If you’ve ever been concerned about the value of podiatry in the general medical world and the importance of our knowledge and contributions, let me disabuse you of that concern. Over a little more than 10 years of practice, I’ve built up a library of ridiculous cases in which patients received incorrect treatment as a result of an overreliance on “advanced” imaging and lack of expertise and clinical acumen.

Over time, I’ve come to realize that most medical specialties (outside a couple, including podiatry and orthopedics) seem to forget about the body below the perineum. Although unfortunate for patients who are treated by providers with little understanding of the lower extremities, it is mostly an opportunity for us in podiatry. When I lecture to providers outside of podiatry, I end up telling them the simplest form of treatment is simply referral, and if anyone reading this is not a lower extremity specialist, I strongly recommend referring your patients with lower leg and foot complaints to your local podiatric colleague. The reason for this is simple: Jjust as with any other medical problem, the current state of knowledge is too complicated for any one doctor to know it all, and no one can treat those particular disorders better than the people who spend their entire professional lives gaining experience and expertise in that area. For the foot and ankle, that’s the podiatrist.

Let me give you a few clinical examples that cover just one common mistake made by non-podiatric physicians: misdiagnosis caused by a lack of clinical acumen and overreliance on imaging. Some of the details will be changed for anonymity, but I’ve left the overall stories intact.

Case of the “Bone Scam”
When I was first in practice, a nurse from a local surgery center came to see me for a second opinion. She had obtained a curb-side consult from a vascular surgeon at that same surgery center about pain in her big toe joint. For some reason – I still can’t figure out why – the vascular surgeon ordered a three-phase bone scan, which showed increased tracer uptake at the big toe joint area. The vascular surgeon diagnosed the nurse with a bone infection and recommended a partial first ray amputation. Smartly, the nurse sought a second opinion. Knowing the limitations of bone scans (highly nonspecific with poor anatomical detail) and a history completely inconsistent with bone infection (she never had an ulcer or other break in the skin) I obtained a radiograph and performed a cheilectomy with bone biopsy. As I’m sure all podiatrists reading this have already figured out, the nurse had mild osteoarthritis rather than osteomyelitis. If she had gone with the first recommendation, she would have undergone an unnecessary amputation, and suffered all of the normal post op hallux amputation sequellae – apropulsive gait, sub two transfer lesion, shoe fitting issues, etc. The vascular surgeon should not have played podiatrist.

Case of The Toe That Shouldn’t Go
Several years back, a diabetic with a dorsal second toe neuropathic ulcer was admitted to the hospital with cellulitis of the foot. Prior to my being consulted, the medicine service ordered an MRI and found “osteomyelitis” of the toe. When I was consulted (with a request to amputate the toe) I saw an ulcer that did not probe to bone overlying the proximal interphalangeal joint and a mildly erythematous clawtoe. Radiographs (which I ordered after the MRI had already been done – the medicine service went straight to the expensive MRI) showed what looked to me like normal bone. I took the patient to surgery, performed an arthroplasty of the affected joint and MTP joint release and sent the bone to pathology and microbiology. Can you guess the result? Completely normal bone. The patient healed uneventfully and has been ulcer free to this toe for the last six years (I still see her for diabetic care). Good thing I didn’t trust the MRI!

Case of the Multiple – Wrong - Opinions
A similar situation occurred about two years ago with a patient that came to me for a SIXTH opinion. Yes, a sixth! Some people are just that persistent. This diabetic gentleman had a second digit mallet toe and previously healed neuropathic ulcer. Someone had ordered an MRI, which came back positive and advised he needed an amputation. He then went to five other doctors who all, except for the doctor just before me – a podiatrist – said he needed the amputation. When he finally came to see me, he wasn’t requesting an alternative diagnosis; rather he demanded I amputate his toe. This toe, that had been on the doctor tour like a rock star traveling to different cities, looked completely normal with the exception of the mild flexible contracture at the distal interphalangeal joint and a bulbous appearance to the tip of the toe due to the chronic pressure. There was no ulcer, callus, fissure, or other break in the skin. Nothing. Nada. Nil.

I told him he didn’t need any treatment, especially not an amputation. He then demanded I amputate his toe, and I vociferously refused. We debated back and forth for literally an hour while my clinic became increasingly backed up. Finally, I told the patient, “I refuse to amputate your normal toe. If you want that done, you’ll have to find someone else.” I finally convinced the patient to simply wait a little and watch how things went. Of course, nothing happened since he didn’t have a bone infection, and he continues to come see me for diabetic surveillance.

I could go on like this for ages! But I’ll finish off with one final unfortunate example. This one’s my favorite, because it’s the most recent. I’m literally sitting here shaking my head as I write this.

Case of the Monster Paronychia
Just the other day a very nice prediabetic lady came in as a follow-up from a recent hospitalization for cellulitis of her great toe. About two months previously she went to her primary care doctor with redness and swelling around the right great toenail. She was prescribed oral antibiotics, which she completed. A week later, the toe became increasingly red and swollen after bumping the same toe, so she went to the ER. Radiographs were taken, she was diagnosed with a fractured toe, and then had an MRI.

I know what you’re saying: “An MRI? Who in their right mind would order that?” I know! But they did. Guess what the radiologist diagnosed?

Yup. Osteomyelitis. You got it!

She was admitted for a week and a PICC line was inserted, and the patient received four weeks of two different antibiotics. At the end of this, she saw another doctor (that’s doctor number three) who told her she needed to have her toe amputated. Refusing this, she went to another hospital who admitted her (admit number two and doctor number four), and one of my residents finally saw her and correctly recommended a partial nail avulsion, which the patient refused. She was discharged to follow up with me. When the patient saw me, she had a completely normal toe other than incurvation of the nail.

It’s astonishing that this poor woman underwent so much treatment, for it turned out she had nothing more than a simple ingrown toenail. I’m not exaggerating this story at all…it was just an ingrown nail. You see, during all this time, no one removed the offending nail, so the patient had recurrent nail issues. It’s almost unbelievable if it weren’t so common.

The commonalities between these cases are almost painfully obvious.

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“I have two good pieces of advice for all medical providers. First, the history and physical must correlate or something’s missing. Similarly, any imaging ordered must correlate with the history and physical.”

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I have two good pieces of advice for all medical providers. First, the history and physical must correlate or something’s missing. Similarly, any imaging ordered must correlate with the history and physical. The body is a machine that malfunctions in predictable ways. If something doesn’t fit then you’re missing something. Don’t just order more tests. Go back and think logically through the problem…and then refer.

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“If something doesn’t fit then you’re missing something. Don’t just order more tests. Go back and think logically through the problem…and then refer.”

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Second, don’t treat diseases outside of your knowledge and scope. Consult someone with more knowledge and expertise than you. You’re not less of a doctor if you ask for help. Consult the experts. For the foot and ankle that means podiatry. I’ll see you for the next consult.