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I have an acute ankle sprain in my clinic4 days old. Seeking advice from those who have seen these through to the end with good results, please.

Mostly I think these go straight to G.P or physiotherapists, mine came through a Chiropractor referral who put the patient's strained back in after injury.

CASE HISTORY:Middle aged female has a pedicure where exuberant amounts of oil is left on feet, and she places sandals with forefoot strap and reasonably high heels on. After enquiring that oil is removed, she is ignored, but self help tissues are supplied. Patient walks a few meters-50 or so and falls on R/side twisting foot about forefoot due to strap halting release of foot from the shoe whilst she is slipping. Lat ankle sprain takes place.

Signs and symptoms: constant pain level 8/10 (Pain scale used; where 0=no pain, 10=extreme pain). med and lat ankle pain, forefoot to partial toes(trapped by shoe strap) some mild swelling foot dorsum, and 1/3 lower leg frontal pain. Some gastrocs and soleus pain.

Saw her Sat, discussed amy issue-patient wants shopping centre to pay for my costs. I said please see GP-they have more weight as far as documentation of her injury and they will refer you, and inform of any legalities. Spooky- so I forgot to order immediate X-rays durinig initial.

I referred to physio as she'll need soft tissue attention with ultrasound and rehabilitation exercises, proprioception etc, and scar tissue prevention.

She clearly has mod/severe pes planus and I said I'll assess biomechanically shortly-1st see physio 3 times next week and I'd like a report. It's a partime practice I'm not there daily. i said gentle motion of ankle advised with heat to prevent scar tissue mean time.

Lastly, patient self treatment consisted of heat (guana/emu? oil and wheat pack) and elevation most of the days prioir to seeing me.

All replies welcome especially before Sat this week prior to her review.

Many thanks,

Pod777

Did you clinically/radiographically rule out Lisfranc injury???

Radiographs are necessary initially to guide treatment.

Initial treatment if no fracture or dislocation: Elastic wrap during waking hours to reduce edema. Brace-boot walker during ambulation to reduce pain with walking and immobilize area of injury. Ice 20 min three times a day with possible elevation until edema improves. Range of motions out of brace 30-60 minutes/day. Ideally send out for physical therapy referral with goals to reduce edema, reduce pain with range of motion, increase strength and increase weightbearing capacity three times a week for 2-4 weeks.

Later on once edema is reduced and patient can walk more comfortably out of the brace-boot walker: Dispense velcro strap or lace-up ankle brace for weightbearing activities. Encourage stable, low heel shoes. Continue some icing if edema persists. Continue home range of motion and strengthening program. Avoid uneven surfaces for ambulation initially.

As far as the shopping center paying for her treatment, this would be a far stretch even here in California where the lawsuit is a way of life.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

As a physiotherapist who is almost over the line in podiatry, I will throw in my 5 cents worth.

An acute ankle sprain should be the domain of the podiatrist, but sadly, it is not.

Would I go to the typical podiatrist for my acute ankle sprain? No. Does this mean that I would have faith in the typical physiotherapist in relation to my ankle sprain? No.


As always, the assessment must be thorough, without exacerbating the acute condition considerably.

I disagree with Kevin if he championed radiographs as necessary for most acute ankle sprains in the initial phases. Decent clinical assessment should sound out the warning bells.

Most physiotherapists in Australia over-indulge in the proprioception - evertor strength and electrotherapy triumvirate. Ultrasound? For goodness sake, it would have been easy to prove its worth by now beyond doubt. Ultrasound = Run out of ideas. Evertor strength? Many a physiotherapist would be wise to open up to the concept of STJ axis (although I don't believe for one second that most lateral ligament sprains are secondary to a lateral STJ axis). And proprioception? Nice easy concept, but is more of an nth order issue than most of us realise. Bit like worrying about the paint-job on the 1983 Volvo that has blown a gasket.


As for podiatrists, it is invariably difficult to put biomechanical theory in the draw for 5 minutes, even at the dinner table. Is 'pronation' really super relevant when an acute ankle sprain hobbles in? Not at that point in time I would say. There may come a time when the typical podiatrist 'owns' the ankle sprain. Before this time, radical change would need to occur at undergraduate and/or continuing education levels.



