Canadian Medical Alliance for the Preservation of the Lower Extremity
Podiatric Medicine and Surgery
Podiatric Medicine is the medical discipline devoted to the
foot and lower extremity. ("Pod-" is Greek for 'foot,' and
'iatros' is Greek for 'physician.')
To provide context to the status of podiatric medicine and
surgery in Canada, let's start with some background of the
profession in the United States, where the profession in its
current and modern form originates.
As is the case with any physician, podiatric training in the United States begins with four years of undergraduate university training, where the student receives a bachelor degree. Students then take the same medical college application tests as any physician, and if the scores are acceptable, they then enter four years of medical and surgical training. Upon completion, the student earns a doctorate degree. The doctorate degree is followed by three years of hospital-based surgical residency training. Some then go on to additional fellowship training in specialized fields such as pediatrics, sports medicine,
specialized surgery and the diabetic foot.
Once in practice, board certification is an additional process one may pursue to demonstrate competence and expertise in a specialty field. The American Board of Foot and Ankle Surgery (ABFAS) and the American Board of Podiatric Medicine (ABPM) are the two major boards in the profession. Sub-specialty certification exists. For instance, physician-level wound healing
certification exists as one such subspecialty discipline.
Podiatrists in the US work in offices and hospitals, and have positions in top-quality academic institutions like Harvard and Yale, the University of Chicago, Penn, Columbia and Stanford. They serve on the staff of ballet companies, the Olympics and professional sports teams.
There are approximately 13,500 podiatrists practicing in the United States, and each year there are approximately 60 million visits to a podiatrist. So podiatric medicine is relatively well understood and well established in the US.
In Canada, the podiatric profession has a more complicated story.
Podiatrists in British Columbia and Alberta have the same standard of training as the US. In fact, as there are no US-level schools in Canada, all podiatrists in these provinces were trained in the United States, and did the same post-graduate training. The scope of practice is similar, too.
Podiatrists prescribe medicines, and perform all mannerof surgical procedures.
Quebec has a similar, but not identical standard to the US, BC and Alberta. However, the province does not require a residency to practice. The majority of practitioners in Quebec were trained at a school in Quebec, with the instruction in French. Unfortunately, the school is not accredited in many parts of English-speaking Canada, with the result that there are few Quebec-trained podiatrists in much of Canada.
For the most part, practitioners in the Prairies have a British-level of training. The training is different from the US model, as is the scope of practice.
Ontario has some US-trained podiatrists, but there are fewer since the province has moved to a lesser-trained chiropody model based on a level of instruction somewhat unique to Ontario, different both from the US, UK and Quebec models.
In the Maritime provinces, the title of 'podiatrist' is largely unregulated. The people using the title 'podiatrist' there have varying degrees of education and training.
This inconsistency in education, training and scope of practice has made
things difficult for the podiatric profession in Canada. Sometimes
physicians trained in Canada haven't encountered a podiatrist
and are not familiar with the profession. Sometimes they
know the term, but have a misunderstanding as to the
level of medical training podiatrists receive and are
unaware of their scope of practice, particularly
when the physician was trained in a place
where the word 'podiatrist' has one
meaning, then they practice in a
place where the term means
something rather different.
Government officials are often
similarly uneducated with regards
to the podiatric profession. This has
led to the unfortunate situation that we
see today where most podiatric services are
not covered by provincial health, even in BC and
Alberta, where the training is greatest.
This is unfortunate for the Canadian public, because the
efficacy and value of podiatric medicine and surgery has been
demonstrated repeatedly in the medical literature.
As this is a website devoted to wound care, let's look at some recent
studies on the value of podiatric medicine specifically in the wound care setting.
Recent Studies on the Value of Podiatric Medicine in Wound Care in Canada and the US
A 2020 study out of Quebec reviewed 12 studies concerning the effect of podiatric medicine on diabetic foot ulcer healing and lower extremity amputation was conducted. The combined statistics from those studies suggested that patients treated by a team with podiatrists were 31% less likely to suffer any form of amputation (toes, metatarsals, legs), and 55% less likely to suffer a major amputation (leg amputation). (Reduced risk of any amputation: 0.69, 95% CI 0.54-0.89, I2 = 64%, P = 0.002; Reduced risk of major amputation RR: 0.45, 95% CI 0.23-0.90, I2 = 67%, P < 0.02.)
