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According to the American Podiatric Medical Association (APMA; see Resources), “[f ]oot and ankle disorders are among the most widespread and neglected health problems affecting people in this country.”1 Podiatry deals with diagnosis, treatment, and prevention of conditions of the human foot, ankle, and related structures.2 The direct predecessor of the APMA was the National Association of Chiropodists (NAC), established in 1912. Because the public often confused “chiropodists” with “chiropractors,” the NAC adopted its present name in 1957. However, the United Kingdom and some other countries have been slower to adopt the term “podiatrist.”2,*

Socrates is reputed to have said: “To him whose feet hurt, everything hurts.”3 Believing that foot health is interwoven with the overall physical and emotional health of an individual, integrative podiatry practitioners draw on botanical/homeo-pathic therapies, prolotherapy, and other modalities as adjuncts to conventional podiatry.4 This article describes the trend to-ward more integrative and preventive practice in podiatry, and the complementary and alternative medicine (CAM) modali-ties that are being incorporated into this field.

Professional Education, Specialties, and Status

For licensing as a doctor of podiatric medicine (D.P.M.), a podiatrist is required to complete 4 years of graduate educa-tion at an accredited podiatric medical college beyond under-graduate education, with an emphasis on science or premedical coursework; undergo 2–3 years of postdoctoral hospital resi-

dency training; and pass a state licensing examination. Spe-cialty areas include pediatrics, geriatrics, orthopedics, sports medicine, biomechanics, surgery, and primary care. Podiatrists in the United States can become board certified in primary care, orthopedics, and foot and ankle surgery.2 Podiatry has been referred to as a nonallopathic profession that has been accepted by mainstream medicine and, therefore, can serve as a model for other CAM practitioners seeking acceptance by the allopathic establishment.5

Preventive Care Focus

Podiatrists have traditionally focused on proper foot care and footwear, and treating common conditions, including tin-ea pedis (athlete’s foot), heel pain caused by plantar fasciitis, bunions, neuroma (enlarged inflamed nerves), arthritis, and diabetes-related foot problems with prescription medications, orthotics and other foot- and leg-support aids, exercises, and surgery. Integrative podiatry adds herbal and homeopathic medicines and other modalities to this repertoire of treatment options.

Like integrative podiatry, conventional podiatry is starting to focus more on preventive care. For example, Ronald D. Jensen, D.P.M., the current president of the APMA, emphasizes pre-ventive podiatric care in treating patients with diabetes to avert foot and leg amputations.6

Podiatrists are also addressing weight control in their prac-tices, given that: “[e]ven a small amount of excess weight can lead to big increases in workload for the feet,” according to Paul Langer, D.P.M., a clinical faculty member at the University of Minnesota Medical School in Minneapolis. Dr. Langer esti-mates that active persons who are just 10 pounds overweight

ALTERNATIVE AND COMPLEMENTARY THERAPIES DOI: 10.1089/act.2010.16207 • MARY ANN LIEBERT, INC. • VOL. 16 NO. 2APRIL 2010

Innovative Therapies in Podiatry and Physical Medicine

Sala Horowitz, Ph.D.

*Visit www.apma.org/Main/Menu/AboutPodiatry/APMAOverview/History and www.foot-health.info/chiropody/ for more information about this difference in terminology.

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ALTERNATIVE AND COMPLEMENTARY THERAPIES • APRIL 2010

MARY ANN LIEBERT, INC. • VOL. 16 NO. 2

subject their feet to about 100,000 pounds of extra impact daily, while more-sedentary people who are 30 lbs overweight subject their feet to 150,000 lbs of additional impact.7 Obesity is a well-known risk factor for diabetes and its lower-extremity complica-tions. Although foot problems and inappropriate footwear are recognized risk factors for falls and subsequent health problems, podiatry’s role in fall prevention tends to be overlooked.8

CAM Modalities

Podiatry was reported among the CAM modalities used by survey respondents between ages 60 and 80.9 Podiatrists may seek CAM treatment options as alternatives to corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) because of the high risk profiles of such agents.

