New Zealand, and certain provinces of Canada, the title “chiropodist” is often used. The titles “podiatrist” and “chiropodist”, in these countries, are now interchangeable, with the term “podiatrist” becoming more favoured within the profession. In the UK, individuals may not use the title “podiatrist” or “chiropodist” unless they are registrants of the Health Professions Council (HPC). They are protected titles and their use by non-registrants is unlawful. Such registration is normally only granted to those holding a specialised Bachelors degree or Diploma in Podiatry from one of the 13 recognised schools of podiatry in the UK. In these countries they usually only treat the foot through non-invasive procedures, they can however perform minor surgical procedures such as nail surgery using local anaesthetics. The United States is one of the few countries that grants more invasive surgical privileges to podiatrists.

Though the title "chiropodist" was previously used in the United States to designate what is now known as a "podiatrist," the title "chiropodist" is now considered to be an antiquated and etymologically incorrect term.

Australia
In Australia, Podiatry is classified as an allied health profession, and is practised by individuals licensed by their represpective State Boards of Podiatry. There are seven registration boards and six teaching centres, with two levels of awards — unclassified bachelors degree and honours level. In Australia there exists 2 levels of professional accreditation and professional privilege; Podiatrist and Podiatric Surgeon (Surgical Podiatrist in the state of Queensland). Australian podiatrists are be able to practice abroad with their qualifications recognised in some Commonwealth countries.

Education and Training
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 anatomy, medical chemistry, biochemistry, physiology and patient psychology, similar to the medical curriculum. The following two years will then be spent focusing on podiatry specific areas such as podiatric biomechanics and human gait, podiatric orthopaedics or the non-surgical management of foot abnormalities, basic pharmacology, general medicine, general pathology, local and general anaesthesia, and surgical techniques such as Partial Nail Avulsion.

Australian Podiatric Surgeons are specialist podiatrists with further training in basic medicine, basic pharmacology, and training in foot surgery. They first complete a degree of 4 years, 2 years of clinical experience. Following this, a masters 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), and passing oral and written exams, Registrars may qualify for Fellowship status.

Prescribing Rights
There is considerable variation between state laws regarding the prescribing rights of Australian Podiatrists. While all are able to utilize local anaesthesia for minor surgical techniques, some states allow suitable qualified podiatrists further privileges. Recent legislative changes, which are expected to come into effect soon, will allow Victorian graduates to prescribe relevant schedule 4 poisons. In other states such as Western Australia and South Australia, podiatrists with Masters Degree's in Podiatry, and extensive training in pharmacology are authorised to prescribe S4 poisons. States such as Queensland and New South Wales only grant prescribing privilege to those who are fellows of the Australasian College of Podiatric Surgeons, and thus are Podiatric Surgeons.

Canada
In some parts of Canada the situation is legislatively stratified between the U.S. and British systems. For instance, in some provinces like British Columbia and Alberta, the standards is the same Doctor of Podiatric Medicine (D.P.M.) level as in the United States. Quebec, too, has recently changed to the D.P.M. level of training. Also in Quebec, in 2004, Université du Québec de Trois-Rivières started the first program of Podiatric Medicine in Canada. In the prairie provinces, the standard has been based on the British model of chiropody. Recognising this fact, in the province of Ontario, chiropodists and podiatrists are legislatively distinct occupational designations. Ontario chiropodists have a narrower scope of permitted practice than Ontario podiatrists (i.e., limitations on surgical practice). Both occupations are governed by the College of Chiropodists of Ontario. Persons licensed after July 1993 in Ontario can only be licensed as a chiropodist and cannot be licensed as a podiatrist, regardless of their training.

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.

United Kingdom
A podiatrist is a specialist who studies foot pathology from a structural and functional standpoint, and who treats medical problems dealing with the foot.

Scope of practice:
 * High risk patient management
 * Sports injuries and biomechanics
 * Foot and nail surgery
 * Foot health education
 * Foot surgery: congential and acquired deformities e.g flat foot, tarsal coalitions, bunion (hallux abducto valgus), digital deformity, ankle instability

In the UK any practitioner working under the reserved title Podiatrist must be registered with the Health Professions Council.

The Society of Chiropodists and Podiatrists is the largest professional body and trade union for registered chiropodists and students. The Society represents over 11,000 members working in private practice, the NHS, education, and the retail sector.

The Alliance of Private Sector Chiropody and Podiatry Practitioners represents both Podiatrists and Foot Health Practitioners who can be consulted directly by the public for early attention.

The profession of podiatry has developed from its origins in chiropody to become a medical speciality dealing with assessment, diagnosis and treatment of the lower limb.

