The Institute Bookshelf

Recommended titles for practitioners and students

The Institute of Podiatrists are excited and proud to have commissioned 2 dynamic and important handbooks written specifically by way of an introduction to the foot and as a supportive learning companion. Written by David R Tollafield, a highly experienced podiatry professional and renowned podiatric author.

An introduction to the foot & its common problems in the adult

The challenging subject of foot and lower limb mechanics is admirably clarified and easy to follow in this 180-page paperback, Pocket sized book. Well- illustrated, clear and informative, this book will appeal to podiatrists and foot health practitioners at all levels, whether you are new to the anatomy and workings of the foot or as a reference for reminder. This book will also appeal to other professions and healthcare professionals who have an interest in the foot.

The Foot – a professional learning companion

This companion course, sets out different styles of questions, offering tips for open and closed methods, especially multi-choice options.

Divided into two parts: questions in the first and detailed explanations in the second part. Supporting self-assessment for foot health practitioners and students on university courses, this handy aid helps understand the finer parts of foot health science in eight study areas.

Written by Helen Rawse

To read this article please click here

Case Notes is a regular feature in the IoCP quarterly publication – Podiatry Review. Every member will have seen unusual patients and/or will have unusual conditions which will be of interest to the readership, colleagues and peers.

Case Notes is an expansion on your own medical notes ensuring you do not identify the patient, unless you have written consent.

We welcome all submissions of your findings to be featured in our Podiatry Review, please contact for more information or to submit your case!

Health Education England, along with the Foot Health Consortium are launching a consultation to seek the views of stakeholders on a draft set of standards for the foot health practitioner and podiatry support workforce.

The consultation will be open from Monday 23 November 2020 – midday Friday 15 February 2021.

The Standards have been developed to support the NHS to effectively use the full skills mix of the foot health workforce to meet demand by providing a clear understanding of the footcare treatments that foot health practitioners and the podiatry support workforce can safely perform. The needs and safety of patients is central in this work.

We would therefore value your feedback about the standards via the consultation and look forward to hearing your comments and suggestions as we take this vital and important next step.

Please visit the HEE consultation webpage for the consultation survey link and two important documents that will help you respond to the consultation.

The Consultation on standards for the non–regulated foot health workforce sets out the background to the work to develop the Standards. It then explains more about how the Standards have been developed and how it is proposed they will be used. The draft Standards on which we are seeking your feedback have been published alongside this consultation document.

Visit the HEE website for the Standards and Consultation document that will accompany the consultation

In 2019, we gathered as a Consortium of Foot Health Leaders to address the problem of the falling recruitment numbers on traditional routes into podiatry. The priority of the Consortium is to develop a foot health career ladder and educational resources that will support and increase the number of podiatrists and podiatry support workers working in the NHS.

The work of the Consortium has enabled a better understanding of the workforce that provides foot care, with the aim of optimising this workforce for the benefit of those who use the services of any practitioner, in England, who work in this arena.

These Foot Health Education and Training Standards are the result of a year’s work to increase the supply of podiatrists in the NHS workforce. We also want to ensure that the NHS recognises the knowledge and skills of the wider foot care support workforce.

We are proud to work in partnership with Community trade union, we believe a good modern trade union is not only essential to a positive and safe workplace but more importantly gives self-employed workers like us a strong and collective voice.

Community is a proud champion of the five million strong self-employed and freelance community across the UK, including chiropodists and podiatrists.

For many people, self-employment is the answer to finding a good work-life balance and can be extremely rewarding. It can also mean longer hours, less pay, more worry about your finances and employment. By partnering with Community we want to give you that help, as well as campaign on the issues that matter to us as a sector.

As a member of Community, IOCP/COFH members can:

Advice and support

Community union provides advice and support through their service centre of expert legal advisors, dedicated to supporting members with any questions or help members may need.

Whether its advice on client relations, self-assessment tax returns, debt recovery and late payments, welfare benefits, discrimination and health and safety issues – Community can help.

Campaign and organise

By building and strengthening our collective voice as part of Community, we can ensure our voices are heard. Community is a proud campaigning union and the strength of their membership paired with their political affiliations means they can take the issues you care about and make sure they are heard across the UK at every level.

Pay and conditions

Community can support you at work with individual representation to get the best deal, and secure fair treatment and fair pay.

Education and training

By becoming a member of Community, you can access bespoke education and training opportunities that works well for freelancers and the self-employed. This includes access to hundreds of free online courses to develop key business skills.

Discounts and savings

You can save money on a range of leisure, insurance and retail products through Community’s discounts on a range of professional and personal products and services.

To join follow the link from the November members e-newsletter or login to the members area of our website


Applications are invited for the positions of accredited mentors on the Institutes successful FHP course. With the advent of the Foot Health Consortium set up by Health Education England, which the Institute is a board member of, FHP training will undoubtedly become a higher profile area in footcare and it is essential that training organisations ensure that training offered is of the highest possible quality.
As many members will know, a substantial proportion of entrants to the IOCP training program have been put forward by HCPC registered IOCP members wishing to include FHPs in their treatment teams in the same fashion as dental practices have, for example, hygienists to support the delivery of structured care. This is an exciting move forward which the IOCP with its more than 80 year history of delivering flexible training is well fitted to deliver.
Mentors will be responsible for supervising community placements within their own practices – be they domiciliary or surgery based, and will be remunerated for each student they ‘take under their wing’. Mentors must have appropriate qualifications or experience and be willing to attend seminar style training for the role. An adult teaching qualification is preferred such as the former city and guilds or the more recent level three award in adult education and training but of equal importance is appropriate experience and a genuine desire to take the whole profession of foot health of all levels and types forward.
In the first instance please supply a CV detailing your experience, reason for applying and details of your practice to Jill Burnett-Hurst, General Manager at the IOCP to receive further information and for a friendly informal discussion.

Up to 80% of the population are estimated to need the services of either an NHS or private podiatrist at some stage of their life, to deal with health problems of the feet. Whilst parts of the profession have continued to provide urgent emergency treatments during the current pandemic, podiatry now has to work out new methods of returning to its additional roles of regular preventative care for the many millions of people, including many  vulnerable people such as diabetics, who need such care every year. Podiatrist Martin Harvey, chief executive of the national professional body the Institute of Chiropodists and Podiatrists said; “our members face the challenge that in order to work on peoples feet we are certainly not socially distant, so we have had to implement and develop new systems of working giving the maximum possibly safety to patient and podiatrist alike. Let me reassure the public that as regulated Health Professionals we are ensuring that we adhere to the highest possible standards of personal protection equipment and your feet are as safe as we can possibly make them in our hands. Members of the public can see the detailed guidance available to our members on the Institutes website


Written by Martin Harvey FPodM PGCert BSc

Podiatrist Independent Prescriber


It is frequently said (or it was at least by my dear old Granny) that there is nothing new under the Sun. Whilst the discoverers of the Higgs Boson may take issue with Granny’s statement there is, I believe, quite a bit of truth in it. Even in the case of injecting some of the substances now being used to augment dystrophic plantar fibro-fatty padding, which one could be forgiven for believing to represent a brand new modality now being introduced to a suffering public.

When I was first introduced to the delights of sticking needles into people in return for payment (to seek to deal with tissue injuries may I add, not to extort payment of unpaid fees), more years ago than I care to remember, I keenly believed that injection and similar regenerative therapies were all cutting edge stuff, at the forefront of modern podiatric science. However, when I first started to teach these said therapies to colleagues as CPD some 13 years ago or so, it became evident as I researched the necessary background that these ‘new’ therapies drew on older therapies that stretched back decades – and even in certain cases regarding their underpinning principles to ancient Greece.

In order to discuss the action of fillers later, to establish a background let us first consider a simple connective tissue injury, say the medial ligament of the talocrural joint – a frequently encountered injury[1],[2]. Now, ligaments are, as we well know in podiatry, some of the most challenging injuries to deal with. From the perspective of appropriate injection therapies we may consider using a parenteral corticosteroid such as depo-medrone (POM-A exemption) or kenalog (POM requiring independent prescription) with the intent of dealing with this ‘inflamed’ site of injury.

Alas, more research will show that often there is little ‘true’ inflammation in such injuries, with the pain frequently being caused by nerve fibres that have been stretched by the injury to the ligament or tendon that they run through[3],[4]. From the foregoing we can reasonably hypothesise that what is frequently required is not an anti-inflammatory agent but instead something to actually drive healing forward, essentially initiate a healing response in the host tissue.