Botanical/Homeopathic TreatmentsMarigold, particularly the Tagetes patula and Calendula of-

ficinalis species, has been used as an herbal remedy for treat-ing skin and other ailments since antiquity. Marigold therapy was first described in the podiatric literature in 1980 as a treatment for plantar hyperkeratotic lesions, which involve an increase in the thickness of the stratum corneum (horny) layer of the skin.10

The Marigold Clinic at the Royal London Homeopathic Hospital, established in 1992, is run by M. Tariq Khan, Ph.D., B.Sc. (Pod.Med.), D.F.Hom. (Pod.), a homeopathic podiatrist who specializes in treating chronic foot disorders and sports injuries involving the feet. Patients typically attend the clinic once a week for 2–4 weeks and are given a home-care regi-men.11 Dr. Khan has described what happens:

The treatment is a two-pronged approach. First, the pa-tient is seen by a trained podiatrist in marigold therapy on a weekly basis for up to 3 weeks. A poultice of marigold is applied with a protective pad. The follow-up treatment consists of an oil and tincture of marigold the patient uses at home following the initial poultice treatment.†

Tracy Vlahovic, D.P.M., a professor at Temple University’s School of Podiatric Medicine who received training at the Marigold Clinic, says of Dr. Khan’s marigold-extract prod-ucts (manufactured by Marigold Footcare, Ltd., London): “All the mixtures work differently. One mixture will have antiviral properties, which work best for treating a wart. Another mix-ture will have keratolytic [epidermis-thinning] qualities, which work best in treating corns and calluses.” Dr. Vlahovic found marigold to be a valuable alternative treatment option for ver-rucae (plantar warts), especially in HIV-positive patients, be-cause common procedures such as cryotherapy (freezing) or surgical removal can compromise their weakened immune sys-

tems further. In a study of patients with warts, four to six treat-ments with marigold cleared or greatly reduced the number and size of the patients’ warts.12

Marigold therapy may also be a viable alternative to fre-quently unsuccessful caustic methods of treatment for patients with corns and plantar callus (hyperkeratosis), hallux abducto valgus (deformity of the first pedal metatarsophalangeal joint of the big toe), and associated bunions. A double-blinded, placebo-controlled trial assessed the effectiveness of marigold therapy using Dr. Khan’s Tagetes preparations. Twenty patients with bilateral hallux abducto valgus and an associated bunion, and 40 patients with unilateral hallux abducto valgus and an associated bunion were treated for 8 weeks. Reduction of pain and width of each lesion was significant in the patients who received the marigold preparations plus a protective pad, com-pared with placebo.13

In a case study of a patient who had not gotten relief for a chronic plantar callus from conventional treatments, Dr. Khan’s regimen with Tagetes was applied. Following each ap-plication (number unspecified), the patient reported reduced symptoms on a visual analog scale (VAS), a greater time in-terval between return of symptoms, a reduced lesion size, and a greater tolerance of callus reduction that allowed complete local enucleation of the corn.14

Calendula off icinalis (calendula) is one of the dozen botani-cals in Traumeel® (Heel, Inc., Albuquerque, NM), a homeo-pathic preparation that has been called an anti-inflammatory, antiedematous, antiexudative injected solution, which, accord-ing to a website for the product, also contains the following ingredients: Arnica montana (mountain arnica), Hamamelis virginiana (witch hazel), millefolium (milfoil), Belladonna (deadly nightshade), Aconitum napellus (monkshood), Cham-omilla (chamomile), Symphytum off icinale (comfrey), Bellis perennis (daisy), Echinacea angustifolia (narrow-leafed cone-flower), Echinacea purpurea (purple coneflower), and Hyperi-†Personal communication with Dr. Khan.

Selected Foot Facts• Eachfoothas26bones;bothfeetcontainone-quarterofall

the bones (206) in the human body.

