Podiatrists are therapists who are specially trained in foot and leg therapy and whose area of responsibility extends from preventive, therapeutic and rehabilitative treatment to the fields of dermatology, diabetology, microbiology, hygiene and orthopaedics. The basis for practicing the profession is a basic understanding of medicine, additional knowledge in the specialist areas mentioned and also in anatomy, angiology, surgery, pathology, physiology, first aid and knowledge of materials and goods. A general practice structure and the basic organization of treatment and practice procedures with quality management are also the basis for practicing this medical profession.
You can take the CME test in our learning platform after recommended review of the materials. Please click on the following button:
Podiatrists, now also known as podos for short, are therapists specially trained in foot and leg treatment, whose area of responsibility extends from preventive, therapeutic and rehabilitative treatment to the fields of dermatology, diabetology, microbiology, hygiene and orthopaedics (Fig. 1). The basis for practicing the profession is a basic understanding of medicine, additional knowledge in the above-mentioned specialist areas and also in anatomy, angiology, surgery, pathology, physiology, pharmacology, professional, legal and political studies, first aid, material and product knowledge, natural sciences, pedagogy, psychology, language and literature, sociology, dressing techniques, physical and podological therapy measures and aids [1]. A general practice structure and the basic organization of treatment and practice procedures with quality management are also the basis for the practice of this medical profession.
Podiatric expertise and skills in the treatment of hyperkeratosis, excessive callus formation where new cell formation predominates over desquamation, such as callosities and clavi in various locations [2], also on foot stumps after partial foot amputations, wound edge keratoses or in nails, especially for the prevention or treatment of unguis incarnatus and the promotion of physiological nail growth [2], advice on home foot care for ulcerated and non-ulcerated feet, shoe and plantar orthosis care and movement exercises to improve mobility and as muscle training, and the use of electrotherapy all help to significantly improve the quality of life of those affected. This progress in the development of well-being, which is also perceived by patients themselves, is reflected, among other things, in their conscientious adherence to podiatry treatment appointments and attendance at check-ups. Together with the skills of other professional groups involved in wounds, it is possible to maintain or restore the mobility of those affected, which promotes independence and noticeably improves their quality of life. The most appropriate and feasible individual treatment is determined in consultation with the patient, taking into account the influencing and supporting components such as dressing material or relief options from the wide range of podiatric therapy measures in consultation with the attending physicians, nursing staff and supporting family members, and is constantly reviewed and, if necessary, modified during the course of therapy.
Method
Due to the limited number of German-language study programs in the field of podiatry, the statements made by members of the profession are currently based primarily on literature references, specialist books, expert knowledge, foreign study results and their own experience. With an increasing selection of literature, at least in German-language professional journals published by professional associations, and constantly updated specialist literature with revised editions, it is clear that podiatry has long since left the dusty image of “foot care” behind and is moving further in the direction of independent medical therapy in the specialist field of foot, ankle and lower extremity with skills in diagnosis, diagnosis and therapy selection.
However, evidence-based therapeutic measures are difficult to prove, as there is a lack of research facilities, money and also patients who are willing to leave the practices “without” treatment in order to form a control group to the “treated”; whereby it is undoubtedly also problematic to simulate a podological “non-treatment”.
However, there are all the more case reports and testimonials from experts that prove that podiatry treatments also have a holistically positive influence on patients’ quality of life. For example, the PodoJournal of the Association of German Podiatrists (VDP) e.V. has published a case report every month since 2017 with a detailed medical history, dermatological, orthopaedic, angiological, neurological and podological findings, as far as possible within the podiatry framework, epicrisis with therapy goal, treatment plan, therapy carried out, patient advice also for self-treatment at home, discussion with conclusion and literature and source references, in order to also show the background and circumstances of successful and less successful therapies or treatment errors [3].
Since 2015, there have also been bachelor’s theses from the podiatry degree program at Steinbeis University Berlin and advanced master’s theses by podiatrists from degree programs such as pedagogy for teachers at vocational schools in the healthcare sector or healthcare management at other universities, which can be used for literature research.
Discussion
Being mobile and walking well means being able to go through life independently, mobile and self-determined and to shape it yourself, if the psyche allows it. Wounds, i.e. lesions that are caused by damage to the skin and represent a loss of barrier between the body and the environment [4,5], restrict mobility due to various factors and have an impact on people’s everyday lives, even if they occur on the feet.
Factors that impair patient mobility can include: pain, insecurity, fear of falling, lack of proprioception, diffuse anxiety, an environment that is not conducive to movement – including at home -, external factors such as many stairs or tripping hazards, a restrictive social environment, lack of exercise, increasing joint immobility, incorrect footwear. And severe physical impairments such as
- Systemic diseases, chronic pain
- Increasing age, dizziness, visual impairment
- Amputations, other orthopaedic restrictions, ankylosing spondylitis and co.