United States
In the United States, podiatric medicine and surgery is practiced by a licensed Doctor of Podiatric Medicine (D.P.M.). Education consists of a second entry degree which is a four-year program followed by a two- or three-year residency. Similar to Medical School, this training follows their four-year undergraduate college degree. The first four years of podiatric medical school are similar to training that traditional physicians (either medical doctors or osteopathic doctors) receive, but with more emphasis on foot, ankle and lower extremity problems and less emphasis on other topics such as embryology and pediatrics. Some of the podiatric medical schools are integrating into MD and DO schools for the first year or two. Being classified as a second entry degree, in order to be considered for admission an applicant must first complete a minimum of 90 semester hours at the university level and/or complete a bachelor's degree. The D.P.M. degree itself takes a minimum of four years to complete. Dentists likewise, have a separate educational school system. Thus there are five medical professions that allow for independent diagnosis and medical and surgical treatment: M.D., D.O., D.P.M., OD, and DDS/DMD.

The four-year podiatric medical school is followed by a residency, which is the hands-on post-doctoral training. There are two standard residencies named Podiatric Medicine and Surgery 24 or 36 (PM&S 24 or PM&S 36). These represent the two- or three-year residency training. Podiatric residents rotate through all main areas of medicine such as: emergency, pediatric, internal medicine, orthopedic and general surgery and of course podiatry — both clinic and surgical. During these rotations, attending physicians train the resident physicians in medicine and surgery. The surgical training varies from forefoot surgery to more complex foot, ankle, and leg reconstruction and salvage as well as trauma.

Podiatrists may independently diagnose, treat and prescribe medicine and perform surgery for disorders of the foot and in most states the ankle and leg. Board certification exists for podiatric physicians. Two speciality boards aligned with three areas of special practice are recognized by the Council on Podiatric Medical Education and the Joint Committee on the Recognition of Specialty Boards. Recognition is based on a board demonstrating that it can meet criteria established by the podiatric medical profession. The specialty board that certifies in the specialty areas of primary podiatric medicine and podiatric orthopedics is the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. The specialty board that certifies in the specialty area of podiatric surgery is the American Board of Podiatric Surgery. The surgical board certification is divided into foot surgery and rearfoot/ankle reconstruction surgery. The rearfoot and ankle board certification requires at least a three-year residency to qualify. The surgical board which certifies minimally invasive percutaneous surgery is the American Board of Foot and Ankle Surgery. All of the surgical board certifications require applicants to submit their surgical cases to the board committee. The applicants then take written and oral exams prior to becoming board certified.

In the United States, the previous titles used for the Doctor of Podiatric Medicine (D.P.M.) degree were Doctor of Surgical Chiropody (D.S.C.) and Doctor of Podiatry (Pod.D.) Podiatry in the US currently encompasses a broader spectrum of medical practice than it used to. Podiatrists can now perform medical and surgical procedures in all 50 states, though the specific scope of practice does vary slightly in each state.

Early educational developments
William Mathias Scholl began his career in Chicago, 1899, in a small shoe store specializing in comfort and specialist footwear. His concern for customers with painful foot conditions motivated him to enroll in medical school to study the anatomy and physiology of the foot.

By 1904 he had graduated from the Illinois Medical College as a doctor of medicine (M.D.) and launched his first foot care product, an arch support — The Foot-eazer. Dr. Scholl made it his life-long mission to improve the health, comfort and well-being of people through their feet.

In 1907 the Scholl Manufacturing Co. Inc. was created and in 1912 Dr. Scholl founded the Illinois College of Chiropody and Orthopaedics. By 1913, the company was expanding worldwide and Dr. Scholl's first Foot Comfort Service shop opened in London. By the 1930s the company expanded its range for the comfort of the legs and began to make a range of compression hosiery for the relief of swollen ankles and varicose veins. Dr. Scholl was a prolific inventor and went on to create a range of remedy and cushioning devices covering the whole spectrum of common foot conditions.

In 1959 the first Scholl Exercise Sandal was created and became an international fashion hit and an icon for the brand.

Dr. Scholl's is a brand of foot-care products manufactured by Schering-Plough and footwear made by Brown Shoe Company. William M. Scholl died in 1968 at the age of 86, leaving the company to his nephew, William H. Scholl. The company had an initial public offering in 1971.

Just prior to Scholl founding a Chiropody College in Illinois, other innovators and individuals around the United States were founding other institutions of learning for foot care. Among these was M.J. Lewi, M.D. who founded what is now the oldest and largest college of podiatric medicine located in New York City. His institution later became the M.J. Lewi School of Podiatric Medicine and ultimately became the New York College of Podiatric Medicine.

The New York College of Podiatric Medicine notes that by 1911 the New York School of Chiropody had been created, dedicated to educating and training chiropodists. Dr. Maurice J. Lewi, a physician and educator, then serving as Secretary to the New York State Board of Examiners, was named the first president of the school.

