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A Travis County judge had defined the foot and connected it to the anklebone.
This week's ruling caps a five-year fight between Texas podiatrists, who are doctors of podiatric medicine, and orthopedic surgeons, who are medical doctors, over where the foot ends and the ankle begins.
Medical doctors objected when the Texas State Board of Podiatric Medical Examiners included the ankle in their definition of the foot, meaning that podiatrists can treat ankles.
But Travis County District Judge Darlene Byrne ruled in favor of the podiatrists when she found that the foot is indeed connected to the anklebone, not to mention all the bones of the toes. Simply put, the ankle is part of the foot. "It wasn't before," said Hemant Makan, an investigator with the Texas State Board of Podiatric Medical Examiners.
The Texas Medical Association plans to appeal. The ruling could set a precedent, said Susan Henricks, the attorney representing the Texas Medical Association and the Texas Orthopedic Association.
"If they can do that, then why can't psychologists pass a rule that says they can do prescriptions or optometrists do cataract surgery?"she said.
Austin podiatrist Jason Hubbard never thought the vitality of his practice would depend on the legal definition of "foot."
But a war is waging between Texas' 1,900 orthopedists and 850 podiatrists about where the foot ends and the leg begins, and the ankle is the battleground.
Travis County District Judge Darlene Byrne ruled Aug. 23 that the Austin-based Texas State Board of Podiatric Medical Examiners didn't overstep its authority by defining the "human foot" as, in part, "the tibia and fibula in their articulation with the talus."
Or, in layman's terms, the ankle.
An appeal is planned by the plaintiffs, the Texas Orthopaedic Association and the Texas Medical Association. Both associations are based in Austin.
For now, the ruling means podiatrists can continue to perform ankle surgery.
The judge's decision punctuates a lengthy legal battle between Texas orthopedic surgeons and podiatrists about podiatrists' increasing surgical work on ankles -- biological real estate traditionally reserved for orthopedists.
In 1923, the Texas Legislature passed a law defining the practice of podiatry as the treatment of "the human foot." That definition was accurate at the time, Hubbard says, because "most podiatrists were clipping people's toenails."
Eighty years later, many podiatrists are trained in both foot and ankle surgery and go through extensive surgical residency programs, Hubbard says.
That prompted the Board of Podiatric Medical Examiners, the state agency charged with regulating podiatry, to issue a rule in 2001 expanding the Legislature's 1923 "foot" definition to include ankles.
The following year, the Texas Orthopaedic Association and the Texas Medical Association sued the board, asking the court to invalidate the rule. Bryne's ruling upholds the board's expanded definition.
Jim Zukowski, executive director of the podiatric board, says his agency sets "the boundary lines of podiatric medicine," and its foot definition fits "the current practice of podiatric medicine in this state."
The board defined the meaning of "foot" to provide clarification after hospitals had indicated they were confused about ankle-operating privileges for podiatrists, Zukowski says.
Podiatrist Hubbard, who wasn't involved in the suit, says he's qualified to operate on ankles. Hubbard says one-third of his practice consists of reconstructive foot and ankle surgery.
He says he spent three years in surgical residency, training with podiatrists and orthopedic surgeons alike, and is an associate member of the American College of Foot and Ankle Surgery. Most states now allow podiatrists to perform ankle surgery.
"If we, in Texas, limit that scope of practice," he says, "we're going to stop getting the best of the best coming to Texas, and we're going to lower the standard of medical care in the community."
Hubbard says he "would not have started [his] practice in Texas" if he had known he would be prevented from doing ankle surgery here.
"Our bread and butter is doing basic foot surgery, but the people who are trained to do the more advanced surgery should be able to do the advanced surgery," he says.
But Austin orthopedic surgeon Robert Schoen, a member of The Orthopaedic Group, says his general medical training is what sets him apart from podiatrists. Although Schoen says podiatrists don't cut into his business, he says orthopedic specialists are interested in the foot and ankle because of their importance to the body's skeletal system.
"You need to understand the basics of disease and healing. ... We've taken care of everything -- the entire muscular-skeletal system," he says of orthopedic specialists. "I'm not sure they [podiatrists] understand that as well as we do."
The orthopedists' attorney takes the argument further.
"Most podiatrists are not qualified to do ankle surgery," says Susan Henricks, a partner at Austin law firm Hull Henricks & MacRae LLP, who represented the state orthopaedic and medical associations in their suit against the podiatry board.
"If they've been doing ankle surgeries, they can do it. But it's illegal," Henricks says.
Donna Parker, executive director of the Texas Orthopaedic Association, says: "It's not a matter of money, turf battle or anything else. It's a matter of patient safety."
Podiatrist Hubbard says these arguments are "absolutely ridiculous."
For podiatrists to operate on ankles at a hospital, they must go through numerous checks and balances, such as a hospital credentialing system that required Hubbard to document all 3,000 surgical cases he worked on during his residency.
"You could change the definition to [include] foot, ankle, knee, hip and spine, and no hospital is going to allow [surgery] to occur unless you have the documented proof that you had the overabundance of training to do it," he says.