Podiatry

Podiatry () or podiatric medicine () 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 in countries such as the United Kingdom, Australia, and Canada.
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 chiropractics, 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 podologue (French) or podólogo (Spanish and Italian). 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) (also known as a "podiatric physician" or "podiatric surgeon") is a medical specialist who diagnoses and treats conditions affecting the foot, ankle, and structures of the leg. The US podiatric medical school curriculum (equivalent to US MD and DO pathways) 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 podiatric physicians and surgeons 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.
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
Podiatric sports medicine.
Sports podiatry covers the following two areas: foot and lower limb chronic overuse injuries and mechanical performance enhancement to minimise injury and to maximise efficiency
Podopaediatrics.
Podopaediatrics is a specialty of podiatric medicine that focuses on the treatment of medical lower limb issues in children.
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. 
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. 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:
The Board approved until 21 November 2019, the accredited Doctor of Podiatric Surgery 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 to 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 and 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 use 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 has also adopted the DPM level of training, although other academic designations may register. Also, in 2004, Université du Québec à Trois-Rivières started the first and only program of Podiatric Medicine in Canada based on the American definition of podiatry. This program enlists 25 students yearly across Canada and leads to a DPM upon obtaining 195 credits. In the prairie and Atlantic provinces, the standard was originally based on the British model now called podiatry (chiropody). 
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 in Ontario perform soft tissue surgical procedures.
Chiropodists and podiatrists are regulated by the College of Chiropodists of Ontario, which had 701 chiropodists and 54 podiatrists registered as of December 31, 2019.
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 them 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."
United States.
In the United States, medical and surgical care of the foot and ankle is mainly provided by two groups of physicians: "podiatric surgeons" (who hold the degree of Doctor of Podiatric Medicine or DPM) and "orthopedic surgeons" (MD or DO).
The first two years of podiatric medical school is equivalent to training that M.D. and D.O. students receive, but with an emphasized scope on foot, ankle, and lower extremity. 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 or more commonly, complete a bachelor's degree with emphasis on general/organic chemistry, biochemistry, biology, etc. In addition, potential students are required to take the Medical College Admission Test (MCAT). The DPM degree itself takes a minimum of four years to complete.
The four-year podiatric medical school is followed by a surgical based residency, which is hands-on post-doctoral training. As of July 2013, all residency programs in podiatry were required to transition to a minimum three-years of post-doctoral training. Podiatric residents rotate through core areas of medicine and surgery. They work under MD supervision in such rotations as emergency medicine, internal medicine, infectious disease, behavioral medicine, physical medicine & rehabilitation, vascular surgery, general surgery, orthopedic surgery, plastic surgery, dermatology and of course podiatric surgery and medicine. Fellowship training is available after residency in such fields such as geriatrics, foot and ankle traumatology, infectious disease etc. In reality though, the residency training of most podiatry residencies today are already highly inclusive of these medical areas. In most states, their scope is limited to areas at or below the ankle joint, however, some states include the leg, as well as the hand as within the scope of podiatry. 
Upon completion of their residency, podiatrists can decide to become board certified by a number of specialty boards including the more common American Board of Podiatric Medicine and/or the American Board of Podiatric Surgery. The American Board of Podiatric Medical Specialties (ABPMS) has been certifying podiatrists since 1998. Within the American Board of Podiatric Surgery, PM&S 24 graduates can sit for Board Certification in Foot Surgery and those that complete PM&S 36 can sit for Board Certification in Foot Surgery and Board Certification in Reconstructive Rearfoot & Ankle Surgery. Both boards in ABPS are examined as separate tracks. Though the ABPS and ABPM are more common, other boards are equally challenging and confer board qualified/certified status. Many hospitals and insurance plans do not require board eligibility or certification to participate.
Podiatrists certified by the ABPS have successfully completed an intense board certification process comparable to that undertaken by individual MD and DO specialties. There are two surgical certifications under ABPS. They are Foot Surgery and Reconstructive Rearfoot/Ankle (RRA) Surgery. In order to be Board Certified in RRA, the sitting candidate has to have already achieved board certification in Foot Surgery. Certification by ABPS requires initial successful passing of the written examination. Then the candidate is required to submit surgical logs indicating experience and variety. Once accepted, the candidate has to successfully pass oral examination and computer questions of clinical simulation.
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 Service (IHS), the Rural Health Centers (RHC) and Community Health Center (FQHC) systems established by the US 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.
Some podiatrists have primarily surgical practices. Some specialists complete additional fellowship training in reconstruction of the foot and ankle from the effect of diabetes or physical trauma. Other surgeons practice minimally invasive percutaneous surgery for cosmetic correction of hammer toes and bunions. Podiatrists use medical, orthopedic, biomechanical and surgical principles to maintain and correct foot deformities.
Colleges and education.
There are nine colleges of podiatric medicine in the United States. These are governed by the American Association of Colleges of Podiatric Medicine (AACPM). The AACPM describes its mission as to enhance academic podiatric medicine. All podiatric medical schools in the United States are accredited by the Council on Podiatric Medical Education.
Podiatric subspecialities.
Podiatrists treat a wide variety of foot and lower extremity conditions, through nonsurgical and surgical approaches. The American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM) offers a comprehensive board qualification and certification process in podiatric medicine and orthopedics. Podiatric Medicine and Orthopedics is the medical specialty concerned with the comprehensive and continuous foot health care of patients. There are those podiatric physicians who also specialize (i.e., specialists) in such fields of practice of podiatric medical specialties as:
In Australia there is now an option to be a podiatric assistant. The qualification is a Certificate IV in Allied Health Assistance specialising in podiatry. They work as a part of a podiatric medical team in a variety of clinical and non clinical settings. There are currently developing strategies to further use these skilled workers. Worldwide there are common professional accreditation pathways to be a podiatric assistant. There are many fields such as podiatric nurse: