Protecting musculoskeletal care: Perspective of the president of the American Orthopaedic Foot and Ankle Society

Advocacy should never be about professional turf, but rather about preserving the quality of care our patients receive. When it comes to the ankle and leg, we need to lead the way and need your help.

There is growing evidence that compared to podiatrists, orthopaedic surgeons provide foot and ankle care with lower complications, reduced costs, and more efficiency. A 2024 national Medicare analysis of nearly 46,000 ankle fracture repairs showed that orthopaedic surgeons delivered significantly more cost-efficient care than podiatrists, with median Medicare payments 3-5% lower across all fracture types. Moreover, a retrospective cohort study from Chan et al., published in 2019 the Journal of the AAOS®, found lower complication rates among patients treated by orthopaedic surgeons with ankle arthrodesis and ankle arthroplasty compared to those treated by podiatrists.

Did you know that podiatrists can now legally perform hand surgery in five states (Alabama, Ohio, West Virginia, Michigan, and Minnesota)? In 27 states, they can legally perform surgery on the leg. These expanded privileges are being granted through state-level legislation and hospital credential decisions, often without the awareness or input of orthopaedic surgeons. This scope expansion is accelerating, despite fundamental differences in education, training, and clinical oversight between podiatrists and orthopaedic surgeons.

Did you know that podiatrists — due to state legislation — are considered physicians in 36 states? The American Medical Association definition of a physician is “an individual who has received a ‘Doctor of Medicine’ or a ‘Doctor of Osteopathic Medicine’ degree or an equivalent degree following successful completion of a prescribed course of study from a school of medicine or osteopathic medicine.” Orthopaedic foot and ankle surgeons have the same foundational training as all orthopaedic surgeons, plus additional fellowship training in foot and ankle surgery. This training reflects our broad medical knowledge and systemic understanding of human health. In contrast, podiatrists attend podiatric school, complete a three-year residency focused exclusively on the foot and ankle, and have no formal requirement for training in the management of orthopaedic conditions outside the foot and ankle. Despite these fundamental differences, we continue to face challenges with public education distinguishing us from podiatry, due to their aggressive marketing and liberal use of the title of “physician.”

We ask our orthopaedic colleagues to help perpetuate accurate information to our medical colleagues and patients. AAOS has a position statement on the surgical care of the lower extremity discussing these training differences. The American Orthopaedic Foot and Ankle Society (AOFAS) also has a position statement on podiatry.

Did you know that the number of residency spots for podiatric surgery is not capped by the Centers for Medicare & Medicaid Services; therefore, there is no limit to the number of podiatrists being trained each year? The AAOS Position Statement on the Financing of Graduate Medical Education states, “The unlimited number of funded podiatry training positions serves as an advantage to podiatrists, who are more limited than orthopaedic surgeons in the type of musculoskeletal services they can provide. Exclusions to the resident limits should be eliminated.”

Orthopaedic residency positions are federally regulated, tightly capped, and highly competitive. In 2025, 929 allopathic medical students matched into orthopaedic residency programs with no unmatched spots. In a typical year, approximately one-third of medical school applicants for orthopaedic surgery residency slots do not match. In 2025, 57 orthopaedic residents matched into orthopaedic foot and ankle fellowships. In contrast, in the fall of 2024, 525 students matriculated into podiatric school, all of whom will go on to do a three-year residency upon completion. As a result, podiatric workforce growth has outpaced orthopaedic training growth, and podiatrists are increasingly being credentialed for procedures beyond their traditional scope, without meeting equivalent standards of education and training.

Did you know that we need your help? As orthopaedic surgeons, we have a responsibility to advocate for training standards that reflect the complexity of the care we provide. We encourage you to engage your hospital credentialing committees, educate lawmakers and healthcare leaders on the differences between orthopaedic and podiatric training, and partner with national organizations such as AAOS and AOFAS to prevent podiatric scope creep from expanding to the knee or hip as it has with the hand and leg. In doing so, we can help ensure that musculoskeletal care remains safe, comprehensive, and physician-led. Our patients deserve surgeons trained to care for the whole system — not just a single region in isolation. Let’s work together to preserve the integrity of orthopaedic surgery and ensure that all patients receive the high-quality, evidence-based care they need and expect.

David B. Thordarson, MD, is president of AOFAS.