• Eachfoothas33jointsandanetworkofmorethan100muscles, ligaments, and tendons.

• Everystepplaces1.5timesaperson’sbodyweightofpres-sure on each foot (e.g., a 150-lb person places 225 lbs of pressure on each foot with every step).

Source: American Podiatric Medical Association. Fast Facts on the Foot—2009: 2009 Foot Ailments Survey. Online document at: www.apma.org/MainMenu/News/Surveys/Foot-Fast-Facts/General-Foot-Health--Fast-Facts.aspx Accessed De-cember 29, 2009.

People who are 30 lbs overweight subject their feet to 150,000 lbs

of additional impact.

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cum perforatum (St. John’s wort). The prescription formulation also contains the mineral component Hepar sulphuris calcareum (calcium sulfide).15

The preparation is indicated for treating symptoms associ-ated with inflammatory, exudative, and degenerative process-es resulting from acute trauma, repetitive or overuse injuries,

and minor pain associated with such conditions. Administra-tion—alone or in combination with a local anesthetic—may be injected intravenously (i.v.), intramuscularly (i.m.), sub-cutaneously (s.c.), or intradermally. Rare adverse effects can result from sensitivity to a component botanical; there are no known interactions with other medications.15

Melaleuca alternifolia (tea tree) oil, the essential oil of an Australian native plant, has long been used as a topical antiseptic agent to treat cutaneous infections. Laboratory studies have demonstrated the antimicrobial properties of tea tree oil, which are thought to result from the compound terpinen-4-ol. Although skin products that contain tea tree oil may produce contact dermatitis, these allergic reactions may be caused by other components of such products (e.g., eucalyptol).16 But historical experience with the oil sug-gests that the topical use at normal concentrations is rela-tively safe.17

A randomized, double-blinded trial involving 104 patients evaluated the efficacy of tea tree oil cream for treating tinea pe-dis, compared with 1% tolnaftate (an over-the-counter [OTC] antifungal agent) and placebo creams. All three groups in the trial had clinical reduction of inflammation, scaling, itching, and burning. While there were no significant differences be-tween the tea tree (n = 37) and placebo (n = 34) groups in be-coming cured at the microscopic level of infection, the tea tree oil cream (10%) reduced symptoms as effectively as tolnaftate (n = 33). The researchers concluded that relief of symptoms may be “the basis for the popular use of tea tree oil in the treat-ment of tinea pedis.”18

In another randomized, placebo-controlled, double-blind-ed trial of tea tree oil for treating tinea pedis, efficacy and safety of a 25% and a 50% solution of tea tree oil was studied in 158 patients diagnosed with the infection. Patients applied the solution twice daily to affected areas for 4 weeks, and were evaluated after 2 and 4 weeks of treatment. There was a marked clinical response seen in 68% of the 50% tea tree oil group and 72% of the 25% tea tree oil group, compared with 39% in the placebo group. Four patients developed moder-ate-to-severe dermatitis that improved quickly when the ap-plications were discontinued.19

ProlotherapyProlotherapy involves injection of a proliferant (a mild ir-

ritant solution), in conjunction with an anesthetic (e.g., lido-caine), that stimulates the immune system to produce a healing cascade of responses in affected tissue.20 Painful conditions of the ligaments, tendons, and cartilage of the foot and ankle are among the many conditions that may be helped by prolothera-py.21 Dextrose (pharmaceutical-grade sugar water), the irritant that is often injected in the painful area, affects collagen and cartilage, soft tissues that support the immune system’s innate healing mechanism.22 Other proliferant substances used in-clude glucose, Serapin® (a water-based extract of Nepenthes

Selected Results from a Foot Ailments Survey

• Onlyaquarter(25%)ofAmericanswhohaveexperiencedfoot ailments have seen any type of physician about this problem,and,ofthatnumber,just12%havevisitedpodia-trists.