- Damage to the musculoskeletal system, spinal disorders
- Neurological diseases, spasticity, paralysis, multiple sclerosis
- Chronic inflammation, foot malpositions
- Wounds, especially on the feet.
Wounds on the foot and leg impair mobility due to a wide variety of factors such as pain on exertion, a thick bandage that does not fit in the shoe, waiting for wound experts or nursing services to come and change the bandage, unpleasant odors in the event of infection, fear of delayed wound healing if the wound is not kept at rest, bandage shoe impractical, only slow walking possible, risk of falling(!), and driving a car with wound care not possible [10].
The restricted mobility of people with foot wounds, including those with diabetes mellitus, is particularly prevalent in podiatry practices in Germany, as treating physicians can issue prescriptions for podiatric therapy every 4-8 weeks for patients with late neurological complications (diabetic foot, DF), including neuropathic and paraplegic foot (NF, QF), in order to avoid further complications such as minor and major amputations. The costs are then covered by the public health system, the health insurance companies, because the injury caused by self-treatment during nail cutting and callus removal and improperly performed foot care should be avoided as a late complication with limited proprioception, especially in the case of sensory disorders of an existing neuropathy or polyneuropathy. There is no limit to the number of treatment units per year in Germany, but the frequency of treatment must not be less than 4 weeks as a rule. In Switzerland, the annual prescription quantity covered by compulsory health insurance (OKP) is limited to 4-6 sessions, depending on the clinical picture of diabetes mellitus. The prescribed amount per prescription is three or a maximum of six complex or partial podiatric treatments [6]. Private health insurers cover the costs of podiatric therapies with different reimbursement rates for their policyholders.
Regular presentation in podiatry practices means that emergencies requiring medical treatment are recognized earlier. This helps to prevent serious complications, as a person with diabetes mellitus has a lower limb amputation every 20 seconds [7]. Having a podiatrist/podiatrist in the team caring for people with diabetes mellitus reduces the risk of infections and amputations [8].
In addition, doctors, physiotherapists, orthopaedic shoemakers, diabetes assistants and other professional groups involved are able to concentrate on their professional field when complaints that can be remedied by podiatry have been remedied. The podiatry skills involved in wound care include
- Individual utilization of podiatric treatment techniques: manual, mechanical, medicinal, physical, sharp debridement down to the basement membrane
- Management of complicated dermatological conditions such as defective keratinization in clavi, verrucae (with viral infection), scar keratinization, wound edge keratoses, pathological nail growth, nail dolences, etc. with the aid of pressure relief with foam rubber and felt or orthoses
- Professional toenail shortening and removal of excessive callosities, even if a wound dressing had to be applied, thus reducing the risk of injury to neighboring toes and the skin of the foot in general
- Support for wound management through physical therapy measures such as the use of cold plasma, for example
- Hygiene and infection protection measures, wound disinfection, including PPE (personal protective equipment) and sterile instruments packaged in sterile barrier systems
- Podiatric ethics and commitment to lifelong learning
- Knowledge of dressing techniques and wound dressings on the foot and leg
- Medical understanding as the basis for any treatment measures
- Special knowledge of podological biomechanics and corrective or soft bedding measures and shoe inspection
- form a further auxiliary instance for patient support and reduce the distance between check-ups without placing an additional burden on doctors’ practices
- Patient education and instruction
- Team competence, also interdisciplinary
- Documentation and therapy report.
During the shoe inspection, special attention is paid to the actual footwear worn by the patient, whereby possible incorrect loads are identified, which can then be changed together with the orthopaedic shoemaker and treating doctor. Podiatrists usually spend 30-45 minutes with patients and have the opportunity to talk about their habits, pain, problems and solutions to their foot problems; incorrect weight-bearing and chafing caused by household or gardening shoes or improper socks can be identified and remedied. A foot template made by podiatrists – standing barefoot on a sheet of paper, outline the foot and add 1 cm to the toes for adults – clearly shows the space required in the shoe and can be cut out and put in to test whether the shoe fits. If the template only fits with creases in the paper, the corresponding areas of size and width are too small and too narrow.
As part of a bachelor’s thesis in the podiatry specialization, a screening was carried out on randomly selected test subjects who were called into a podiatry practice as patients. Among other things, the position of the posterior calcaneus in a relaxed stance (RCSP-Relaxed Calcaneus Stance Position) was recorded. The screening of these patients who came to the podiatry practice showed that 66% of those examined had hyperpronation of the foot with eversion of the calcaneus in a relaxed foot position. This hyperpronation can be caused by a dysfunction of the posterior tibialis muscle, always affects the posterior tibialis muscle and is an indication of a predisposition to pes planus. The insole coverage was 50%. Statistically, 16% of people at risk of pes planus are without orthotic treatment. With 58% of the people examined suffering from the metabolic disease diabetes mellitus, there is a high risk that the 8% of this group who statistically walk without insoles will suffer serious, even life-threatening foot lesions as a result of incorrect loading. In the worst case, infection of a foot wound can lead to erysipelas with subsequent sepsis. For the health and quality of life of these people, detection and treatment is important and possible in podiatry practice [9].
