This article by a Consultant Podiatric Surgeon explains what conditions can be treated by podiatry and which conditions may be appropriate for surgery. This will be of interest to anyone suffering from a foot-related problem who would like to know what their treatment options are.
- What is the difference between a podiatrist and a podiatric surgeon?
- Who regulates podiatry and podiatric surgery?
- General podiatry
- Diagnosis and management
- Podiatric surgery
A podiatrist studies for three years to obtain a degree in Podiatry or Podiatric Medicine. Podiatrists are independent clinicians, qualified to diagnose and treat foot problems. Many podiatrists specialise in specific areas of work such as diabetes, rheumatology, sports injuries etc.
With the exception of nail surgery, podiatrists use non-surgical methods of treatment and this remains the mainstay of treatment for most foot problems. Until recently, podiatrists in the United Kingdom were known as chiropodists.
A podiatric surgeon is a podiatrist who has undertaken extensive postgraduate training in foot surgery. They are therefore not registered medical professionals (doctors) but specialists in the treatment of all foot problems using both conservative (non-surgical) and surgical treatment methods.
A podiatrist is specifically trained to assess, diagnose and manage foot complaints. Podiatric surgeons are highly specialised in that they will only operate on the foot, rather like a dental surgeon who will only treat your mouth. Podiatric surgery is a proven and effective aspect of foot healthcare with thousands of foot operations performed each year.
The training involves:
- 3 year full time degree in Podiatry
- 2 year general podiatric practice
- 2 year primary fellowship - Postgraduate Certificate in Podiatry
- 2 year surgical training programme - Postgraduate Diploma in Podiatry
- Final Fellowship examination
- 3 year specialist training (Clinical Fellow in Podiatric Surgery)
- Accreditation with the Faculty of Podiatric Surgery
- Consultant Podiatric Surgeon
Training and the award of Fellowships in Podiatric Surgery are provided by the Faculty of Surgery, of the Society of Chiropodists & Podiatrists. The Health Professions Council (HPC) regulates all podiatrists and podiatric surgeons, both of whom are required to be registered with the HPC.
The vast majority of foot conditions can be managed conservatively (i.e. without surgery) and this is the mainstay of treatment. The common conditions treated include:
- Bunions, hammertoes, neuromas, plantar fasciitis
- Sports injuries of the foot, ankle and leg/lower back
- Rheumatoid arthritis
- Neurovascular disease
- Ingrown toenails
A podiatrist will use a wide range of assessment and management techniques and, where necessary, liaise with other medical specialities to co-ordinate care. These include:
- Neurological assessment
- Vascular assessment
- Video and plantar pressure analysis of walking and running (gait analysis)
- X-rays, ultrasound and MRI scans
- Footwear assessment, advice and provision
- Specialised shoe inserts (orthoses)
- Injection therapy
- Skin surgery
Although conservative care is sufficient for the majority of patients, those that do not respond may require surgical correction.
Whilst foot surgery has traditionally been thought of as extremely painful, advances in techniques, local anaesthetics and painkillers mean that many people can now benefit from corrective surgery with minimal post-operative discomfort.
In order to determine the nature of the condition, the suitability for surgery and the most appropriate operation, a detailed assessment is necessary.
This can include:
- A detailed medical and personal social history
- Physical examination
- Further investigations: Ultrasound, CT/MRI scans, blood tests etc.
This will allow a diagnosis and management plan to be determined with the benefits and risks outlined. Information sheets are provided if surgery is indicated so that the patient can consider the options in more detail. Patients will often require a second consultation to discuss any questions, review appropriate investigations and obtain informed consent.
All patients undergoing surgery are required to give informed consent. This means that the nature of the operation, intended benefits, and potential risks are clearly and carefully explained. Whenever possible, the consent form should be signed in advance of surgery and the patient provided with a copy of the consent form.
The majority of foot operations can be performed easily and safely under local anaesthetic. Although the patient is awake, a screen is used so that they cannot see the operation. The anaesthetic injections are generally given around the ankle and knee as these allow for a better and longer lasting anaesthetic. Increasingly, Podiatric Surgeons use ultrasound to guide the needle to the nerve. In some instances it can take between 24–36 hours for the anaesthetic to wear off completely.
However, some patients feel nervous and prefer to be asleep. General anaesthetic techniques are extremely safe and are available when required. Local anaesthetic injections are still administered once the patient is asleep so that there is no pain when they wake up and that less general anaesthetic would be required during the operation. This reduces the risk and reduces post-operative nausea and sickness.
For patients who do not like the thought of a general anaesthetic but still feel nervous then a sedative can be given. Local anaesthetic injections are still required but this is an extremely effective combination for foot surgery.
Whichever anaesthetic technique is used, the majority of foot surgery can be performed on a day case basis, meaning that the patient does not need to stay in hospital overnight. As long as there is sufficient home support, patients can go home on the same day.
- Early return to activity
- Correction of the underlying deformity
- Reduced pain
- Improved function
All invasive surgery carries risks which includes the general risks of surgery (pain, infection, bleeding, deep vein thrombosis etc.) as well as risks specific to the condition and operation being performed. These should be discussed with the patient in detail prior to the operation and appropriate information sheets should be provided. Furthermore, the majority of complications can be managed and result in no lasting side effects.
The faculty of surgery of the Society of Chiropodists & Podiatrists has produced a range of information sheets so that this advice is consistent between practitioners.
Audits of the Podiatric Surgery service have shown consistently high patient satisfaction and outcomes with low complication rates [1,2].
Most foot conditions have a surgical option if the conservative measures have failed to relieve the symptoms sufficiently. The vast majority of foot surgery is performed on the forefoot (front of the foot) and includes:
- Ingrowing toenails
- Bunions (hallux valgus)
- Arthritis of the big toe (hallux rigidus)
- Painful corns
However, more complex conditions may also benefit from surgery, particularly if they are causing significant pain and are affecting walking or activity. These include:
- Arthritis of the foot and ankle
- Flat feet
- Tendon injuries
- Achilles tendon problems
- Ankle sprains
All too often, people take their feet for granted and ignore or put up with the pain. Simple advice and conservative care may be all that is required to resolve problems with feet and a podiatrist is specifically trained to assess and manage these conditions.
For more resistant cases, a Podiatric Surgeon is able to offer effective and safe surgery to resolve the problem while trying to minimise the recovery period as much as possible.
At my clinic, I specialise in the assessment and management of all these conditions using advanced assessment techniques, co-ordinated conservative care and, where appropriate, surgical intervention.
1. Kilmartin TE, Podiatric Surgery in a community trust; a review of activity, surgical outcomes, complications and patient satisfaction over a 4 year period. 2002. Foot 11(4): 218-227
2. Maher AJ, Metcalfe SA. A report of UK experience in 917 cases of day care foot surgery using a validated outcome tool. 2009. Foot 19(2): 101-106