What is Podiatry?

From conversations with both legal and other (health) professionals it is very evident to me that Podiatry is something of an unknown. So here is my presentation of what UK Podiatry is, does, and the difference between UK Podiatry and Podiatry in the USA (the two are often confused).

What is Podiatry?
Podiatry is a science based healthcare profession which places emphasis on the promotion, maintenance, and restoration of foot health. A Podiatrist is autonomous, in that he or she can direct treatment without the patient being referred by their doctor.

What are the qualifications for Podiatry and how long does it take to study?
Like most other healthcare professions nowadays, Podiatry is a degree course. The degree runs for three years (four in Scotland where it can be accessed at the age of seventeen rather than the usual eighteen).
The end qualification is either a BSc(Hons) Podiatric Medicine, or more usually BSc(Hons) Podiatry. The two degree have much the same content.

Study consists of:

Year 1 - Podiatric Foundation Studies, Lower Limb Anatomy, General Anatomy and Physiology, Knowledge and Skills for Professional Practice Placement, Communication and Psychology for Health Sciences.

Year 2 - Introductory and Applied Biomechanics, Patient Assessment, Pharmacotherapeutics for Podiatrists and Pathophysiology.

Year 3 - The High Risk Foot, Medicine and Surgery for Podiatrists, Prescribing in Practice, Evidence Based Practice and Professional Issues for Allied Health Professionals. Surgical tuition in Year 3 is not confined to the foot - the first operation I witnessed as a third-year student many years ago was a hip replacement.

Although Podiatrists have prescribing rights for, and can inject local anaesthetics, and can carry out limited surgery, they are not qualified to carry out bone surgery procedures like bunion removal and toe-straightening. This requires a further period of study, both theory and practical. This is not, as one newspaper published recently (having been fed misinformation by some interested third party) a matter of a year or so. 
Bone surgery theory is covered by an MSc. Supervised practical work is then carried out within the NHS over a period of some years.

So, a Podiatrist has done some surgical training, but is not qualified to carry out bone surgery.
A Podiatric Surgeon is qualified to carry out bone surgery. He or she has done the same Podiatry undergraduate degree, but has then completed a further course of surgical training.

All Podiatrists qualifying in the USA are qualified to prescribe drugs and carry out bone surgery. 

And just to confuse matters further, some of us have done some additional bone surgery training without becoming Podiatric Surgeons........

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Case history 2.

This claimant was referred to me by a Solicitor who wanted more information and accurate costings for foot orthotics.
The Solicitor "inherited" the file, which generally means it has had a period of inactivity. This case was over four years old.

The claimant was involved  in a road traffic accident in which his left foot and ankle were injured.
Damage was such that the ankle was subsequently surgically fused, and the first and second toes were amputated.

Ankle fixation and amputation of the big toe both materially affect gait, and may also have a damaging effect upon the opposing lower limb, overloading it and the major joints within it (hip, knee, ankle and big-toe joint), and so accelerated wear-and-tear arthritis is a factor to be considered in cases where one limb only is damaged initially.

A Rehabilitation Cost Report obtained earlier for this client suggested that an annual allowance towards future specialist footwear of £400.00 would be sufficient to meet the client needs.
In my opinion this figure was unrealistically low, and probably based on NHS footwear provision costs.
I was able to provide information and references which showed that NHS footwear provision is variable, and that in this case gait, and therefore need, had not been properly assessed.
I was further able to suggest, with references, that privately-sourced orthotics and footwear could provide better comfort and functionality, and better continuity of care.

The initial costings for gait analysis, orthotics and bespoke footwear came to £3,500.00, with annual costs thereafter of £1,850.00. These costs were accepted by the other side as being reasonable.

Conclusions.
In lower limb and foot injury cases rote costings for foot orthotics and bespoke footwear may be unrealistically low.

Gait should always be assessed when lower limb damage is present.

Continuity of care is an important factor in overall rehabilitation.

Rehab case study.

Rehab doesn't always mean physiotherapy and occupational therapy.

This case study illustrates how a correctly-prescribed custom foot orthotic can mean the difference between normal walking and limping, even in a young, fit client.

An otherwise fit 28 year-old male self-referred for treatment to his left foot.
He had previously been involved in a motorbike accident in which his left heel had been degloved. Clinically, degloving presents as skin and subcutaneous tissue being removed from the hand or foot, in this case by a spinning rear spoke motorbike wheel.

The injury had been operated on successfully, and had healed uneventfully, but with almost complete loss of fatty padding from around the heelbone. This is not uncommon in degloving injuries which affect the back part of the foot. Invariably, as in this case, the client is unable to heelstrike or bear weight on the heel for any length of time. Heelstrike is an important component of normal walking, without which a subject will walk with an antalgic gait (limp). Older people who have lost flexibility in their knees and hips often demonstrate this type of gait very well.

Stock foot orthotics had been issued by the NHS. They were cushioned, but not supportive, and were ineffective in allowing the client to maintain normal gait.

Treatment.
Barefoot computer gait analysis confirmed lack of heelstrike during normal walking.
A plaster cast was taken of the left foot to accurately capture the heel-to-toe profile of the foot. A biomechanical foot orthotic was designed which featured a deep heel cup into which a substantial amount of soft cushioning was incorporated. This was to replicate and replace the natural fatty padding around the heelbone. A small heelraise was also added to the orthotic to replace limb length  lost when the cushioning compressed during weightbearing. The orthotic shell was moulded from mildy flexible polypropylene, to which robust cushioning was added from the heel to the forefoot. Specific care was taken with regard to orthotic materials given the age, weight, and likely activity level of a fit young male.

Results.
Once the foot orthotic had been fitted the client found he was able to heelstrike with no discomfort. As his bodyweight moved forwards the foot was cradled and held in a stable position to allow normal push-off to occur. After a few weeks of using the orthotic the client was reassessed. His walking was normal with the orthotic. Without the orthotic he reverted to a laboured limp.

Conclusions.
Because there is no satisfactory surgical replacement of lost fatty tissue around the heel the client will have to wear this type of orthotic for life. The successful orthotic design could also be incorporated into a bespoke shoe or boot, resulting in a low-bulk alternative. This option may be more suitable for some client groups (eg young females) for whom the ability to wear fashion footwear some of the time may be important.

The sometimes quite considerable cost of custom foot orthotics and bespoke footwear should be carefully considered in clinical negligence and personal injury cases which affect the lower limb or foot.

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