• Heelpainisthemostcommonfootproblem,with43%ofre-spondents reporting that they had experienced this ailment within the past year, followed by pain in the balls of their feet (35%),toenailproblems(33%),andsweatyfeetorfootodor(32%).Sixin10(60%)ofrespondentswhohaveexperiencedheel pain in the last 12 months reported that they have trouble with daily activities.

• Almost4in10people(39%)whohaveexperiencedfootail-mentsrelyonover-the-counter(OTC)productsandself-carefor relief.

• Sixtypercentofpatientswithdiabetes,butonly39%ofpeople at risk for diabetes, have seen a podiatrist.

Source: American Podiatric Medical Association. Fast Facts on the Foot—2009: 2009 Foot Ailments Survey. Online document at: www.apma.org/MainMenu/News/Surveys/Foot-Fast-Facts/General-Foot-Health--Fast-Facts.aspx Accessed De-cember 29, 2009.

Calendula officinalis (marigold).

Researchers concluded that relief of symptoms may be “the basis

for the popular use of tea tree oil in the treatment of tinea pedis.”

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spp. (pitcher plant); High Chemical Co., Levittown, Pennsyl-vania), an extract of corn, zinc manganese, and an extract of cod liver oil.23

Because the injections purposely induce inflammation, patients are advised to avoid taking anti-inflammatory medications prior to treatment (except an 81-mg baby aspirin taken for cardiovas-cular health). Although the procedure has been used for decades and is considered a safe alternative to steroid injections, health insurers generally do not provide coverage of prolotherapy, based on the limited research evidence currently available.24

A single-blinded randomized study compared the effec-tiveness of eccentric-loading exercises (that cause stretching combined with muscle contraction, used instead of concentric-loading exercises) with prolotherapy injections used singly and in combination for Achilles tendinosis. Participants were ran-domized to a 12-week program of eccentric-loading exercises (n = 15), or prolotherapy injections of hypertonic glucose with lignocaine along the affected tendon (n = 14), or combined treatment (n =14). On the main outcome measures of pain, stiffness, and limitation of activity scores on a questionnaire measured at 6 and 12 weeks, prolotherapy—particularly pro-lotherapy combined with the exercises, provided more-rapid, clinically significant improvements in symptoms than the ex-ercises alone.25

Platelet-Rich Plasma TherapyAnother type of treatment increasingly being used as an al-

ternative to steroid injections, NSAIDs, and surgery to treat soft-muscle injuries is platelet-rich plasma therapy (PRP). PRP involves injecting a small sample of a patient’s plasma, which has been carefully processed to concentrate platelets, into the injury site to stimulate the body’s innate healing pro-cesses naturally.26 A recent study randomized 54 patients, ages 18–70, with Achilles tendinopathy to receive usual care (eccentric exercises) with either a PRP injection or a placebo (saline) injection. Both groups had improved pain and activity level scores, with a slight, but not statistically significant, dif-ference favoring the group that received PRP.27

Extracorporeal Shockwave Therapy Extracorporeal shockwave therapy (ESWT) has been used

as a nonsurgical treatment (like lithotripsy technology is used to break up kidney stones with sound waves) for localized mus-culoskeletal pain since the early 1990s. ESWT devices work by generating a shockwave from an electromagnetic acoustical source through a water-filled generator and concentrating the energy produced through an acoustical lens on a concentrated point at a fixed distance from the lens.

Chronic pain associated with tendonitis of the foot was among the first conditions treated by ESWT. The U.S. Food and Drug Administration (FDA) has approved several ESWT devices since 2000 for treating refractory plantar fasciitis in patients age 18 or older who have symptoms for 6 months or longer and a history of unsuccessful conservative treatment. Contraindications for ESWT are bleeding disorders, use of blood-thinning medications, and pregnancy.28

