The traditional spiritual song Dem Dry Bones
, thought to have been written by African-American songwriter James Weldon Johnson (1871-1938), has been used for decades to teach basic anatomy to children, and includes the lyric "The foot bone's connected to the leg bone" [3
]. Where the ankle fits into this schema could be the topic of an entertaining semantic debate amongst foot health specialists, yet this very question forms the basis of a drawn-out legal case in the USA. The details are freely accessible online [4
], but what follows is a brief chronology of events related to the case.
In 2000, the Texas State Board of Podiatric Medical Examiners (TSBPME) argued that due to uncertainty among podiatrists, insurance companies and hospitals regarding the scope of practice of podiatry, there was a need to define the word 'foot'. The definition they proposed was:
"The foot is the tibia and fibula in their articulation with the talus, and all bones to the toes, inclusive of all soft tissues (muscles, nerves, vascular structures, tendons, ligaments and any other anatomical structures) that insert into the tibia and fibula in their articulation with the talus and all bones to the toes".
This definition was adopted by the TSBPME in April 2001 [4
], despite objections from the Texas Medical Association (TMA) and the Texas Orthopaedic Association (TOA), who claimed that the definition inherently (and impermissibly) expanded the scope of practice of podiatry. The Texan Attorney General concurred, stating that the tibia and fibula are leg
bones, not foot bones, and as such are beyond the scope of podiatry. The TMA and TOA then filed legal action in November 2002 requesting that the Travis County District Court evaluate the validity of the definition.
In August 2005, the District Court concluded that the TSBPME definition was valid, prompting the TMA and TOA to take the case to the Texas Court of Appeals in March 2008. At this hearing, the court found in favour of the TMA and TOA, and reversed the judgement of the District Court. In their ruling, the Court of Appeals stated that because the definition included parts of the body that were neither part of the foot or the ankle (such as various nerves and blood vessels that traverse the leg and terminate in the foot), the District Court ruling effectively authorised podiatrists to undertake procedures outside of their training, thereby constituting an unauthorised practice of medicine. Interestingly, the ruling did acknowledge that "a compelling argument...might be made as to whether - from a medical standpoint - it is reasonable to allow a practitioner treating the foot to consider and treat other anatomical systems that interact with and affect the foot", although it was specified that a legal case would need to be made to support this [6
In August 2008, the Texas Podiatric Medical Association (TPMA) and TSBPME appealed the case to the Texas Supreme Court, which was denied in June 2010, and a subsequent request to rehear the case was turned down by the Supreme Court in July 2010 [5
]. As a result, the TSBPME definition of the foot is now accepted as being legally invalid. However, legal opinion obtained by the TPMA argues that treatment of the ankle is still within the scope of podiatry practice in Texas, as the definition of the foot specified in the Court of Appeals' decision is "limited to that portion of the body at or below
the ankle" (emphasis added) [7
The legal wrangling in this case is clearly driven by scope of practice, professional autonomy, medico-legal and monetary considerations rather than a desire to anatomically locate the talus, and indeed, it is interesting to contemplate how the arguments may have differed if the warring parties were societies of clinical anatomists rather than podiatrists and orthopaedic surgeons. Although the case does not currently have any implications beyond the state of Texas, there is a real possibility that it could set a precedent in other states of the USA, the UK or Australia, or indeed wherever scope of practice conflicts arise between podiatrists and orthopaedic surgeons.
The broader issue raised by this case, however, is that there remains some confusion as to how the foot should be defined. Most dictionaries define the foot by what it is not, i.e. the part of the body below the ankle
]. This is clearly problematic, as the talus could justifiably be considered to be part of both the ankle and the foot. It could also be argued, from a functional anatomy and biomechanical perspective, that no clear distinction between the foot and the ankle can be made, as movement of the ankle joint induces movement in foot joints, and vice versa
]. Even more broadly, there are practical problems with any segmental definition of the foot due to the array of muscular, neural and vascular connections of more proximal structures, although such considerations proved to be the undoing of the somewhat expansive TSBPME definition.
In some respects, JFAR has deftly side-stepped the issue of defining the foot by the inclusion of 'ankle' in the title, although we acknowledge that this was merely good fortune rather than careful planning. In considering the Texas case, we have nevertheless reflected on why we decided to include 'ankle' in the journal title. At the time the journal was being developed, several titles were considered which incorporated various permutations of the words 'foot', 'ankle', 'podiatry', 'clinical' and 'research', and we were obviously cognisant of not overlapping with existing journal titles. The journal could have been called Journal of Foot Research, but it was assumed (although not explicitly discussed) that because the foot and ankle are interdependent, and that the readership of the journal would be involved in treating ankle as well as foot problems, that Journal of Foot and Ankle Research was appropriate. We still believe this to be the case, and therefore feel no need to weigh into a legal, anatomical or semantic debate about where the foot ends and the ankle begins.