In looking for an agent to provoke a host response, we can then find that there is much evidence that injection treatments exist which are believed to provoke healing in cases of traumatic tissue injury where no specific pro-inflammatory mediators are present in any quantity (i.e. no or few prostaglandins, histamines, bradykinins, leukotrienes etc etc). A good example is ‘prolotherapy’, a more than 50 year old modality[5] which seeks to use parenteral agents to stimulate a host healing response in the injured site by using a solution of glucose mixed with a local anaesthetic, to ‘stress’ the fibroblasts present in the injured site and cause them to respond by producing the collagen that is a major element in tissue repair, therefore restoring structure and function to the ligament and eliminating the stretching of the nerve endings, so reducing pain[6] . A little more research then reveals that a similar procedure for hernia repair was patent in the 1930’s[7]

Then however, even more research reveals that this idea of initiating a host response for tissue repair can be traced back to the Greek Physician Hippocrates[8]. Admittedly, good old Hippocrates did not have a hypodermic syringe, nonetheless, when confronted with damaged ligament laxity in the throwing shoulders of his favourite athletes he sought to repair them by provoking a host response. In his case he used a very slim red hot iron (a Kauterion – see the root of cautery?) which he thrust repeatedly through the damaged ligaments to provoke scar tissue formation and which he describes in detail in section IX of his works on the Articulations[9], first published around 400AD.

At this stage gentle reader, you may well be wondering what earthly relevance this has to injecting agents into the plantar foot. Well, a short consideration will reveal that the substances currently used are essentially liquids or gels (either Newtonian[10] or non-Newtonian[11] fluids) – I have personally forswore the Kauterion. The concept sometimes advanced that injected substances somehow stay in place of themselves and in some fashion ‘cushion’ the foot is hard to give credence to because the pressures which develop in the normally healthy foot can be substantial, and in the case of dystrophic or otherwise pathological tissue can be dramatic – typical ‘normal’ pressures are 80-100 kPa standing, 200-500 kPa walking, up to 1500 kPa in some sports and in diabetic plantar tissue pathologies sustained pressures as high as 3000 kPa[12]

Whilst admitting, without getting too enmeshed in fluid mechanics, that there may be some dilatant action going on (think trying to stir a thick paste of cornflour and water – it gets stiffer) such pressures would almost invariably in most cases extravasate the substance injected into the surrounding less compressed tissue. Indeed, if such was not the case and if the injectate became a semi-solid siting in an area of already excessive loading, it could well compress underlying blood vessels with the possibility of provoking tissue necrosis. Therefore it is reasonable to suppose that to a great extent some other mechanism of action is at work in the plantar tissue. Hence it is suggested that a host response is a likely mechanism of action.

It is at this point that we return to the title of this short jotting. Dermal fillers are not a new therapy, they have certainly been around in podiatry for more than fifty years and for non-podiatric applications since very shortly after the second world war. During that period of time the agents used have evolved and varied but the basic principle of parenteral administration by hypodermic has remained constant.

In 1964 the redoubtable American Podiatric Physician, Dr Sol Balkin DPM started to record his use of injectable silicone in the foot to “address the loss of plantar fat” and he published his 41 year clinical and histological study in 2005.[13] As Sol Balkin makes plain in his publication, he himself drew on the earlier work of Harvey D. Kagan MD who in the early 1960’s lectured upon the use of injectable silicone for breast augmentation. In turn Dr Kagan drew on the work of the Japanese physician Dr Rin Sakurai[14] who claimed to have started injecting breasts in 1946. Returning to the foot, Dr Balkin proposed that the injected silicone provoked a “banal and stable fibrous tissue formation” as a result of a “human histologic host response”.

Since Sol Balkin’s time there have been several other uses of silicone as a podiatric filler in both the USA and the UK. Notably in 1996, when the California based company McGahn medical corporation sponsored a double-blind placebo controlled study of silicone injections in the feet of diabetic patients at the Manchester (UK) Royal Infirmary under the oversight of Professor Andrew J.M Boulton MD with good outcomes[15]

Since then the story of fillers in the feet has been varied. Silicone alternately fell into and out of favour, some of the more sensational media suggested it migrated dramatically around the body, it became hard to source, expensive at first before reducing in price and then supplies becoming essentially unobtainable, in the UK at least. However, the present author has certainly used silicone with good effect some years ago when it was available without any adverse effect. Other substances have been tried by various users, autologous fat, bovine collagen, avian collagen etc but most have not commanded a widespread report of success, and again, none of these are used by the present author.