Blanchette V, Brousseau-Foley M, Cloutier L Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis J Foot Ankle Res . 2020 Mar 20;13(1):15. doi: 10.1186/s13047-020-0380-8.
A 2019 Canadian study from Alberta comparing amputations statistics in Calgary (where podiatric care was provided) to Edmonton (where podiatric care was not provided) found that the Calgary area had both significantly lower major amputation rates (45%). Calgary patients still experienced amputations, but more were relatively minor (such a toe) in comparison to Edmonton.
Basiri R, Haverstock BD, Petrasek PF Manji K Reduction in Diabetes-Related Major Amputation Rates After Implementation of a Multidisciplinary Model: An Evaluation in Alberta, Canada J Am Podiatr Med Assoc November 01 2019 https://doi.org/10.7547/19-137
A 2018 Canadian study from Quebec compared the effect of podiatric medical care on diabetic foot ulcer patients (N=67). Before podiatric care was implemented, 27.3% of ulcers resolved in an average of 44.6 weeks. After podiatrists were integrated into patient care, 73.2% of DFUs healed in an average of 19.8 weeks.
Blanchette V, Hains S, Cloutier L. Establishing a multidisciplinary partnership integrating podiatric care into the Quebec public health-care system to improve diabetic foot outcomes: A retrospective cohort. Foot (Edinb). 2019 Mar;38:54-60. doi: 10.1016/j.foot.2018.10.001. Epub 2018 Oct 9. PMID: 30639800
A huge 2018 data-mining study from the University of Michigan examined the impact of establishing a fully-integrated and specialized podiatric serve in a tertiary academic health system on preventative foot care on limb salvage rates. They examined all encounters for diabetes and any foot complications between 2000-2005 and 2010-2015, preceding and after full implementation of podiatry service, respectively. 100 million patient encounters were compared. Podiatric services cut the amputation rate in half and the number of major amputations by a third. Podiatric services also resulted in a shift of care to the less-expensive outpatient setting.
Schmidt BM, Holmes CM, Ye W, Pop-Busui R. A Tale of Two Eras: Mining Big Datafrom Electronic Health Records to Determine Limb Salvage Rates with Podiatry.Curr Diabetes Rev. 2018 Oct 16. doi: 10.2174/1573399814666181017104818. [Epubahead of print] PubMed PMID: 30332970; PubMed Central PMCID: PMC6531350.
A 2010 Duke University study of 656,590 Medicare patients with diabetes, those who were treated by podiatrists experienced 23-69% fewer lower extremity amputations than if treated by other health professionals.
Sloan, F. A., Feinglos, M. N. and Grossman, D. S. , RESEARCH ARTICLE: Receipt of Care and Reduction of Lower Extremity Amputations in a Nationally Representative Sample of U.S. Elderly. Health Services Research, no. doi: 10.1111/j.1475- 6773.2010.01157.x 2010 Aug 16
A 2010 study out of Brown University found that patients treated by podiatrists had half the rate of significant amputations and a significantly higher survival rate of patients with diabetes at high risk for ulceration and limb loss.
Driver VR, Goodman RA, Fabbi M, French MA, Anderson CA “The Impact of a Podiatric Lead Limb Preservation Team on Disease Outcomes and Risk Prediction in the Diabetic Lower Extremity: A Retrospective Cohort Study” J Am Podiatr Med Association 2010 Jul-Aug; 100(4): 235-41
A 2013 University of Tennessee study of 47,753 patients, care by podiatrists in the year prior to a diabetic foot ulcer was associated with fewer re-ulcerations, fewer hospitalizations, and 65-80% fewer major amputations.
Gibson TB, Driver VR, Wrobel JS, Christina JR, Bagalman E, DeFrancis R, Garoufalis MG, Carls GS, Gatwood J. Podiatrist care and outcomes for patients with diabetes and foot ulcer. Int Wound J. 2014 Dec;11(6):641-8. doi:10.1111/iwj.12021. Epub 2013 Feb 4. PubMed PMID: 23374540.
A 2011 healthcare study of 474,000 patients by the Toronto research group Thomson Reuters found that US diabetic patients treated by podiatrists had a cost savings of $19,686 per patient, and for each dollar invested in care by a podiatrist results in $27 to $51 of savings for the health-care delivery system.
They found that non-Medicare patients with diabetes had a 20% lower amputation rate and a 26% lower hospitalization rate if they had seen a podiatrist.
Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, Defrancis RR, Wang S, Bagalman JE, Christina JR
“The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers” J Am Podiatr Med Assoc. 2011 Mar-Apr;101(2):93-115, accessible at: www.tinyurl.com/trstudy.
A 2014 study by (British Columbia-born) Grant Skrepnek and David Armstrong examined the repercussions following Arizona Medicaid’s 2009 announcement that they would cancel coverage to podiatric physicians for their 1.5 million enrollees, with the goal to save $351,000.
The result was that inpatient hospitalizations went up 36.7%, hospitalized stays went up 22.5%, inpatient charges went up 37.5%, severe outcomes (death, amputation, sepsis, etc.) went up 49%.
Overall costs went up $16.7 million. This means that for every dollar saved in cutting podiatry, $44 more was spent on the complications. This is very much in keeping with the 2011 study quoted above.
Based on the results of this study, podiatric medicine has since been re-included by Medicaid in Arizona.
Grant H. Skrepnek, PhD, University of Oklahoma Health Sciences Centre Statistics from a presentation at Georgetown University Hospital Diabetic Limb Salvage conference, October 11, 2014, Washington, DC, accessible at http://www.apma.org/files/FileDownloads/AZMedicaidStudy.pdf
A 2016 study examining the implementation of the Affordable Care Act examined three years of inpatient discharge files in the state of California, and found that even limited podiatric services cut hospital admissions and amputations by 10% and saved 4.1% in costs. The authors indicate that these numbers can be improved with better access to podiatric care, and they recommend the inclusion of podiatric medical services in chronic care to realize the greatest cost savings.
Labovitz JM, Kominski GF "Forecasting the Value of Podiatric Medical Care in Newly Insured Diabetic Patients During Implementation of the Affordable Care Act in California" J Am Podiatr Med Assoc. 2016 May;106(3):163-71. doi: 10.7547/15-026.
A 2002 retrospective study out of Florida looked at the effect of a multidisciplinary team that included podiatrists on diabetic patients. In a control of 118 patients and 116 test patients with the multidisciplinary team over 18 months, the authors found above knee amputations were required in 14 of 76 patients in the control group compared to none in the multidisciplinary group.
Meltzer, DD, Pels S, Payne WG, Mannari RJ, Ochs D, Forbes-Kearns J, Robson MC Decreasing Amputations Rates in Patients with Diabetes J Am Podiatr Med Assoc 92(8): 425-428, 2002
A 2020 meta-analysis of 20 studies conducted by authors at Dartmouth University in New Hampshire and Rosalind Franklin University of Medicine and Science in North Chicago found that healthcare systems can expect a 36-56% decline in amputation rate following the implementation of a multidisciplinary team including podiatrists.
Albright RH, Manohar NB, Murillo JF, Kengne AM, Delgado-Hurtado JJ, Diamond ML, Acciani AL, Fleischer AE Effectiveness of Multidisciplinary care teams in reducing major amputation rate in adults with diabetes: A systemic review and meta-analysis.
A 2004 study in Dallas, Texas found that after implementing a screening / treatment program for diabetic feet involving podiatrists, the incidence of amputations dropped 47.4% (from 12.89 per 1000 diabetics to 6.18), foot-related hospital admissions decreased by 37.8% (from 22.86 per 1000 to 14.23), the length of stay dropped 21.7% (from 4.75 to 3.72 days). There was also a 69.8% decline in skilled nursing facility admissions and 38.2% reduction in length of stay.
Lavery LA, Wunderlich RP, Tredwell JL Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Res Clin Pract. 2004; 70: 31-37
In this 2006 Cleveland, Ohio study, results were assessed following the introduction of a multidisciplinary team that included podiatrists beginning in 2001. Age-adjusted amputation rates for patients with diabetes dropped 27% (5.64 to 4.12 per 1000 patients) between 2001 and 2004. Major amputation rates (defined as above the ankle) decreased 33% (from 2.15 to 1.42). Minor amputation rates decreased 22.6% (from 3.49 to 2.70).
Robbins JM, Nicklas BJ, Augustine S Reducing the rate of amputations in acute diabetic foot infections. Cleve Clin J Med. 2006; 73: 679-683
A small 2010 US study conducted in a county hospital found that initiating care with an organized program with podiatrists resulted in a sharply inverted high-low amputation ration, where there are fewer leg amputations and more small amputations (such as digits). In this case, there was a 72% drop in leg amputations, from 7 to 2.
