Catherine Wright, 61, a retired telephone operator from Quincy who cheerfully admits she wore “fancy high heels” for years, sat propped up, admiring her podiatrist’s handiwork.
On her right foot, where a mish-mash of hammertoes and a nasty bunion had been, Wright had a long incision and a string of neat, black stitches from her big toe halfway along the top of her foot. Her other newly-straightened toes sported smaller incisions — and steel pins to keep them aligned as they healed.
“I don’t think it’ll ever be beautiful,” she said, as her husband Scotty looked the other way, “but I’ll paint up the toenails and be able to walk without pain.”
In the examining room next door, Irene Pozzi, 72, a retired clerical workerfrom Dorchester, gazed at her right foot, a monument to her ongoing battle with rheumatoid arthritis.
Her index toe lay at a right angle to her leg, crunched under her other toes. “I ignore it,” she said matter-of-factly, more interested in her glowing pink, freshly-scraped calluses.
In the waiting room, every seat was taken. A 62-year-old Roslindale man wondered why his foot swelled when he walked. A 57-year-old Dorchester woman wanted her excessively thick toenails cut. A 69-year-old Hingham woman had corns that needed some TLC.
But the crowd this recent January morning was actually nothing special. Business is always booming in the homey South Boston offices of podiatrist Edward Hurwitz, as it is for foot specialists nationwide, because most of us, as we age, either can’t or won’t take good care of our feet ourselves.
Every year, 5.4 million people with sore feet hobble to medical doctors, according to the National Center for Health Statistics.
And that doesn’t include the 68 million of us who take our aching bunions, heels spurs and ingrown toenails to podiatrists, who are not M.D.’s but have four years of post-college training in one of the nation’s seven schools of podiatric medicine.
Indeed, as we walk, run or stumble through life, 75 to 80 percent of us get foot problems of some sort, and the risk goes up sharply with age, says Glenn Gastwirth, deputy executive director of the American Podiatric Medical Association.
Usually, the problems are pedestrian — like hammertoes, a claw-like condition that is triggered by muscle problems and exacerbated by shoes that crunch up the toes; or bunions, which are caused by an inherited tendency toward misaligned big toes and are made worse by bad shoes.
But sometimes, foot problems can be deadly serious, especially for America’s 16 million diagnosed diabetics and another 8 million who have diabetes but don’t know it.
One in four people with diabetes develops foot problems, says podiatrist Pamela Colman of the 10,000-member podiatric association, and for many those problems are tragic.
Every year, government figures show, people with diabetes have more than 50,000 leg amputations above or below the knee, and 34,000 have foot or toe amputations. About half of these surgeries could be avoided with proper foot care.
The problem in diabetes, specialists say, is that excess sugar in the blood triggers a process called glycosylation, in which glucose molecules and their breakdown products infiltrate and stiffen bodily tissues. When this happens in peripheral nerves — like those in the arms, legs and feet — the ability of the nerves to function properly declines markedly.
And without good nerve function, people with diabetes simply don’t feel the pain that tells other people when blisters, calluses or ingrown toenails are becoming infected.
Because diabetes also causes circulatory problems, many people with diabetes also have decreased blood flow to the feet, which means immune cells can’t keep up with otherwise routine infections in the feet, says Geoffrey Habershaw, chief of podiatry at Deaconess Hospital and the Joslin Diabetes Center.
In that joint program and at one other center — the University of Texas Health Science Center in San Antonio — doctors are finding that good foot care reduces amputations.
At the Boston center, many people’s feet are saved by antibiotics — often a combination of several kinds to combat the mixed bag of germs in most foot infections — plus reconstructive surgery and bypass surgery to restore circulation.
The payoff has been dramatic. Fifteen years ago, nearly a third of diabetics with foot infections wound up with an amputation. Today, though the amputation rate is not falling nationwide, it is just 4 percent in the Deaconess-Joslin program.
Specialists are hoping that a two-year-old program called LEAP — Lower Extremity Amputation Prevention program — may bring similar benefits to more people.
Through the government’s LEAP program, health care providers learn to assess nerve function with a simple instrument called the Semmes-Weinstein monofilament, essentially a piece of fishing line that pops out of a plastic handle with 10 grams of force. If the individual cannot feel the tiny pricking sensation, it is a sign of faulty nerve function in the feet.
For most people, though, it’s not the dramatic complications of diabetes but the humdrum effects of aging that cause the most foot problems.
“As people age, ligaments lose elasticity,” especially in those who gain weight,” says Hurwitz of South Boston. “You don’t get bunions because you wore Mary Janes when you were 12, but from bad genes, bad shoes and wear and tear, as ligaments and tendons get loose.”
