The foot, a complex structure, has 26 bones and 33 joints, which all have to work properly to allow each person an average of 115,000 miles in their lifetime. Our feet carry us through this world, and their ability to acclimate to changes in terrain protect us from falls, the number one cause of injuries and death from injury in older Americans. Healthy feet and proper footwear reduce the risk of falling. (See Nurses’ foot health.)
Given the complexity and subjective amount of load-bearing requirements of feet, it’s no surprise that, according to the American Podiatric Medical Association (APMA), at least 75% of Americans will experience foot problems, which increases to over 80% for those who are obese. Nurses play a significant role in preventing and treating foot issues.
Nurses’ foot health
What about the impact of the typical nursing role on nurses’ feet?
- Most nurses take at least 9,000 steps per shift while dealing with all the foot issues that affect the general population.
- To protect their feet, nurses should wear supportive and comfortable shoes, which can improve lower extremity circulation.
- To further improve lower extremity circulation, many nurses wear mild to moderate knee-high compression stockings (5mmHg to 10mmHg or higher).
- Orthotics can enhance shoe support and comfort.
- Nurses who sit for long periods should perform calf stretches and exercises at least every 30 minutes.
Foot health impacts overall health
Foot problems—some inheritable and some acquired—include plantar fasciitis, hammer toes, hyperhidrosis and odor, and bunions. Toenail disorders are the most common.
Most Americans regularly trim their toenails, but less than half adhere to other foot care regimens. Women care for their feet more regularly than men, and younger people are better able to perform recommended foot care regimens than older individuals.
Many people rank foot health low on issues they believe contribute to overall health; however, foot health and overall health have a bi-directional relationship—those with foot issues tend to have a host of other medical problems. According to the APMA, of the 80% of Americans who report having a foot problem, half say that it has impacted their quality of life. In addition to mobility and exercise, foot pain can restrict one’s ability to stand for long periods, sleep, and work. When foot pain and gait instability impair our exercise tolerance, our cardiovascular system will decline over time, increasing our risk for chronic disease and mortality.
In addition, older adults may experience difficulty caring for their feet as a result of physical or mental decline, decreased flexibility, body habitus, poor vision, and arthritic conditions. Older adults also experience more comorbid conditions. For example, diabetes and peripheral arterial disease are the main causes of nontraumatic lower extremity amputation. Substandard foot care typically precedes the domino effect of ulceration, infection, amputation, and cardiovascular decline due to decreased activity.
Access to quality foot care can prevent complications and major lower-limb amputations. Certified foot care nurses (CFCN®s) play an important role in maintaining foot health by identifying problems early and providing appropriate interventions.
Foot care certification
The U.S. Bureau of Labor Statistics predicts that the demand for podiatrists will increase 29% by 2030, with shortages expected. Podiatry groups have called for other professionals to increase their share of foot-related services to ensure patients have access to qualified providers; RNs serve as a key group to answer this call. In addition, because foot care is a manual task, it will remain protected against the growth of AI in healthcare and its potential to displace professionals.
CFCNs perform assessments, implement interventions, and provide patient education. To qualify for initial certification through the Wound, Ostomy and Continence Nursing Certification Board, you must have an RN license, a bachelor’s degree or higher, a minimum of 24 CE/CME hours specific to foot care with a maximum of 8 hours being in basic skin and wound care, and 40 clinical hours with a foot care expert (CFCN, nurse practitioner, physician associate, physician, or podiatrist). Certification adds legitimacy to your practice, and it offers you a network of like-minded individuals to learn and grow with.
Foot assessment
Foot care involves more than safe nail trimming. CFCNs identify signs and symptoms of disease processes that may complicate care. For example, dermatologic, neurologic, orthopedic, and vascular assessments add pertinent information. CFCNs evaluate medications and illnesses affecting the feet, assess proper shoe fit, and teach patients about routine foot care.
In the outpatient environment, foot assessments should be performed at every visit for patients with suspected or confirmed diagnosis of comorbidities, such as peripheral arterial disease and diabetes, which place them at increased risk for complications of foot disease. Low blood flow and microbiome alterations complicate foot wound healing and increase the risk for infection. Routine foot examinations performed by a CFCN or other skilled professional, combined with education in proper foot care, can detect common foot problems, uncover functional decline, and prevent falls. Unskilled foot care can result in serious health problems including wounds, infections, and even amputation.
Routine nail care
Routine nail care serves as the foundational procedure skill for CFCNs. The nail plate protects the soft tissue at the distal end of the phalanges. A variety of disease processes can compromise this function. Appropriate nail trimming and debridement support the ability of the nail plate to protect the digit without contributing to harm.
The provision of safe nail care includes preventing complications of improper care. Some disease states can make identification of the free nail border, the area of the distal nail plate that’s safe to trim, difficult to identify. Very thick yellowed toenails from onychomycosis (nail fungus) or the opaque, yellow-brown thickening of the nail plate seen in onychogryphosis (Ram’s horn nails) can increase the risk of unskilled nail trimmers inadvertently causing wounds, ingrown toenails, pain, and bleeding. (See Onychomycosis.)
Onychomycosis
Fungal nail infection (onychomycosis) of the hallux and second digit.
Tools and equipment to trim nails include tissue nippers, rasps, irises, mechanical rotary tools, ingrown nail shavers, and emery boards. Tool selection depends on several factors, including clinician preference, sterilization ability, cost, and patient presentation.
