10/24/2025    Rod Tomczak, DPM, MD, EdD

Sacred Myths

There are beliefs that people hold which are
undeniably ludicrous. Folks with little money in
their pockets will venture down to the paddock to
watch the horses in the next race walk by and
intuit by their gait and the spring in their steps
which horse is most likely to win the race. Others
will read the racing form and decide that a pound
variance in the weight that the 1200-pound horse
is carrying will make the difference in the race
while ignoring the fact that this is the first
race another horse will run with Lasix and
Butazolidin aboard.

We sanctify myths in podiatry just the same. The
belief that if podiatry changed or disappeared,
care of the diabetic foot would also come to an
inglorious conclusion. Diabetic foot care is not
our sacred domain. And if we do it better, it is
probably because of immersion and the fact that we
have spread the knowledge gained through endless
repetition at seminars sponsored by companies
heavily invested in means, methods, and profits.
As a profession we can not give ourselves the
luxury of thinking these orthobiologics, machines
and procedures are solely the property of
podiatry.

Thirty years ago, athletes, and particularly
runners came to the erroneously believe that if a
doctor somehow added “sports medicine” to his
moniker he or she carried something in their black
bag that the physician who didn’t self-title
didn’t have privy to. That belief has persisted to
this day and the cash flow continued.

When I was in Curacao to open a medical school ,I
applied for a license. They have an incredibly
high rate of amputations because of diabetic
ulcers and osteomyelitis. I met with the lone
orthopedic surgeon on the island. His opinion was
that Curacao did not need what he called a “super
sub-specialist” to care for diabetic patients. In
fact, he told me, he performed all the diabetic
amputations, and to top it off, his brother was
the lone prosthetist on the island. They had a
method to care for diabetics, a family affair, and
in their minds, they felt it was efficient,
proficient, and profitable.

It seems that every podiatrist renders diabetic
foot care and there is a company on the horizon
willing to offer sums of money and other perks if
we are willing to speak about the efficacy of an
external fixator for a paronychia or an
outrageously priced tetracycline that performs no
better than a generic brand. If we can add the
descriptive term fellowship trained to our CV, we
are in even greater demand. This is a small
profession where it’s easy to be an authority who
comes from more than 50 miles away, especially
when the company makes the PowerPoints. COVID
forced the introduction of Webinars, Zoom
presentations, and talking heads. It’s not just
us. I saw a CRNA conference in Greece for this
winter with a concentration on Yoga. The seminar
is fully approved for CEUs and of course run by a
CRNA.

The question remains, “Should there be a board
certification in diabetic wound management?”
Orthopedics offers boarding in body parts and
while diabetic wound management is a process or
procedure. If a podiatrist attempts heroic
measures to salvage a leg because of advanced
disease and the leg is still amputated, there is
no certification for the podiatrist to fall back
on. Expert witnesses tend to be podiatrists on the
payroll of companies that pay large sums to their
experts for their expertise. It's another
ancillary source of income.

If you read The Journal of Foot and Ankle Surgery,
you would be drawn to three interesting
conclusions. One is that podiatry doesn’t perform
all that much limb salvage, two, foot and ankle
surgeons perform a lot of trauma, much of it
rearfoot, and three, at least half of each edition
of the journal is devoted to authors who are
foreign and not podiatrists.

If you look at approved fellowships under CPME you
will notice not one of them uses the word trauma
as a descriptor. If you listened to all the trauma
presentations at podiatric CME’s, you’d begin to
think that most presenters did a fellowship. If
you look at the concentration of trauma articles
in journals, you’d think the only thing we did as
a profession is rearfoot and ankle trauma. Is the
concentration of podiatric rearfoot and ankle
trauma that great or have we created another
sacred myth? Has rearfoot and ankle trauma become
the Cinderella of podiatry?

I remember going to Davos, Switzerland in December
of 1979 and taking the Internal Fixation course
from the originators. It was important because I
was practicing in a small town with no orthopedic
surgeon or podiatrist who felt comfortable with
trauma. Simply put, there was no fight over
trauma cases. If you could figure out Lauge-Hansen
you could reduce an ankle fracture and fixate it.
I had no problem getting rearfoot cases for
boards. But, a lot of what I did was still seat of
the pants. There was a lot of orthopedic training
as a resident, but nothing formal.