In fact, years of wearing attractive but orthopedically-disastrous footwear — including shoes that are too narrow and shoes with more than a one-inch heel — are the main reason women have four times the foot problems of men.
So if you’re among the millions who think it’s normal to kick off your shoes at night and moan, “My feet are killing me!” there’s a simple message: Think again.
Feet are not supposed to hurt. If yours do, it’s time to get help, from a podiatrist or an M.D. trained in orthopedics, like the 14,000 members of the American Orthopedic Foot and Ankle Society, who have four years of medical school plus four to six years of residency training.
For most things, like bunions, corns, heel pain and the like, it probably doesn’t matter which type of specialist you see, as long as he or she is licensed. But podiatrists vary widely in surgical training and experience, so be sure to ask.
For problems above the foot — notably the ankle — it may best to see an orthopedic surgeon.
“If I were a patient with an ankle problem,” says Dr. Mark Myerson, director of foot and ankle services at Union Memorial Hospital in Baltimore, ”I would not go to a podiatrist because podiatrists, across the board, are not generally trained in ankle problems but in problems of the feet.”
The same goes, in his view, for bone fractures and deformities of the feet, including arthritis.
But many podiatrists, among them Habershaw of the Deaconess, disagree, noting that many podiatrists take advanced residency training after podiatry school.
Whomever you consult, what counts is getting help before minor problems become major.
Take it from Catherine Wright, who should know: “I just kept putting things off.”
SIDEBAR 1THE MOST COMMON FOOT PROBLEMS
– Blisters, caused by skin friction. Don’t pop them. Apply moleskin or a Band-Aid and leave in place until it falls off naturally in bath or shower. Keep feet dry and wear socks to cushion feet. Seek help if blisters become inflamed or painful.
– Bunions, misaligned big toe joints that can become swollen and tender. Bunions tend to run in families, but the tendency is aggravated by shoes that are too narrow in the toe. Surgery is recommended if the bunion affects your lifestyle.
– Corns and calluses, protective layers of dead skin caused by friction of bones against skin. Corns may be caused by too-tight shoes and crooked toes. Calluses are caused by friction from faulty foot mechanics, often from arches that are too high or too low. You should file calluses and corns with a pumice stone, but never cut them with sharp instruments. And don’t try to burn them off with acids.
– Hammertoes, a condition in which the toes are bent in a claw-like position. Usually caused by muscle imbalance, but can be aggravated by bad shoes. Buy shoes with ample toe room and soft uppers, the part of the shoe above the sole. If hammertoes affect lifestyle, surgery may be needed.
– Heel pain or heel spurs, caused by plantar fasciitis, an inflammation of the connective tissue on the bottom of feet. They’re caused by faulty foot structure that puts stress on the heel bones. Try over-the-counter anti- inflammatory drugs and ice. Orthotic devices may help redistribute weight.
– Ingrown nails, which dig into the skin because of improper trimming, shoepressure, injury, fungal infection, heredity or poor foot structure. Nails should be clipped straight across, slightly longer than the end of the toe.
– Neuromas, enlarged, benign growths of nerves, usually between the third and fourth toes, caused by bones rubbing against nerves. Orthotic devices and/ or cortisone injections may help, but surgery may be needed if neuromas affect lifestyle.
– Warts, caused by a virus that enters the skin through small cuts. Warts usually go away without treatment. Over-the-counter medication may help, but don’t use these acids on calluses. Warts can also be treated with minor surgery.
SIDEBAR 2A CHECKLIST FOR FOOT CARE
– Check your feet daily for cuts, sores, bumps and red spots, especially if you have diabetes. If you think an infection is brewing, see a foot specialist immediately.
– Have your doctor check your feet at every visit.
– Wash your feet in warm, not hot, water, every day. Do not soak feetbecause this can dry your skin. Dry well between the toes, then put on moisturizing cream to reduce skin cracks.
– Cut toenails straight across. Use an emery board to smooth sharp edges that could cut an adjacent toe.
And when you’re buying shoes:
– Have feet measured while you are standing.
– Try on both shoes and walk around.
– Don’t buy shoes that need “breaking in.” Shoes should feel reasonably comfortable as soon as you buy them.
– Don’t rely on remembering what your size is. Feet get bigger and brands vary.
– Shop for shoes late in the day, because feet swell.
– Get shoes that fit in front, back and sides and distribute your weight well.
– Select shoes with leather uppers, a stiff cup around the heel, appropriate cushioning and flexibility at the ball of the foot.
– If you’re going to wear socks, have them on when you try on shoes.
Specialists offer these tips on foot care:
– Athlete’s foot, a fungal skin disease that starts between the toes or on the bottom of the feet. Symptoms are scaly skin, itching, inflammation and blisters. You can help prevent infection by washing feet daily with soap and warm water, drying thoroughly, and changing shoes and hose often.