By: Ersta Ferryanto and Li-Yuan Lee

Subjective:
A 58 year old male presents for routine nail care. Patient is diabetic and has peripheral neuropathy. An avid bowler, he was crushing the pins on a Friday night. Frame after frame, with no breaks in between, he continued until the last calls were made. He ended the game after ten games. It was not until Sunday morning that he noticed something unusual. After he got out of the shower, he noticed his left foot was red, hot, and swollen with a bony protrusion in the midfoot. He reluctantly went to the emergency department that night. Patient mentioned that he did not drop a ball on his foot. The emergency department did not take any radiographic images. He was discharged that same night. They diagnosed him with a superficial skin infection and he was given antibiotics. Not thinking anything of it, the patient took the medicine as instructed. He arrives at the podiatry clinic three days later on Wednesday for routine nail trim but is also concerned with the infection and bony bump.

Assessment:
Type 2 Diabetes Mellitus
Onychomycotic nails
Acute Charcot

Plan: Patient was sent for imaging. Radiographs showed collapse of the midfoot, indicative of an acute Charcot event. Patient was casted upon his return to the clinic. He will return to the clinic in 2 weeks for a cast evaluation and follow-up radiographs.

For privacy’s sake, creative liberties were taken in documenting this case; however, this is based on a real patient encounter seen by one of us podiatry students on rotation. We wanted to start with this narrative to highlight the importance of awareness and education about common podiatric issues that can be easily missed. A routine nail trim may not be as “routine” as people think. Just taking our patient’s history, something seemed off about the cellulitis diagnosis. The indications that something more serious was occurring was the red, hot, and swollen foot in combination with the bony protrusion in a patient with diabetic neuropathy.

Many people, including those who saw this patient in the emergency room, would not catch on to what was really going on here. The patient has Charcot arthropathy, which is essentially ligamentous laxity and bony dissolution leading to foot collapse that causes a rocker-bottom like foot. This can be elicited by many possible factors: a wrong step down the stairs, a mild twisting of the ankle, or 10 rounds of continuous bowling. Although less than 1% of diabetics experience a Charcot event, it is a life-altering condition which can lead to frequent casting, a large custom boot, intensive reconstructive surgery, ulcerations, or even a below knee amputation.

There is a growing demand for health care professionals everywhere but podiatry is in a unique position in that we serve the growing dichotomy of the American population; one which is increasingly overweight, obese, diabetic, and another which is embracing a lifestyle of fitness and wellness

Why then do these patients often slip between the cracks of an accurate diagnosis? There is simply a lack of education and awareness on lower extremity pathology. This ignorance goes for both medical professionals as well as the general population. Being able to recognize common foot and ankle pathology, especially something as severe as Charcot arthropathy, one should be more familiarized for at risk populations. This is where podiatrists play an important role.

Ignorance is an important issue that our profession faces in current times. Not only are we failing to fill our nation’s need for podiatric physicians, but the general public lacks awareness about our abilities to treat issues like we see in our case. There is a growing demand for health care professionals everywhere but podiatry is in a unique position in that we serve the growing dichotomy of the American population; one which is increasingly overweight, obese, diabetic, and another which is embracing a lifestyle of fitness and wellness.

Our work through PMA is two-fold. It is to promote podiatry in hopes of meeting the demands of our patient population as well as educating people about who podiatrists are and what they are capable of

Our organization, Podiatric Medicine Advocacy (PMA), has the goal of spreading awareness of podiatry. We believe it is best to accomplish our goal by reaching out to the inquiring minds to introduce our profession. We reach students in many avenues like high school classrooms, after school programs, and college lectures. The purpose of these visits is to educate the upcoming generation on what podiatry is and the scope of the profession. We do this through interactive workshops that we continue to develop based on audience demands. We present on the extent of the field, what it takes to get into podiatry school, but also focus on creating meaningful and engaging connections with the students. We curate cases that showcase the breadth of our work. We do this by incorporating hands-on demonstrations with dopplers, hand ties, suturing, and casting with explanations of their relevance to each case. Our expectations are that these students leave with a more wholesome understanding of the field and possibly choose podiatry as a potential career option.

We need to fill the jobs, but we also need people to know that we exist

Our work through PMA is two-fold. It is to promote podiatry in hopes of meeting the demands of our patient population as well as educating people about who podiatrists are and what they are capable of. We need passionate and enthusiastic people to fill in what the previous generation has laid the framework for. We cannot let their efforts go in vain. We have become a respected profession, and we do have an expanded role in the overall health care system, but there is more work to be done. We need to fill the jobs, but we also need people to know that we exist. With our expanding education and surgical training, the profession is prepared to provide care to a growing and complex demand.

There is a timeline where this patient did not have a chance for an appointment with the podiatrist who was able to recognize his symptoms and properly treat him. In a better timeline, our patient would have been educated on the risk of diabetic complications, would have had imaging performed at his ER visit, and would have reached out to podiatry sooner. We want to be a part of a health care system that includes us in these and other similar scenarios. This is the future we are building.

By: Ersta Ferryanto and Li-Yuan Lee

Student Organization: Podiatric Medical Advocacy

School: Des Moines University College of Podiatric Medicine and Surgery

A Foot In the Gutter, It’s Right Up Our Alley

Finalist – Writing Competition 2020

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