Wouldn’t it be better for the profession if
podiatrists had a certification or specialized
fellowship training in both limb salvage and
rearfoot and ankle trauma? Everybody does some
non-complicated ulcer care, but when you can look
into a wound and see your watch on the other side,
you’re into advanced limb salvage. When the
radiologist can’t identify which bone is which and
the general surgeon reminds you of the old
calcaneal fracture procedure where a mallet was
used to further pulverize the calcaneus and mold
into something resembling a calcaneus then cast
it, it’s time to have a fellowship trained trauma
surgeon.

It's not a sacred myth to say these podiatrists
deserve special training and a special designation
as authorities in these areas of care. To be board
certified in rearfoot and ankle is not good enough
today orthopedic surgeons have trauma fellowships,
but we don’t designate any fellowships as trauma.

Each year, approximately 1.6 million people in the
U.S. develop a diabetic ulcer.(1) These account
for almost 80% of diabetes related lower extremity
amputations.(1) There are approximately 280,000
foot or foot and ankle fractures for five years,
approximately 56,000 per year.(2) The number of
non-amputation reconstructive surgeries is much
lower. There can easily be confusion over the
meaning of reconstructive by itself and may not
refer to reconstruction after trauma but rather
after Charcot or some other surgery after
debridement from a diabetic ulcer.

A dedicated fellowship must be different than
board certification in podiatry and be listed as
such to help delete confusion. To reiterate,
serious diabetic foot ulcers affect the largest
number of patients annually, followed by diabetic
amputations/reconstructive procedures with serious
foot and ankle trauma being the least common
category.

It's important to know if a podiatrist has had
additional accredited training in the categories
mentioned above to protect the podiatrist from
frivolous lawsuits especially where expert
witnesses want to earn a hefty paycheck and
discredit another podiatrist. The problem is
having the accreditation of these highly advanced
and perhaps esoteric fellowships provided now by
the same organization that accredits undergraduate
podiatric education. Each Charcot is unique and
most ankle and rearfoot fractures, although
falling within a certain classification require
different methods and equipment to correct the
deformity.

This process would be infinitely easier to attain
if podiatrists had a DO degree and members of
MD/DO foot and ankle fellowships were part of the
accreditation team as acknowledged by ACGME. I sit
back and wonder why the few seem to dictate policy
for the majority. Make all the fellowships what
they need to be. Properly examine the members of
that subgroup and recognize them for what they
have accomplished. Sometimes I think we are
jealous to produce podiatrists who are better than
we are at what we do, more learned than we are,
better problem solvers than we are, and better
teachers than we ever were. Those in power now can
assure the path analysis to credentialing is
disrupted by deflecting the invitation by ACGME to
sit down and talk then inspect our post graduate
programs and make suggestions for their successful
futures.

Of course, abusing our young by not teaching and
pimping them when we do is the new way to eat our
young. MDs and DOs have done away with that
process, but trainers who are themselves insecure
and afraid to be upstaged by Gen Z are a sure way
to start the podiatric extinction process. These
young doctors know more than we ever did at their
stage of training. We have conveniently forgotten
that we surpassed most of our trainers in wisdom,
knowledge, and understanding. For example, we all
learned AO techniques together and some of us
learned better from salesmen than our residency
directors did. Understandably, video game players
made better arthroscopists than their residency
directors. Accept the inevitable and don’t become
another brick in the wall.

References

1.Tan, TW, Caldwell, B, Zhang, V, JAMA;7;
(3)e240801.
2. Naochiro, S, et al, J Foot Ankle Surg, 53(5),
606.

Rod Tomczak, DPM, MD, EdD , Columbus, OH

Other messages in this thread:

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10/27/2025    Robert Kornfeld, DPM

Sacred Myths (Rod Tomczak, DPM, MD, EdD)

I believe Dr. Tomczak has hit more than one nail
on the head here. While a trauma-based fellowship
may make sense for some, and I do believe it is
something that is needed, I do not think it would
be the draw for many and shouldn't be something
that we push our graduates into. One of the things
I have witnessed in my more than 40-year career is
the loss of podiatric medicine from our
residencies. Don't get me wrong. I do believe we
need to be good surgeons. I did thousands of
procedures in my career.