Rogers LC, Bevilacqua NJ Organized programs to prevent lower-extremity amputations. Journal of the American Podiatric Medical Association, 100(2), 2010 pp.101-104.
These are recent North American demonstrate the value podiatrists bring in dealing with wounds, both in their general medical background, their surgical training and their understanding of biomechanics--skills vital for healing wounds--is not replicated in mainstream medicine.
Studies done in other parts of the world show similar success with podiatrists treating wounds.
A Danish study from 2000 found that the implementation of a multidisciplinary team including podiatrists resulted in a 75% reduction in the incidence of major amputations.
Holstein P1, Ellitsgaard N, Olsen BB, Ellitsgaard V. Decreasing incidence of major amputations in people with diabetes. Diabetologia. 2000 Jul;43(7):844-7.
A 2013 follow-up Danish study to the one cited above examined amputations from diabetes between 2000 to 2011 when treated by a multidisciplinary diabetes specialist centre with podiatrists. They found the incidence of all lower‐extremity amputations decreased by 87.5% among men and 47.4% among women with Type 1 diabetes and by 83.3% among men and 79.1% among women with Type 2 diabetes.
M. E. Jørgensen, T. P. Almdal, K. Færch Reduced incidence of lower‐extremity amputations in a Danish diabetes population from 2000 to 2011 First published: 25 September 2013 https://doi.org/10.1111/dme.12320
An 11-year English study published in 2008 found an 82% drop in major amputations with the implementation of a multidisciplinary team including podiatrists.
Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 2008;31:99–101.
A 2014 study from Madrid, Spain analyzed the incidence of lower extremity amputations (LEAs) after introducing a foot care team coordinated by an endocrinologist and a podiatrist. The incidence of LEAs dropped by over a third, from 6.1 per 100,000 to 4.0 per 100,000.
Rubio JA, Aragón-Sánchez J, Jiménez S, Guadalix G, Albarracín A, Salido C, Sanz-Moreno J, Ruiz-Grande F, Gil-Fournier N, Álvarez J. Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot. Int J Low Extrem Wounds. 2014 Mar;13(1):22-6. doi: 10.1177/1534734614521234.
Another study from Madrid, Spain from 2017 found a 26% decline in the incidence of leg amputations in diabetic patients following the implementation of a multidisciplinary unit including podiatry with an annual decline of 3.3% per year. (Incidence of 6.1/100,000 2001-2007 before implementation to 4.5/100,000 2008-2014 after implementation).
Jiménez, S., et al., Trends in the incidence of lower limb amputation after implementation of a Multidisciplinary Diabetic Foot Unit. Endocrinología, Diabetes y Nutrición (English ed.), 2017.
A 2017 study performed at a major hospital in Sydney, Australia examined the rate of diabetic foot infections for those being treated by a multidisciplinary team with podiatrists, and compared that to those not being treated by such a team. They found that patients not treated by a team including podiatrists represented the majority of admissions, and that population had a 40% greater number of amputations than expected compared to the treated group.
Plusch D, Penkala S, Dickson HG, Malone M. Primary care referral to multidisciplinary high risk foot services - too few, too late. J Foot Ankle Res. 2015 Nov 14;8:62. doi: 10.1186/s13047-015-0120-7. PMID: 26582352; PMCID: PMC4650286.
A 2016 study from Guanzhou, China found that when endocrinologists teamed with podiatrists to coordinate a multidisciplinary team to treat diabetic wounds, the overall amputation rate dropped by up to two-thirds, and the above-ankle amputation rate of Grade 3 and 4 ulcers declined from 35.7% to 4.4% in three years.
Wang C, Mai L, Yang C, Liu D, Sun K, Song W, Luo B, Li Y, Xu M, Zhang S, Li F, Ren M, Yan L. Reducing major lower extremity amputations after the introduction of a multidisciplinary team in patient with diabetes foot ulcer. BMC Endocr Disord. 2016 Jul 7;16(1):38. doi: 10.1186/s12902-016-0111-0.
A 2018 British study found that the major diabetes-related lower limb amputation rate "is significantly inversely correlated with foot care services provision," and more effective foot health delivery, including better screening, more clinics with podiatric care resulted in significant reductions in major amputation incidence within 2 years. Failure to provide foot care service resulted in a continued high amputation incidence.
Paisey RB, Abbott A, Levenson R, Harrington A, Browne D, Moore J, Bamford M, Roe M; South-West Cardiovascular Strategic Clinical Network peer diabetic foot service review team. Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England. Diabet Med. 2018 Jan;35(1):53-62. doi: 10.1111/dme.13512. Epub 2017 Oct 11.