High-energy ESWT generally involves only a single treat-ment session of approximately 45 minutes but requires the use of anesthesia. For this reason, Robert A. Kornfeld, D.P.M., a holistic podiatrist in practice in Manhattan and in Lake Suc-cess, New York; founder of the Institute of Integrative Podiatry (see Resources); and an adjunct professor in the Department of Integrative Medicine at the New York College of Podiatric Medicine; treated patients with low-energy ESWT.29 How-ever, other practitioners prefer high-energy ESWT because it produces early suppression of nocireceptor reactivity followed by subsequent target-tissue healing through revascularization and recruitment of new tissue-target specific cells.30

Dr. Kornfeld says that now he prefers to use a MicroVas® (neuroVaix, Broken Arrow, Oklahoma) device rather than ESWT (personal communication). The MicroVas is a noinva-sive device that drains venous beds and raises oxygen levels in damaged tissue, for example, in nonhealing diabetic ulcers, to accelerate healing.

In a randomized multicenter study, three interventions of ra-dial (versus focused) ESWT (at 0.16 mJ/mm(2);2000 impulses) were compared with placebo in 245 patients with heel pain. Fol-lowing 12 weeks of treatment (regimen not specified), and at 12-months’ follow-up, ESWT proved to be significantly superi-or to placebo, with an overall success rate of 61%, compared with 42% for placebo, for reducing pain under various conditions and in terms of patients’ and investigators’ global judgement of ef-fectiveness. No adverse effects were reported.31

A prospective trial was conducted with 40 participants who were randomly assigned to either focused or sham ESWT, and who received 3 applications of 2000 shockwave impulses. At 12 weeks, after baseline measurements of changes in composite heel pain and heel pain under various conditions (morning pain, pain with activities of daily living [ADLs], and pain upon application of pressure), ESWT produced a 73% reduction in composite pain, a 32.7% greater reduction than that achieved with placebo but that was not statistically significant. However, with respect to secondary trial outcomes, ESWT was superior to sham inter-vention. There were no adverse side-effects in either group.32

A retrospective review of 225 patients (involving 246 feet), who had plantar fasciitis for more than 6 months that was un-responsive to at least 5 conservative modalities and who had undergone a series of ESWT treatment between July 2002 and July 2004, was conducted to assess factors related to successful outcomes. In this population, success rates of 71% at 3 months and 77% at 12 months were noted. The researchers found that diabetes mellitus, older age, and psychologic issues had a nega-tive influence on ESWT outcome, but that duration of symp-toms, previous cortisone injections, body–mass index (BMI), and plantar fasciitis thickness did not have a negative effect on the outcome.33 In other trials, ESWT also has shown promise for treating chronic Achilles tendinopathy.34,35

AcupunctureIn a case study series on electroacupuncture treatment for

refractory plantar fasciitis, 11 patients were treated for a minimum of 2 months, once weekly, after other conserva-

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tive methods of treatment had failed. Severity of heel pain was assessed using a VAS; how the pain affected various functions and activities was addressed with a foot-function questionnaire. Nine of the 11 patients reported pain reduc-tion > 50%, and 2 patients reported complete resolution of heel pain.36

Maggot Debridement TherapyMaggot debridement therapy (MDT), once considered

an obsolete therapeutic modality, has been shown to be a useful adjunct for intractable wounds of the lower extremi-ties, such as diabetic foot ulcers.37 In this form of biosur-gery, the maggots used in MDT are of specially bred larvae of the Lucilia sericata species rather than larvae of the house fly (Musculus spp.).38

A Veterans Affairs Medical Center study of 18 men with 20 nonhealing diabetic foot and leg ulcers compared MDT (n = 6) with conventional surgical or nonsurgical treatment

(n = 6), and conventional therapy followed by MDT (n = 8). After 5 weeks, conventionally treated wounds were still covered with necrotic tissue over a third of their surface, whereas the MDT-treated wounds were completely debri-ded at 4 weeks.39

It has been noted that MDT can prevent septicemia in deep wounds. Because maggots help separate necrotic and living tis-sue, bacterial loads are greatly reduced, wound healing takes places at a faster rate,40 and more proximal amputation can be avoided with MDT.41