Nowadays the agents of choice, and certainly those used and taught by the author are based on Hyaluronic Acid (HA). This substance is naturally present in substantial areas of the human organism so one is not introducing anything that is not physiologically present. Other fillers can be used, notably Poly-l-Lactic Acid (PLLA), which is a bio-compatible polymer so not physiologically present. Both HA and PLLA are widely used as facial volumisers to fill out wrinkles and both have decent safety records. Their mechanisms of action are similar, inasmuch as they initiate a host response that provokes the formation of collagen and in the case of HA also attracts interstitial tissue fluid to the area injected (HA is highly hydrophilic in its purified form). There have in some studies been suggestions that PLLA, when used cosmetically, has over-stimulated neocollagenisis in facial areas and one study[16] reported “The mechanism of action of poly-L-lactic acid requires techniques and patient management as incorrect injection technique can cause device-related adverse events by overstimulation of the fibroblasts” but in the feet a little ‘over volumisation’ may, if managed appropriately be less contentious. In the case of HA this has been used for years cosmetically, indeed one manufacturer some years ago celebrated their ‘10 Millionth’ treatment and are now up to their 30 millionth treatment (see: and it has a most impressive safety record. HA is the authors agent of choice due to its safety record and it is this that is used in the CPD courses provided by the Institute of Chiropodists and Podiatrists on which the author and his colleagues teach.

Post treatment care and counselling need to be attended to carefully for good outcomes, particularly in the area of offloading padding, and in order to effectively administer the treatment effective analgesia is required. In the matter of analgesia, where suitably qualified podiatrists require ‘brushing up’ on their tibial and sural blocks, this is part of the course and is of itself a useful revision in these most useful and under-used procedures which can make so many procedures in the foot pain-free.


Feeling inspired? Want to learn more? Join us for our next Dermal Filler CPD course, simply click here



[1] Adirim TA, Cheng TL., Overview of injuries in the young athlete. Sports Med. 2003; 33(1):75-81

[2] MacAuley D., Med Sci Sports Exerc. 1999 Jul; 31(7 Suppl):S409-11

[3] Clancy W. Failed healing responses. In: Leadbetter W, Buckwater J, Gordon S, eds. Tendon trauma and overuse injuries. Park Ridge, IL: American Orthopedic Society for Sports Medicine, 1989, 609–18.

[4] Monga T, Grabois M, (Ed’s) Pain management in Rehabilitation. pp: 24-25. Demos Medical Publishing 2002

[5] Hackett GE., Joint stabilisation through induced ligaments sclerosis. Ohio State Medical Journal, 1953, vol 49: pp. 874 – 884

[6] Banks A., A Rationale for Prolotherapy. J. Orthop. Med 13;54-59,1991

[7] Rice CO., Aratson., Histologic changes in the tissue of man and animals following the injection of irritating solutions intended for the cure of hernia’s. Ill Med. J. 70: 271, Sept. 1936

[8] Hippocrates. Works – on the articulations; section VIII. Francis Adams (trans) London 1849

[9] “It deserves to be known how a shoulder which is subject to frequent dislocations should be treated…The cautery should be applied thus: taking hold with the hands of the skin at the armpit, it is to be drawn into the line, in which the head of the humerus is dislocated; and then the skin thus drawn aside is to be burnt to the opposite side. The burnings should be performed with irons, which are not thick nor much rounded, but of an oblong form (for thus they pass the more readily through), and they are to be pushed forward with the hand; the cauteries should be red-hot, that they may pass through as quickly as possible; for such as are thick pass through slowly, and occasion eschars of a greater breadth than convenient, and there is danger that the cicatrices may break into one another; which, although nothing very bad, is most unseemly, or awkward” Hippocrates. Works – on the articulations; section XI. Francis Adams (trans) London 1849

[10] A Newtonian fluids viscosity remains constant, no matter the amount of shear applied for a constant temperature. These fluids have a linear relationship between viscosity and shear stress.

[11] Non-Newtonian fluids are the opposite of Newtonian fluids. When shear is applied to non-Newtonian fluids, the viscosity of the fluid changes. The behaviour of the fluid can be described one of four ways:

  • Dilatant – Viscosity of the fluid increases when shear is applied. For example: Quicksand. Cornflour and water. Silly putty
  • Pseudoplastic – Pseudoplastic is the opposite of dilatant; the more shear applied, the less viscous it becomes. For example: Ketchup

[12] Whittle, M.W., Gait Analysis (3rd Edn) Butterworth-Heinmann (2003) pp 140-14

[13] Balkin, Sol. DPM Injectable Silicone and the Foot: A 41-Year Clinical and Histologic History. Dermatol Surg 31:11 Part 2:November 2005

[14] Kagan HD. Sakurai injectable silicone formula. Arch Otolaryngol 1963;78,663-8

[15] van Schie CHM, Whaley A, Vileikyte L, et al. Efficacy of injected silicone in the diabetic foot to reduce risk factors for ulceration: a randomized double-blind placebo-controlled trial. Diabetes Care 2000;23,634-8.

[16] Zollino I, Carinci F. The use of poly-L-lactic acid filler in facial volume restoration: A review. OA Dermatology 2014 Feb 22;2(1):3.