Dr. Lewi assisted in developing the first legislation governing the practice of chiropody. He also developed the curricula and training programs for the first course of study at the school.

He was the first to suggest that the term "chiropody" be changed to "podiatry", since the term "chiropody" was etymologically incorrect. Some years later, the term "podiatry" was adopted by all other colleges of podiatric medicine and by the National Association of Chiropodists (NAC), now known as the American Podiatric Medical Association.

Practice characteristics
While the majority of podiatric physicians are in solo practice, there has been a movement toward larger group practices as well as the use of podiatrists in multi-specialty groups including orthopedic groups, treating diabetes or in multi-specialty orthopedic surgical groups. Some podiatrists work within clinic practices such as the Indian Health System (IHS), the Rural Health Centers (RHC) and Community Health Center (FQHC) systems established by the Federal government to provide services to under insured and non-insured patients as well as within the United States Department of Veterans Affairs providing care to veterans of military service.

Scope of practice
The differences in podiatric medical and surgical practice are determined by state law. Podiatrists are often defined as physicians in most States. Each state allows or limits the practice of podiatric medicine to the foot, ankle, and in many States, portions of the leg or related leg structures.

This may include surgery above the ankle and leg in 44 states. Most states require completion of a residency or a post-graduate training to practice. Most podiatric surgeons work in surgery centers or hospitals performing both medical and surgical treatments for patients. As in many other specialties, some podiatrists work in nursing homes and some perform house calls for patients. Podiatric patients range from newborns and infants to the geriatric.

Medical and orthopedic practice
Some podiatrists limit their practices to the non-(hospital) surgical treatment of patients. Because much work in podiatric medicine and surgery involves cutting of some kind, many procedures are considered surgical by insurance companies including tasks such as the cutting of nails, removing of corns or callus, which the general public would not ordinarily consider to be surgery. These podiatrists use their skills in handling arthritic, diabetic, and other medical problems associated with the feet and lower extremities. Some use devices fitted in shoes (orthotics) or modify the shoe itself to make walking better or easier. Some practices focus on sports medicine and treat many runners, dancers, soccer players, and other athletes.



Surgical practice
Within the scope of practice, podiatrists are the experts at foot, ankle & related leg structures surgery. Some podiatrists have primarily surgical practices. Some specialists complete additional fellowship training in reconstruction of the foot, ankle and leg. Many podiatric surgeons specialize in minimally invasive percutaneous surgery. Most podiatrists utilize medical, orthopedic, biomechanical and surgical practices. Indeed, surgical podiatric principles rest on a base of orthopedic and kinesthetic knowledge.

Distinction from Orthopedic Foot and Ankle Surgery
Orthopaedic foot and ankle specialistis first must complete a medical degree either (MD, MBBS, MBChB, etc) or Osteopathic D.O. degree. After completion of medical school orthopaedic surgeons complete a 5-6 year residency program. A majority of orthopedic residency programs dedicated 12 week or less to foot and ankle surgery. To compensate for this, some orthopedic surgeons may complete a foot and ankle fellowship that varies from 3 - 12 months. This contrasts with podiatric surgeons who have a residency of 2 to 3 years dedicated to foot and ankle surgery. Some of the practice of orthopedic surgeons and podiatrists is overlapping. Foot and ankle orthopaedic surgeons often work in the same practices as podiatrists, and will occasionally refer patients to one another.

Job opportunities and salary
The US Department of Labor, Bureau of Labor Statistics expects the need for podiatrists to rise, but slowly because podiatrists tend to have long careers before retirement. The most recent podiatric practice survey in 2006 revealed a median salary of $150,000 and in 2007, podiatric medicine placed 15th on the Forbes survey of “America’s 25 Best Paying Jobs.”

Colleges and education
There are eight colleges of podiatric medicine in the United States with a ninth school being added in 2009 at Western University of Health Sciences. These are governed by the American Association of Colleges of Podiatric Medicine (AACPM). The AACPM describes its mission as to enhance academic podiatric medicine.

Speciality branches
Podiatrists worldwide, regardless of educational pathways, treat a wide variety of foot and lower extremity conditions, through conservative or surgical approaches.

Amongst those subspecialties are such fields of practice as:


 * General Podiatry Practice
 * Podopaediatrics (the study of children's foot and ankle conditions)
 * Sports Medicine
 * Diabetic foot and wound care
 * Forensic Podiatry (the study of footprints, footwear, shoeprints and feet associated with crime scene investigations)
 * Rheumatology
 * Gerontology
 * Reconstructive foot and ankle surgery
 * Minimally invasive percutaneous surgery

Professional societies and organizations

 * Alpha Gamma Kappa
 * Kappa Tau Epsilon
 * Pi Delta National Honor Society
 * Student National Podiatric Medical Association (SNPMA)
 * American Podiatric Medical Students' Association (APMSA)