Ron

Ron:

The plaintiff's attorneys will love it if you champion not taking radiographs of any ankle sprain since that would mean you would, on occasion, be moblilizing fractures when they should be immobilized. As for me, and for 95% of the podiatrists and orthopedic surgeons here in the US, radiographs are a necessary part of ruling out fracture and/or disclocation in anything other than a mild sprain of the foot and/or ankle due to the liability issue.


Two years later in the courtroom........

"But your honor, I didn't feel that radiographs were necessary because she only had pain and swelling in her ankle."

Plaintiff's Attorney: "What would have been the problem with performing the three simple x-rays of the ankle for your patient who eventually was diagnosed with an osteochondral fracture of their talus which eventually led to her developing degenerative arthritis of her ankle that has now prevented her from continuing her employment and supporting her five children. "

"I suppose none, but taking x-rays at the time would have been more expensive."

Plaintiff's Attorney: "More expensive than the two surgeries she has already had and the one or two more she will now need due to your negligence in not performing three simple x-rays that would have changed your course of treatment for this poor lady??"

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I think may be more reflective of the jurisdiction. Ron is in Australia; Kevin is in the USA - the standards are different.

The ethical standard for a x-ray here (and exposure to ionizing radiation) is that the outcome of the x-ray has to have a potential to alter the treatment. I get the impression in the USA, that the standard is the practice of PYBM (protect your butt medicine).

In reality, the 'gold standard' should be guided by the Ottawa ankle rules for if an x-ray is needed or not. While there are some problematic issues with these rules, they are where all the research and evidence has been focused (ie we know their specificity and sensitivity, so can make clinical judgements based on that data).

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Craig: Who decided that the Ottawa ankle rules are the "gold standard" for when ankle/foot x-rays should be performed or not??

I think that if I had an ankle injury I would rather see a clinician that did not follow the "Ottawa ankle rules" since the clinician following the "Ottawa ankle rules" would miss the following diagnoses that may occur due to ankle sprains:

1. LisFranc's fracture-dislocation
2. Osteochondral fractures of talar dome
3. Fracture of posterior process of talus
4. Proximal fibular fractures

As far as radiation exposure???....no more than taking a plane flight. What is the big deal about taking a set of ankle/foot x-rays???...who is harmed by this procedure, certainly not the patient!! It seems to me that the only people harmed are the government authorities who want to "keep a lid on costs", with the risk of harm from missing a fracture or dislocation being much greater than the miniscule radiation exposure to the patient's distal lower extremities.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

I don't think anyone decided - its just these are the only "rules" or "guidelines" developed. They have been widely adopted by emergency depts around the world. A lot of research has been done on the Ottawa Rules and none on any other "guidelines". I was careful with my words and said: "the 'gold standard' should be guided by the Ottawa ankle rules".

NB the amount of research done on ottawa ankle rules.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

I agree with Kevin. The Ottawa ankle rules do NOT hold up in court here in the US. I suspect they were derived to save money when treating the huddled masses, rather than to improve medical care.

When an elite professional athlete sprains an ankle, do we first take a poke at the malleolei or cart them off for plain films (and perhaps an MRI)???

I don't worry about the radiation, but I am afraid of my microwave oven....

Nick

Craig and Colleagues:

Obviously the Ottawa ankle rules seem like a improvement for emergency room doctors who have a limited knowledge of foot and lower extremity anatomy. But a foot and ankle specialist should not need to be limited by a limited set of "rules" but may rather want to use a much more complete approach to clinically assessing ankle sprains that would include a little bit more than pressing on the malleoli, navicular and styloid process.

I am certainly not advocating performing x-rays on all patients with ankle sprains. I don't recommend or perform radiographs on minor sprains. However, missing a large osteochondral injury of the talus or a LisFrank's fracture dislocation, which I have seen commonly missed by emergency room physicians (with degenerative arthritis of the ankle/foot as a result), would be unnacceptable for most patients if these patients knew the serious long-term sequellae of the clinician missing these diagnoses by not performing x-rays initially.

Certainly scout ankle and foot radiographs for moderate to severe ankle sprains makes good medical sense, are not very expensive, have minimum health risk and give the patient the calming reassurance that they don't have a fracture or disclocation of their ankle or foot.

Great discussion!