Casuistry
Podiatric procedure and therapeutic measures for patients with foot wounds (Fig. 2-10):
Conclusion
Podiatric therapy can make an important contribution to maintaining the mobility of patients with foot wounds and complement the work of the doctor. The general and special podiatric treatment measures support the medical care of patients with foot wounds.
Even the co-care in the podiatry practices for mobile patients shortens the care intervals without placing an additional burden on the medical practices; in the event of worsening or relevant findings, the podiatry practice contacts the medical practice and transfers the patient for assessment. A further advantage is the podiatry treatment time of around 25-45 minutes during dermatological therapy, as this can be used to involve patients in the formulation of individual therapy goals and the joint determination of treatment measures, which promotes adherence to therapy.
Organization Podiatry Switzerland |
The Organization Podologie Schweiz (OPS) is the umbrella organization of the three Swiss professional and specialist associations Schweizerischer Podologen-Verband (SPV), Société Suisse des Podologues (SSP) and Unione Podologi della Svizzera Italiana (UPSI). In addition to maintaining relations between the three language regions, the association’s main concern is the recognition and implementation of podological services by the basic insurance (KVG) and other insurance providers. Further information can be found on the website www.ops.swiss |
The regular, close treatment intervals of 4-6 weeks for medically prescribed podiatry treatments provide an opportunity to discuss the current state of mobility, the ability to move with an active change of location and an examination of individual motility, mobility without locomotion, for example of individual joints. The professional groups involved in diabetic foot problems can, if they are networked on an interdisciplinary basis, inform patients even better about their health-preserving measures, hold patient colloquia, find joint ways to improve mobility despite wounds and thus maintain the quality of life and greater independence of those being treated.
This progress in the development of well-being and the trust felt by patients is reflected, among other things, in the conscientious adherence to podiatry treatment appointments. Together as a team with the patient, family members and interested and committed therapists, it is possible to improve the mobility situation for people with foot wounds!
Take-Home-Messages
- Podiatric therapy can make an important contribution to maintaining the mobility of patients
with foot wounds and complement the work of doctors. - Podiatric therapy encompasses a number of competencies, including advice on holistic salutogenesis (health maintenance) and, more specifically, changes to the structure of the skin and nails through the manual activity of the practitioner and changes to the stress zones when walking.
- These skills and abilities to solve problems in the areas mentioned, as well as the willingness to do so, result in
the support of medical therapy at every contact in the podiatry practice by treating and advising patients.
Literature:
- Training and Examination Ordinance for Podiatrists (PodAPrV) Annex 1 (to § 1 para. 1) Reference of the original text: BGBl. I 2002, 16-22, www.gesetze-im-internet.de/podaprv/anlage_1.html; 11.05.2024.
- Contract for podiatry services, Podiatry Associations-Spitzenverband Bund der Krankenkassen/GKV-Spitzenverband, Annex 1a and Annex 1b: Service description in the version dated 20.10.2023 to the contract in accordance with Section 125 (1) SGB V for podiatry in the version dated 30.11.2020; 18.05.2024.
- Kuberka-Wiese C: PodoJournal since 2017, Association of German Podiatrists (VDP) e.V., digital issues since 2022 April, https://podojournal.verband-deutscher-podologen.de/de/profiles/aacd9257c659/editions; 13.05.2024.
- Initiative Chronische Wunden ICW: Definition of a wound, www.icwunden.de/wundwissen/standards-definitionen/#W; 16.11.2023 ,
- Antwerpes F, Rohner T: Definition Wunde, DocCheck Flexikon, flexikon.doccheck.com/en/wound; 16.11.2023.
- Contract pursuant to § 125 para. 1 SGB V and amendment agreement to the contract pursuant to § 125 para. 1 SGB V on the provision of podiatry services and their remuneration, Podiatry Associations – National Association of Statutory Health Insurance Funds / National Association of Statutory Health Insurance Funds; 13.05.2024.
- Armstrong D: Interview November 14, 2019 Miami at FIP World Congress of Podiatry, facebook.com/FIPIFP/videos/272223577021889.
- American Podiatric Medicine Association, www.apma.org/diabeticwoundcare.
- Kuberka-Wiese C: The posterior tibialis muscle and its relevance for podiatric therapy, Bachelor Thesis 2015, Steinbeis University Berlin.
- Kuberka-Wiese C: Wound and still walking well? Better interdisciplinary management of the diabetic foot with podiatry! Poster and lecture, Nuremberg Wound Congress 2023.
InFo DIABETOLOGIE & ENDOKRINOLOGIE 2024; 1(3): 10–14