A 2018 study out of Kuwait found that the introduction of a podiatry provision in a multidisciplinary team led to a diminished healing rate (52 days) for diabetic foot ulcers--similar to British and US rates, locations with access to podiatric care, and much lower than rates reported in 2010 in India (241 days to heal) where podiatric care is lacking.
Messenger G, Masoetsa R, Hussain I, Devarajan S, Jahromi M. Diabetic foot ulcer outcomes from a podiatry led tertiary service in Kuwait. Diabet Foot Ankle. 2018 May 28;9(1):1471927. doi: 10.1080/2000625X.2018.1471927. eCollection 2018.
A 2018 study out of Frankston (metropolitan Melbourne) Australia found that the economic benefits of having podiatrists treat diabetic and high-risk patients to prevent severe infections and lower the rate of lower extremity amputations more than covered the cost to cost to educate and train them.
Couch AG, Foo J, James AM Maloney S, Williams CM. Implementing a podiatry prescribing mentoring program in a public health service: a cost-description study. J Foot Ankle Res. 2018 Jul 13;11:40. doi: 10.1186/s13047-018-0282-1. eCollection 2018.
A 1999 study from Lithuania compared patients treated by a multi-disciplinary team including podiatrists with those not treated by such a team. They found that the intervention group had 48% fewer ulcerations compared to those in the non-intervention group, (30.4% vs 58.4%).
Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study. Diabetes Care. 1999 Sep;22(9):1428-31. doi: 10.2337/diacare.22.9.1428. PMID: 10480504.
A 2021 study from the Catalonia, Spain found a huge increase in demand for podiatric services when a diabetic foot program was established. From 2009 to 2018, patient visits went from 1,726 to 213,095. The number of podiatrists required went from 165 to 470.
J. Ruiz-Toledo, A. J. Zalacain-Vicuna and E. de Planell-Mas Evaluation of the Complementary Health Provision of the Podiatric Foot Care Program for Diabetic Patients in Catalonia (Spain) Int J Environ Res Public Health 2021 Vol. 18 Issue 10 Accession Number: 34064991 PMCID: PMC8151618 DOI: 10.3390/ijerph18105093
A 2010 study in Singapore examined the results of a multidisciplinary team including podiatrists treating diabetic feet. They found a 40% drop in the length of hospitalized stay (20.36 days to 12.20 days), a 65% reduction in major amputations (31.15% to 11.01%), and a 63% reduction in significant complications (19.67% to 7.34%).
Nather A, Siok Bee C, Keng Lin W, Xin-Bei Valerie C, Liang S, Tambyah PA Value of team approach combined with clinical pathway for diabetic foot problems: a clinical evaluation. Diabet Foot Ankle. 2010; 1
Study after study, in countries around the world, the story is the same. Podiatric medical care is valued by patients. It saves limbs, saves lives, and saves money. Yet Canada still doesn't insure podiatric services for this care.
Part of what the Canadian Medical Alliance for the Preservation of the Lower Extremity (Canadian MAPLE) does is advocacy--promoting access to good quality foot care for Canadians. Part of this is that we believe Canada should join the rest of the world and make certain podiatric medicine and surgery is an insured service by provincial health plans for the treatment of diabetic and other high-risk, lower-extremity wounds.
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Each foot has 26 bones. They combine to contain nearly one quarter of all the bones (206) of the body.
Each foot is made up of a complex and intricate network of over 100 tendons, ligaments, and muscles.
Every step places 1.5 times your body weight of pressure on your foot. (So a 150-pound person places 225 pounds of pressure on the foot with every step).
The average person walks 5,000 to 7,000 steps a day. The American Podiatric Medical Association (APMA) estimates that the average person will walk nearly 100,000 miles in a lifetime, between three to four times the earth’s circumferences.
--American Podiatric Medical Association
This page written by Dr. S A Schumacher
Surrey, British Columbia Canada
"The human foot is a masterpiece of engineering and a work of art"
--Leonardo da Vinci
Podiatry (/poʊˈdaɪ.ətri/) or podiatric medicine (/poʊdiˈætrɪk, -ˈdaɪ.ətrɪk/) is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of disorders of the foot, ankle and lower extremity.
"I marvel that society would pay a surgeon a large sum of money to remove a persons leg, but nothing to save it."
--George Bernard Shaw