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Here is an article on frequent foot fractures that are misdiagnosed as "ankle sprains". http://www.aafp.org/afp/20020901/785.html I like the idea of palpating in a "malleolar zone" and "midfoot zone" much better.

Also, here is a very nice article on how to examine for possibly ankle fractures with a history of an "ankle sprain". http://www.emedicine.com/sports/topic4.htm This is much more in line with the way that I think about these injuries and how I decide when and when to not x-ray the patient. I don't think the Ottawa ankle rules will detect proximal fibular fractures that can occur with ankle sprains, do they??

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Who mobilizes acute injuries? I would call that more brawn and less brain.

Could not care less if it was 100%. The herd might be walking in one direction but that doesn't mean the cliff is further away.

Why not extrapolate Kevin? Why not consider an MRI, or even an arthroscopy for every 'non-mild' ankle sprain? We would not want to miss a scintilla of pathology would we.

Ron:

Unfortunately, in this country, the plaintiff's attorney would probably be asking you why an MRI scan was not done sooner, if you were deposed or asked in court regarding this matter. Hopefully Australia is a little more "sane" in this regard.

By the way, isn't it always in the patient's best interest to not miss pathology?

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Wow,

Been busy, getting more and more interesting patients lately. Back to comment on this one, though.

1. Much appreciate the physio standpoint, and sadly agree that Podiatry should by now take on the Rights to Ankle Sprains! The physio who responded here sounds very well adjusted and balanced in his comments.

2. Ethically speaking, I understand the fear USA Pods must live in from $$$spinning law industry that I hear hang about hospitals insighting patients to sue. The Lawyers here, may well be more sick eternally than the physically ill patient!

3. X-Rays? yes, a dilema indeed. Pain severity and mobility eg 'just try to stand on sore foot' next to table for quick ready support.(after I see good foot perform 1st).
Marie Currie died from her discovery, please don't forget this simple history of X-Rays- hence any guideliness in the usage of this technology is essential.

If conservative treatment doesn't work, we always get back to that X-Ray to check if 1000 possible disorders of the bones took place initially. I tell my patients my advice and why, so they can decide on x-rays if they like. None so far asked me to get x-rays after hearing my reasons for not ordering, interesting enough.

4. Finally, since patient seeks compensation, to me she has immediatelly ordered those x-rays herself-so I did. Will see them soon. Foot is alot better with physio, and lisfranc is unlikelly as that area feels much better. I'd say her pain threshold is not so high, and she may have exaggerated pain level??

5. I'm now investigating ultrasounds and aim to purchase one. I suggest other PODiatrists consider the same, so we can say we ARE the LOWER LIMB SPECIALISTS. An ankle is too close to foot/ sprains too common to pretend we can't treat them all the way, in my opinion.

Much appreciate the GREAT input from you all. Things to learn

Modern x-ray units have about as much in common with the early experiments in x-ray that were performed by the pioneers of radiography as the today's modern computers have with the computers of the 1960s. No comparison!!

A roundtrip transcontinental airflight will give you more radiation exposure than a chest x-ray.
http://irb.ucsd.edu/RadiationEquivalents.pdf

Of course, we should not perform x-rays when we don't need to. However, it certainly makes common sense to perform radiographs when osseous abnormalities may be suspected. I rarely have a patient refuse x-rays when I tell them that I think it is a good idea for them. They appreciate my medical concern and attention to their problem. They are always relieved when the x-rays are negative and are often also relieved when the x-rays show something that other physicians, who have not performed x-rays, have previously missed. And, by the way, I have all my x-rays performed at a radiology facility down the street from my office so I don't make any money from ordering x-rays on my patients for foot surgery, foot and lower extremity trauma, etc.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Right,Modern machines are improved, however every machine breaks down at times, Radiographers wear protection, have radiation exposure constantly monitored on their lab coats, hide themselves from the room with the patient in it ALWAYS, warnings are up for pregnant mothers to STAY AWAY. Too many coincidences??

As far as radiation type it has a VERY HIGH RISK POTENTIAL. Not to irritate you, but I think diffuse radiation and direct 'impact' to your foot and whole body(as a result of proximity) and I'd say increased cancer etc can easily result from TOO MUCH Diagnostic imaging in a life time. So we keep it to a minimum, considering every one else will order some as well-GP,Chiropractors LOVE its etc. It always has to be a judjement call if we are in the business of Healthcare= 'Do no harm' OATH.