But just look at how things have evolved in our
profession. The better the surgical training for
our residents became and the more we were pushing
well-trained, surgically oriented podiatrists into
society, insurance companies lost their respect
for surgeons and slashed fees to the point of
absurdity. And if that is how a podiatrist is
expecting to earn his or her living, it is going
to be a struggle going forward.

At the same time, I have come up against some very
disturbing experiences in the last 10 or so years.
I happen to specialize in chronic foot and ankle
pain and work from a functional
medicine/regenerative medicine perspective. Many,
if not most, of my patients have already seen a
number of podiatrists before finding me. And the
stories I hear are very upsetting. Patients who
were never touched. No exam. No work-up. Just an
x-ray and a recommendation for surgery. Many of my
patients have had surgery...some have had many
surgeries to correct the same problem by different
podiatrists. Each one failed. Very few had a
legitimate biomechanical evaluation, or any. Many
were never given orthotics, or if they were, they
are OTC devices you can buy from Amazon.

I saw a patient for a second opinion. The first
podiatrist recommended a 5th metatarsal osteotomy
for a painful lesion sub 5th met head. As I
inspected her foot, there was a rather large
lesion in the area. I asked her when she saw the
other podiatrist (thinking it was quite a while
ago because the lesion was quite thick). She said
last week. I asked her if the prior podiatrist
trimmed the lesion. The answer was no. And there
was no biomechanical evaluation. And again, this
doctor did not touch the patient. As is my habit
from my training, I began debriding the lesion. As
I got through the superficial part of the callus,
I felt a clicking under my scalpel. It was a piece
of glass. The patient then remembered breaking a
glass in her kitchen and getting glass in the
foot. She thought she got it all out. I removed
the glass fragment. Problem solved.

I also had a patient (a runner) who was suffering
from pain in the 1st MTP joint. A fusion was
recommended by two other podiatrists. Passive ROM
was restricted to about 45 degrees of
dorsiflexion. The 1st ray was profoundly
hypermobile. No orthotic was recommended to this
patient. Just surgery. I put the patient in a
custom orthotic with a 1st ray cut out. About 75%
of the discomfort was resolved. To work toward
getting him asymptomatic, I gave him an HA
injection followed 2 weeks later by an RPA
injection. He has been asymptomatic since then (7
months now). And is running long distances again.

IMO, we need to return to medical management.
Obviously, if conservative management does not
succeed, surgery can always be done. But podiatry
has fooled itself into thinking we would achieve
more respect from the MD/DO world if we became
super surgeons (sacred myth) and we could achieve
payment parity with MDs and DOs. That definitely
has not happened. And when a surgery fails, it's
imperative that we examine why it failed. Not just
from a procedural failure point of view. But from
an immune system perspective. I understand the
first surgeon. I can even understand the second.
But the third surgeon needs to ask why these prior
surgeries failed. It's usually not a surgical
problem. It's an immune efficiency problem where
repair dynamics are less than desirable.

Finally, I agree (and I never did before) that the
D.P.M. degree needs to be retired. It's time we
merged our specialty into MD and DO programs so
future podiatrists won't be embarrassed to call
themselves podiatrists. And that is obvious when
you go to LinkedIn and see that very few
podiatrists call themselves podiatrists. They are
foot surgeons or foot and ankle surgeons.

I can honestly say I owe a lot to the practice of
podiatric medicine and surgery. It provided me
with a degree to create a beautiful and successful
life. But I do not feel I owe my thanks to a
profession that has chronically mishandled our
challenges. And too many young podiatrists have
shared with me that they were told in residency
that they would never survive without PE
employment. That is totally untrue and unfair.

I graduated in 1980, and in all of my years as a
podiatrist, I do not believe we have solved most
of the problems we faced way back then and sadly,
we have created others that have not served us
well. And now we have come to the point where we
speak about the extinction of podiatry. That would
be a great loss to medicine.

Robert Kornfeld, DPM, New York, NY