A Veterinary Application

A holistic approach has also been applied to hoof care in equine podiatry. This approach was founded on the compa-rable principle for podiatric care of humans that the animal has the innate ability to heal itself.42

Clinical Perspectives

“A holistic method improves foot symptoms and pro-motes overall body health,” remarked Vicki L. Stone, D.P.M., a podiatric physician and surgeon practicing at the Portland Wellness Center in Portland, Oregon. The Center also includes a naturopathic physician, physical therapist, licensed acupuncturist, and massage therapist. Dr. Stone also said:

A holistic approach also looks at a person’s diet, level of nutrition, level of hydration, lifestyle, and stress, as well as helping to identify physiologic mechanisms that are contributing to pathology. . . .We need to stimulate the immune system and support it in every way we can. This includes homeopathic injections, nutritional and herbal support, and supplements.

Among the conditions Dr. Stone treats integratively are plantar fasciitis, tendonitis, bursitis, arthritis, neuropathy, neu-roma, peripheral vascular disease, fungal toenails, Raynaud’s syndrome, warts, psoriasis (with lesions on the feet), and ex-tremely sweaty feet.43

John Hahn, D.P.M., N.D., who also practices holistic podia-try in Portland, Oregon, has found homeopathic remedies to be safe, effective alternatives to NSAIDs and opioids for long-term and postoperative treatment of chronic arthritic joint pain; plantar fasciitis; and sports injuries, such as tendonitis, fractures, and sprains.

Dr. Hahn uses Traumeel and another product, Zeel® (Heel, Inc.), singly or together, in injectable or oral formulations, sometimes in conjunction with a local anesthetic (lidocaine or bupivacaine). “Patients tolerate these injections very well. One can give these injections weekly without any danger of adverse reactions or soft-tissue instability that one may see with steroid injections,” Dr. Hahn said. Follow-up care may

ResourcesOrganizations

American Podiatric Medical Association (APMA) 9312OldGeorgetownRoad Bethesda, MD 20814 Phone: (301) 581-9200 Website: www.apma.org

TheAPMArepresentsmostofthecountry’sestimated15,000podiatrists, and serves as a resource on all aspects of podiatry forprofessionalsandthepublic.ItpublishestheJournal of the American Podiatric Medical Association.

Institute for Integrative Podiatry Medicine(IIPM) P.O.Box290 Glen Cove, New York 11542 Phone: (516) 869-3338 E-mail: [email protected] Website: www.integpodmed.com

Asateachinginstitute,theIIPMprovidesresourcesforpodia-trists who want to incorporate complementary medical modali-ties into their practices. A member directory is available.

Website

www.podiatrytoday.com Podiatry Today (Malvern PA: HMP Communications, LLC)

Reading for Your Patients

Great Feet for Life: Footcare and Footware for Healthy Aging

By Paul R. Langer, D.P.M. Minneapolis: Fairview Press, 2007

Maggot-treated wounds were completely debrided at 4 weeks

in a study.

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be with an oral form of Zeel or Traumeel, or a topical cream form of Zeel.

A study of these products indicated that their mechanisms of action are inhibitory effects on 5-lipoxygenase and cy-clooxygenase-1 (COX-1) and COX-2 enzymes.44 While pri-marily using homeopathic remedies and weight management strategies for plantar fasciitis, Dr. Hahn may utilize ESWT as a treatment option.

Conclusion

Mainstream podiatry is emphasizing prevention to a greater degree and expanding the discipline’s repertoire of treatments. Treatments used in integrative podiatry include botanical/ homeopathic medicines, such as marigold and tea tree oil, prolotherapy, ESWT, acupuncture, and MDT. Further research is warranted to support clinical practice suggesting that these nonsurgical alternatives to steroids, NSAIDs, and surgery are safe and effective. Patients with, or at risk for, diabetes may especially benefit from being treated by an integrative podiatrist. n

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