777:

The reason radiology technicians wear protection and I wear protection when when performing x-rays during a surgical procedure is because of the volume of x-rays being performed. This is common sense. However, when an individual needs an x-ray, they don't need to worry about radiation illness unless they are going to be having x-rays every week for a year. And in our discussions above, we are talking about a single set of diagnostic films possibly for the first time in the patient's life, not repeated x-rays.

Tell me 777, how would you diagnose a 12 year old girl with a Freiberg's infraction of her 2nd metatarsal head if you are so afraid of exposing patients occasionally to x-rays? I just saw this same patient with Freiber'g infraction today that had been referred to me for orthotics. The podiatrist appropriately ordered x-rays the first visit since she had swelling and had some pain in the 2nd MPJ without a history of trauma, even though she runs and plays softball.

If you were the parent of this young girl, would you rather she went to a doctor that, on the first visit, ordered x-rays to rule out osseous pathology, established a definitive diagnosis on the first visit, and went straight to work to relieve her pain with a radiologically confirmed diagnosis? Or would you rather she went to a doctor that gave her padding, cushioning, icing, NSAIDS, reduced activity for 6 months only to find out 6 months later when the pain wasn't going away, when the doctor "got up the courage" to recommend x-rays on the patient, that she had avascular necrosis of her metatarsal head??? If I was the parent, I would think the second doctor was basically an idiot and would never recommend that any of my friends or relatives go to him/her again for treatment.

777, sounds like your fear of diagnostic radiology is based on poor information and a lack of knowledge of basic radiological facts. Please provide me with just one reference (more would be better but I think you will have your work cut out for you finding one reference) that shows that any number of foot and/or ankle x-rays have ever caused any radiation harm to any patient during their lifetimes since you seem to live in dreaded fear of diagnostic radiology. By the way, I told the orthopedic surgeon I have worked with for the past 20 years about your comments on worrying about radiation exposure on foot/ankle x-rays and I haven't seen him laugh that hard in quite a while.....he wants to know where you are from.

By the way, 777, have you ever taken a course on radiology, or
taken or ordered an x-ray on a patient???

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin,

Sorry to down right infuriate you, but this forum is subject to world wide Podiatry input, some of which either spurs us on to explore different point of view, or we agree to disagree.

Yes, my degree course incorporated X-Rays reading, ordering and a visit to the radiography dept at our UNI. Our teaching came via a brilliant American Podiatric surgeon, who I quote from his notes to us (unfortunatelly have no time to chase up x-ray danger articles presently. I'll let those very interested do it for me. Analysing opossing data I'm short on time also, but should be done. Cop out? Not if I stated all in a form of professional opinion, only, at this point in time.)

His words, our american Podiatric surgeon, were"The x-ray is a specific means of proving what the clinician suspects through history and physical examination and is not a medical ""fishing trip""

Since timeline for fracture to show up can be as long as 6 weeks, if patient is not improving following extensive history and physical exame tc. We've missed little in that time, accept ruled out other conditions perhaps.

Your 12 year old female patient may not have a history of trauma, but has significant sporting activity to facilitate one thinking about an injury ocurred. At her age she may have so much enthusiasm, she ignores a minute amt of time it takes to cause it. Freibergs being a marching fracture can happen pretty easily marching , let alone runn ing, etc. I would consider X-rays based on 'deductive/inductive' History. taking.

I simply try to avoid unnecessary radiation- not ban it altogether. I don't think I'm game to reply to your next response, Kevin, but , perhaps in humor, I hope she's not pregnant-not impossible in old USA or otherwise, hey! :)

Signed off,


Cheeky Pod777

Not infuriated 777, I am just not understanding your seeming reluctance to perform a diagnostic test that is as routine here with American podiatrists and orthopedic surgeons as is ordering routine blood and/or urine tests prior to foot surgery. Possibly this is a difference in training of podiatrists between countries.