In addition to universal precautions, potential loose nail fragments, body fluids, and fine skin or nail particulates guide the selection of personal protective equipment (PPE), which may include eye protection and masks. When using a mechanical rotary tool, fungus particulates may become airborne; CFCNs can protect their airway and skin from colonization by selecting the appropriate PPE.
The nail-trimming procedure includes avoiding potential soft-tissue injury and fomentation of onychocryptosis (ingrown toenails) by trimming the nail straight across as opposed to along the natural curve of the nail. Trim the nail no more than 1/16″ to 1/8″ from the end of the toe, and smooth edges with an emery board or similar tool to avoid sharp edges catching on materials or cutting adjacent digits. Cuticles, an anatomic structure that protects the nail root, shouldn’t be trimmed.
Perform nail debridement, rather than trimming, if the nail has abnormal thickness or appearance. This procedure may require nail care curettes and scalpels.
Discard tools or appropriately sanitize them between patients. Some equipment, such as emery boards, can’t be sterilized because their porosity traps germs. Follow Centers for Disease Control and Prevention sterilization guidelines, which may include disinfectant solutions, cold sterilization, and autoclaves.
Patient considerations, including poor circulation, acute infections, or extremely thick nails, may preclude or necessitate a modified approach to nail debridement. CFCNs should know which assessment findings require referral for safe patient management.
Legal and professional considerations
CFCNs who want to start their own clinic or business should evaluate which setting and reimbursement platform to pursue. Reimbursement options include establishing a set cash fee for services, choosing to seek reimbursement through insurance, and offering the foot clinic on a volunteer basis or as a free service. Although nurses should check their state nurse practice act prior to developing their business structure, foot care remains one of the few areas that allows RN self-employment.
Medicare expects beneficiaries or caregivers to perform routine foot care (nail trimming and shaving, paring, cutting, and removal of calluses [keratoma and tyloma] and corns [heloma]), so it’s excluded from coverage. CFCNs providing routine foot care must collect payment from
the patient if health insurance doesn’t provide coverage.
Any foot care that requires a provider (nurse practitioner, physician associate, medical doctor, doctor of osteopathy, doctor of podiatric medicine) isn’t considered routine. For example, if the patient has a systemic condition or experiences marked limitations in ambulation, pain, or a secondary infection from thickening or other dystrophy of an infected nail plate, Medicare may cover foot care. The Centers for Medicare & Medicaid Services website lists codes that indicate medical necessity. However, on occasion, providers perform services that would be appropriate to delegate to nursing. In this case, the services are considered routine and not covered by Medicare. Choosing to pursue the insurance reimbursement model also requires the clinician to follow a specific frequency of care. Medicare typically covers only the provision of foot care every 60 days.
CFCNs may perform covered foot care services if all CMS requirements are met. These requirements are subject to change, so CFCNs should follow the most recent requirements. (See CFCN® Medicare requirements.)
CFCN® requirements for billing Medicare
An RN who holds foot care certification (CFCN®) may perform Medicare-covered foot care services when all of the following requirements are met:
- The CFCN performs foot care services under the direct supervision of a physician or other practitioner.
- All requirements of the “incident to” provision are met per the Centers for Medicare & Medicaid Services Medicare Benefit Policy Manual.*
- Documentation submitted for reimbursement should include proof of CFCN accreditation.
- The CFCN and the foot care services provided meet all other coverage provisions outlined in A52996 Billing and Coding: Routine Foot Care.
*“Incident to” provisions refer to circumstances in which services aren’t provided under the direct supervision of a provider. The provider is actively involved in the patient’s care and responsible for the services provided, but they’re not directly present at the time the specific service is performed.
Many CFCNs open their own foot care clinics in various settings, including clinics, hospitals, long-term care and assisted living facilities, and in the community. These clinics are usually private pay, where a set fee is charged for each individual. In the home health setting, CFCNs may offer discounts if they provide care to more than one individual in the home or if the patient also requests fingernail care. Cash reimbursement, or having a set fee that’s not sought through insurance, offers several benefits. When delivering foot care in community settings (such as senior centers, fire departments, or churches), nurses can maximize their impact by increasing the number of individuals they care for.
Meet the demand
The demand for CFCNs who can provide affordable care in convenient settings continues to increase. This specialty offers many benefits for nurses, which can impact their quality of life, including more control over their work hours and potentially higher salaries. If you’re interested in foot care certification, visit wocncb.org to learn more, or reach out to a local CFCN to ask about shadowing opportunities.
Foot health is tied to overall quality of life. Foot problems can limit a patient’s participation in the emotional, social, and physical tasks that make life enjoyable. By delivering expert evidence-based care, CFCNs can provide treatment and prevention.
Laura Swoboda is the director of skin and wound care at the Healing Institute in Milwaukee, Wisconsin.
American Nurse Journal. 2025; 20(7). Doi: 10.51256/ANJ0725123
References
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American Association of Colleges of Podiatric Medicine. Doctor of podiatric medicine (DPM). aacpm.org/becoming-a-podiatric-physician
American Podiatric Medical Association. Public Opinion Research on Foot Health and Care. Findings from a survey of 1000 US adults. March 2014. www.apma.org/apmamain/document-server/?cfp=/apmamain/assets/file/public/studies/apma2014todayspodiatristsurveyallfindings.pdf
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Centers for Disease Control and Prevention. Guide to Infection Prevention for Outpatient Podiatry Services. October 2028. cdc.gov/infection-control/media/pdfs/Podiatry-Guide-508.pdf
Centers for Medicare & Medicaid Services. Billing and coding: Foot care. 2024. cms.gov/medicare-coverage-database/view/article.aspx?articleId=56232
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