References

1. Ohio Foot and Ankle Medical Association. DPM scope of practice. Accessed June 23, 2025. https://www.ohfama.org/aws/OHFAMA/pt/sp/dpm
2. Ohio Revised Code, Section 4731.51: Defining practice of podiatric medicine and surgery. Published Sept. 29, 2017. Accessed June 23, 2025. https://codes.ohio.gov/ohio-revised-code/section-4731.51
3. Ghafoorian R. Memorandum of law: Health Occupation Revision Act (HORA) 2023 — Podiatrists. Medical Society of the District of Columbia. Health Occupation Revision Act (HORA) – Podiatrists. Published March 11, 2024. Accessed June 23, 2025. https://www.msdc.org/docs/default-source/msdc/hora-podiatrists.pdf
4. Podiatric Medical Board of California. Frequently asked questions. Accessed June 23, 2025. https://pmbc.ca.gov/forms_pubs/tp_faqs.pdf
5. Student Doctor Network. Scope of practice comparison chart: DPM, MD, DO, DDS, DMD, NP, PA. 2018 Accessed June 23, 2025. https://forums.studentdoctor.net/attachments/scope-chart-updated-2018-final-pdf.332899/
6. Justia Law. 2020 Georgia Code Title 43 – Professions and Businesses Chapter 35 – Podiatry Practice. Accessed June 23, 2025. https://law.justia.com/codes/georgia/2020/title-43/chapter-35/section-43-35-3/
7. Lewis G: SB 169 – Health Occupations – Podiatric Physicians – Letter of Support. Maryland Department of Health. Published Jan. 26, 2021. Accessed June 23, 2025. https://mgaleg.maryland.gov/cmte_testimony/2021/ehe/612_01252021_113225-646.pdf
8. American Medical Association Policy Finder. Definition of a Physician H-405.969. 2024. Accessed June 23, 2025. https://policysearch.ama-assn.org/policyfinder/detail/H-405.969?uri=%2FAMADoc%2FHOD.xml-0-3589.xml
9. AAOS. Position statement: surgical care of the lower extremities. Published June 2012. Accessed June 23, 2025. https://www.aaos.org/contentassets/1cd7f41417ec4dd4b5c4c48532183b96/1148-surgical-care-of-the-lower-extremities.pdf
10. American Orthopaedic Foot and Ankle Society. Position statement: podiatry. Published July 2025. Accessed June 23, 2025. https://www.aofas.org/docs/default-source/research-and-policy/position-statements/position-statement-on-podiatry.pdf
11. AAOS. Position statement: the financing of graduate medical education. Published June 2015. Accessed June 23, 2025. https://www.aaos.org/contentassets/1cd7f41417ec4dd4b5c4c48532183b96/1109-the-financing-of-graduate-medical-education.pdf
12. Weiner JP, Steinwachs DM, Frank RG, Schwartz KJ. Elective foot surgery: relative roles of doctors of podiatric medicine and orthopedic surgeons. Am J Public Health. 1987;77(8):987-992.
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14. Hartnett DA, DeFroda SF, Ahmed SA, Eltorai AEM, Blankenhorn B, Daniels AH. Malpractice claims associated with foot surgery. Published April 28, 2020. Accessed June 23, 2025. https://orthopedicreviews.openmedicalpublishing.org/article/23064
15. Allen C, Younger A, Veljkovic A, Glazebrook M. Orthopedic versus podiatric care of the foot and ankle: a literature review. Orthop Clin North Am. 2021;52(2):177-180. doi:10.1016/j.ocl.2020.12.004
16. Chan JJ, Chan JC, Poeran J, Zubizarreta N, Mazumdar M, Vulcano E. Surgeon type and outcomes after inpatient ankle arthrodesis and total ankle arthroplasty: a retrospective cohort study using the Nationwide Premier Healthcare Claims Database. J Bone Joint Surg Am. 2019;101(2):127-135. doi:10.2106/JBJS.17.01555
17. Meyers J, Campbell P, Lieber A, et al. A retrospective cohort analysis comparing the costs of ankle fracture fixation in orthopaedics and podiatry in a U.S. Medicare limited data set. Foot Ankle Int. 2024;45(11):1279-1291. doi: 10.1177/10711007241268225.
18. Chan JY, Truntzer JN, Gardner MJ, Bishop JA. Lower complication rate following ankle fracture fixation by orthopaedic surgeons versus podiatrists. J Am Acad Orthop Surg. 2019;27(16):607-612. doi: 10.5435/JAAOS-D-18-00630.