I understand the inherent health risks of x-rays. However, with the caution taken at x-ray facilities to minimize radiation exposure, along with the shielding of x-ray units from scatter radiation, along with the minimal dosing required to the foot and ankle, I don't think you will find many podiatrists or orthopedic surgeons here in the States that even considers harm occurring to the patient with simple extremity x-rays. Maybe in your country, the x-rays are more harmful than they are here in the US?? I would still appreciate if you could dig up any medical literature that supports your very cautious view that performing extremity diagnostic x-rays will harm patients.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin et al

It is not so much the training between countries as the legal definition of practice which lies at the heart of this matter. As previously posted on another thread treating ankles may be outwith the legal scope of practice of podiatry in some areas. Hence an absence of clear clinical pathways.

As we know there is a difference in what we do for a living and it would be naive for anyone to assume the forum is a homogenous group. Perhaps given time this may occur. To paraphrase Oscar Wilde, US podiatry and the rest of the World podiatry is divided by a common language.

I also agree there is mounting evidence to question the once overcautiousness about the potential hazards from extremity diagnostic medical imaging.

Cheers
Cameron

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

Kevin,

I don't think I've ever heard you so exasperated!

Yes, I'm afraid there is a popular misconception in Australian podiatry an extremity x-ray is a source of fear and danger, and should be considered very carefully...I think this nonsense is propogated by the university system IMHO.

The relative risk of health concerns from an extremity x-ray should be given a real reality check.

I'm afraid it probably is true, from your suggestion, that many Australian podiatrists are insultated and undereducated about anything to do with the broader world of surgery and medicine to put a foot x-ray into perspective. This likely stems from our lack of hospital interships, residencies, prescribing priveleges and limited surgical activities.

In reality, as you probably already know, that is what divides most Australasian podiatrists from the US podiatry profession. :(

LL

LL

There is a misconception all North American pods practice surgery but in truth this is a myth and less than 2% of Australasian (and UK) pods are trained in surgical podiatry, fewer still make a living from it, albeit they hold the qualifications to do so. The main problem is there are just not enough
feet with access to elective surgical podiatry to make a larger surgical community practicable.

Cameron

__________________

Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

Cameron

Well acquainted with the situation regarding practicing of podiatric surgery worldwide. However, I think the key issue here is the *exposure* to surgery and medicine (read; pharmacotherapy) that comes with US training and legislation.

Kevin may be able to confirm this (at least from CCPM perspective), but it is my understanding that even DPMs seeking priveleges in podiatric orthopaedics and primary podiatric medicine (not necessarily in podiatric surgery) will be exposed or trained in a far greater range of surgical procedures and pharmacotherapy than your average UK/Australasian podiatrist.

We just don't seem to train our new blood to take much of a step beyond primary skin and nail care and non-surgical biomechanical therapies...

POD777

From a treatment point of view it is not, in my experience, usual for a person with a sprained ankle to seek help from a podiatrist. This is unfortunate since in my case I am very succesful in this area due to a lot of experience of ankle sprains that are quite common in judo.

I usually treat RICE, anti inversion taping, heel lifts, passive and active mobilisation, deep massage, Icing daily initially and then contrast bath, strengthening and stretching exercises.

Usually I can have a pain free weight bearing ankle in 1 week to 2 weeks at most depending on age and severity.

I have found the worst thing to do is molly coddle the injury. Get it moving and weight bearing early as possible.

If the sprain is not too severe I.C.E, massage and mobilising and taping as early as possible, ie from time of sprain, will resolve the injury very quickly eg one or 2 days.

In your case it has been a while since injury and in these cases I have found that anti inversion taping and heel lifts + a lateral heel or f/foot wedge is very effective at off loading the strained tissues.

It is quite important though to establish the exact route of the injury and tissues involved so that the appropriate posting and strapping can be applied to off load the strain.

Then work on mobilisation, strenghtening and stretching.

I often refer to physio for ultrasound as this speeds up tissue healing, reduction of imflamation and reduces possibilty of scar tissue build up.

Patients that do come to see me have usually been to A & E and had x - rays (no fracture) and been given a prescription for NSAIDS and rest for two weeks plus sometimes a bit of tubigrip. If they follow this advice the sprain will often last for many months.

This is my experience, don't know if it helps?

All the best Dave Smith.

