Confusion reigns for many Americans on the question of what does a foot doctor do and what do they treat. Podiatrists are physicians trained to treat the foot, ankle, and lower leg. This necessarily includes the care of various skin conditions, orthopedic issues, sometimes pain from malfunctioning nerves. This makes it an interesting and unique specialty, very different from most because we treat a region of the body rather than an organ system, the proverbial skin and bones.
For example, a neurologist treats nerve problems, but so does a podiatrist. Like an orthopedist, we treat many joint, tendon and bone problems. A variety of infections can develop in the foot and lower leg, thus we also function as an infectious disease physician. We absolutely need to be specialists at evaluating and treating the complex, interconnected biomechanical workings of this part of the anatomy. Bearing the weight of the human body leads to some distinct conditions, as does the motions and mechanics of gait.
The following is a case history describing a recent patient’s experience with podiatric medicine. The individual in question was a middle-aged Caucasian female, we’ll call her Dianne, who presented to my office with complaints of mild, occasional heel pain. She had been wearing a pair of custom foot orthotics for years but was noting some occasional heel pain of late and guessed she might need to have a new pair prescribed.
During Dianne’s initial visit, after a discussion of her symptoms and the history of the problem, a physical exam was performed. This included an evaluation of her blood flow, her nerve function, and, naturally, her musculoskeletal status. It was during the evaluation of her dermatologic system, her skin and associated structures, that a small dark spot was seen on the outside of her leg just below her knee.
This was a rather innocuous looking lesion, brownish in one area, tan in another. It wasn’t tender when pressured but was slightly raised above the surrounding skin. This spot, although quite benign in appearance, was somehow suspicious looking (it just didn’t strike me as “quite right”) so a biopsy was recommended. This is a simple procedure, entailing little to no pain when appropriately performed, but is able to provide definitive information on the nature of the lesion.
Much to our chagrin, the report came back as a malignant melanoma, a deadly skin lesion too often fatal. This is typically because of a delay in getting a specific diagnosis. The most critical factor is the depth of the cancer, with deeper penetration leading to a poorer prognosis. That is what happens generally when these aren’t identified in a timely fashion.
Dianne was referred to an oncologic dermatologist, a skin doctor specializing in cancer. The current practice guidelines usually recommend a Mohs procedure, in which tissue is taken from the site of the mass in concentrically larger circles until the margins are clear and no cancerous cells are seen. This is a rather destructive technique but has yielded the highest rate of resolution, i.e. a cure.
Following the surgery, Dianne returned to my office in, shall we say, a “tizzy” due to the hole in the side of her leg, a result of the procedure. It was accurately compared to two full size Oreo cookies stacked on top of each other. It had created a formidable defect. This operation was successful in ridding her of this dangerous malignancy but had left her with a serious wound. As mentioned, a podiatrist may “wear many hats” with wound care being one of mine.
As a wound care specialist, it is essential to approach each ulcer or wound individually. Identifying the obstacles to healing is vital. Because of the size of the opening, abundant tissue needed to be grown. Negative pressure wound therapy, referred to as a wound vac, was selected. By creating a vacuum over the surface of the wound, the production of new, vascularized tissue is stimulated.
After the void was sufficiently filled, a skin graft was obtained from a different area, and used to cover the defect. This piece was very thin, termed a split thickness graft, providing skin cells to the wound but also providing skin cells to the donor site. Because the patient was healthy and this region of the leg has a good blood supply, no significant obstacles to healing allowed for the progressive and successful closure of Dianne’s wound. And this was a result of the treatment of a life threatening skin cancer.
Depending on their orientation and training, a podiatrist may also assist a patient in being able to walk better or reduce their risk of falls and become more stable. Our skills also lead to fewer diabetic amputations, an undesirable outcome less frequent when our ministrations are utilized. Many patients experience less knee and back pain, or can walk farther, by utilizing podiatric therapies in the form of prescription foot/body supports called foot orthotics.
Of course, we perform the expected services, straightening hammertoes and curing calluses. But our expertise goes beyond the obvious. A podiatrist may be the first to identify diabetes or the presence of rheumatoid arthritis. Indeed, a podiatric physician is like a specialist and a generalist rolled up into one, providing specialized care and primary care at the same time, filling a unique but necessary role in modern medicine.