From 1983-1984, I did a one year "surgery residency" then from 1984-1985 did the CCPM Biomechanics Fellowship. At the time, about 75% of my classmates (106 in number) at CCPM got into a surgical residency program, either one or two years. Now, podiatry school graduates all are required to do at least a 2 year postgraduate residency program that is heavily slanted toward surgery training.

To practice in California currently, the podiatrist must have attended podiatry school for four years and got their DPM degree (after receiving their BS or BA from an undergraduate college), then will do at least 2 additional years of residency training. Therefore, the youngest that a "rookie" podiatrist can practice here in California is about 28 years old, which is the age I started practicing podiatry in private practice in 1985. The age of the podiatrist upon entering private practice and the amount of surgery training seem to be the biggest differences beween podiatry here in the States and in other countries.

Podiatrists here in the States, can do any surgery on the rearfoot and forefoot, write prescriptions for medicines directly to patients, give injections from the ankle distally (but may also give peroneal nerve blocks at the knee), may admit patients to hospitals, do history and physicals on admitting (new privilege), and order and perform radiographs and fluoroscopy. However, since our education is not funded by the government, most podiatry students finish their residencies with student loans well over $100,000.00 (US dollars). This fact creates additional financial hardship, especially for those trying to start a private practice also. This combined with the insurance companies paying less over the years for surgery and other services over the last 10+ years, has made many young (and older) podiatrists very unhappy about their financial prospects here in the US.

As we all know, the grass is always greener on the other side of the ocean so there are always positives and minuses to any podiatry situation in each country. Luckily, I have become acquainted with some very fine podiatrists in many countries that share my interest in biomechanics and sport medicine that has kept up my interest in these subjects over the years. In general, however, podiatrists in the US are not too interested in a subject if it doesn't somehow involve cutting or putting the latest fixation device onto bones of the foot and ankle. This is really too bad since I expect that when I retire from podiatry, within the next few decades, there will be very few podiatrists here in the US who will be capable of lecturing or teaching biomechanics at a high level. We are not currently training podiatrists in biomechanics in their post-graduate years since the Biomechanics Fellowship program at the California College is no longer in existence. This is the program that Ron Valmassy, Rich Blake, Eric Fuller, Larry Huppin and myself all completed. I am sorry to see this happen since unless something changes within the next few decades here with our podiatric education system focusing more energy on producing leaders in biomechanics, biomechanics will become an afterthought of the profession. I fully expect that in 20 years that the leaders in biomechanics within the podiatry profession will all be coming from Australia, England and the other countries that have research-based programs that emphasize the importance of biomechanics and have not become "podiatric orthopedic surgeons" due to their disregard for the vital importance of foot and lower extremity biomechanics.

Sorry to go on like this, but with my 50th birthday only a week away, I am feeling the tug of time a little harder recently and, as a result, have been wondering if all of the work I have put into trying to educate podiatrists on these important subjects over the past 20+ years has really made any difference at all.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Cameron

Kevin's comments might suggest that the 'evolution' in podiatry in the US has led to a situation where all podiatrists are now trained in (correct me if I am wrong) at least forefoot and 'lump and bump' rearfoot surgery. Whether they go on to practice any significant amounts of surgery is then up to the individual, naturally.

I wonder how many Australasian podiatrists have even dissected a cadaver, let alone observed or assisted in theatre? Don't get me wrong, I'm not saying surgery is some sort of panacea that all podiatrists should offer (as you say there is only a certain number of feet to go around) - but having some exposure and training in this area at least broaden's the mind into general medicine, anatomy and pathology in a more tangible manner than didactic subjects at an under/post -graduate level can ever hope to achieve.

I guess those differences around the world help make this forum so interesting - but also makes you question the convention educational approaches on offer.

To quote you kind self - 'what say you?'

LL

LL et al

>We just don't seem to train our new blood to take much of a step beyond primary skin and nail care and non-surgical biomechanical therapies...

I think you make a very salient point. In Commonwealth countries (for want of a collective description), the glass ceiling is defined by a graduating podiatrist. At this time a new graduate will be competent in skills considered necessary for a base grade practitioner entering their first position. "primary skin and nail care and non-surgical biomechanical therapies...," would seem just about right. Although I doubt whether it takes four years to achieve.

Structurally the US educational system is quite different for both historic and politico-economic reasons. Podiatry in the States is technically a second degree which is not the case elsewhere. The academic equivalence of a DPM is classified in Australia (anyway) as an honours level, undergraduate degree.
By itself this is anomalous but a clear indication the academic content of US podiatry programs is not higher degree level, as determined by Independent)academe. This is not intended as a criticism, only an observation.

At the present time the fundamental difference between the two courses is the difference between training and education. In the undergraduate programs across the Commonwealth education is the focus as defined by a Bachelor of Science (uniform), whereas US programs prefer a comprehensive vocational training (to a very high level and grounded within the US medical system), graduates are awarded a professional doctorate. Centres of Podiatric Education in the US are highly competitive, some of which are private and outwith the public university system. As you know podiatry in the US is not uniform and different States legislate in accordance with past history and practice. This means in some states you require formal training with certification and others, not so.

To attract fee paying students US Centres of Podiatric Education cater for the highest common denominator and provide attractive syllabuses to meet the ideal (i.e. an accumulated set of skills which would allow a graduate to practice in any State). To that extent the qualification is artificial because there is a lack of uniformity in America and by comparison the Commonwealth model is set by clearly defined parameters. (good or bad?)

The competence component of vocational degrees defines what graduates will be able to do on successful completion and hits a glass ceiling at the base level for registration (legal requirement governed by Parliamentary/State Acts). This in turn determines the course content, syllabus and delivery. If the professional base level was raised then this would automatically knock onto the centres of podiatric education. Presently we look from one pasture to the other and think " the US model looks much better," but to adopt it in the absence of a supporting mechanism guaranteed to sustain a uniform change would be folly.

I do wish I had a dollar for every time I have heard teaching colleagues wax eloquent about how they will use the existing system (private and public) to implement a comprehensive training for undergraduate podiatrists promoting specialist skill acquisitions, far beyond the base grade of a new graduate. Yet it is obvious to all there is neither insufficient opportunity nor available expertise, let alone the money, to even pilot such an event. Sadly these practicalities do not prevent the same individuals from developing a mindset which is both unrealistic and very counterproductive to real development.

Not all that surprisingly in the US there are now signs pod curriculum is more influenced by an academic perspective ( pod envy) which is tempered with a vocational training. The point being the US system is changing more towards a Commonwealth model, including shorter courses.


How do you change podiatry education in Australasia?

That real development will not take place within undergraduate education, which by all accounts is efficient. It truly belongs within post basic education and will be driven by recognition of specialisation by the Registration Boards (Australasia). This has already happened very successfully in podiatric surgery so there is no reason the same cannot be repeated for other specialist interest areas. To succeed however the profession must be in unison and articulate same at the highest level.

What say you?

Cameron

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Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

LL

I wonder how many Australasian podiatrists have even dissected a cadaver...

No arguement from me there. Morbid, classic and functional anatomy are all important components of a podiatry program. Although politcal correctness and costs necessitate more pre-sected specimen work is done now with actual dissection more the exception than the rule. Duty of care also has impacted on local anaesthesia training which is routinely done on anatomical models.

I only know of one podiatry education centre in the world that did not include an orthopaedic input involving theatre visits. This was due to a "black-balling" by local orthopods (including their State Association) because they did not approve of surgical podiatry. It was all before my time and there was a lot of history which led up to the boycot. With no orthopaedic leader this created a lot of work for teaching staff to ensure a seamless program was presented to fulfill the syllabus requirements. Otherwise in the places I have worked in and visited have all had excellent orthopaedic input.

Cheers
Cameron

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Cameron Kippen, Podologist and Shoe Historian




Cameron Kippen

Great post, which shows your understanding of the ankle is way above par. Why is it unfortunate that the masses don't rush to a podiatrist with an ankle complaint? Is the typical podiatrist going to approach it like you? I doubt it. Moreover, it is 'unfortunate' that the rest of us don't approach ankle injuries like you do.

My only difference-of-opinion lies within the 'molly coddle' statement. The greatest mistake that the musculo-skeletal clinician makes is that we tend to push it too early. We tend to push down the accelerator pedal before the tyres are securely on.

The most important philosophy I stand by is my traffic-light theory for acute injury. Red light timeframe = protection and molly coddling. Green light timeframe = stretch/strength etc... Orange = in between.



Ron