Dr. Hochman

You have been in private practice for three years now. What made you become interested in gender-specific medicine as it relates to podiatry?

From the time that I was in medical school, I noticed that men and women often came into the office with different problems. There is a different emphasis on pain management and function. I also found that men and women presented their problems differently to the doctor, with men more likely to de-emphasize the pain that they felt. Lastly, I was aware of the reactions that patients had to me, as a female podiatrist. Most opened up to me after expressing initial surprise and I became focused on the differences between men and women in their medical needs and goals. When I did some research, I discovered that there were not a lot of studies comparing gender specifics with respect to foot problems. So, I decided to pursue this avenue.

Are there differences in the feet of men and women, aside from size?

Yes. In fact, the differences in foot size tend to emerge as early as three years old. Children’s feet grow proportionally about 8 to 10mm a year until adolescence, which typically starts around 12 in females and 15 in males. After this time, males have a more rapid growth spurt than females. Men’s feet are both longer and wider than women’s feet. Men’s feet also spread more when they stand. That is why it is so important to walk around when a person tries on shoes. Women’s bones are thinner and the ligaments may be looser, leading to more flexibility.

Can you discuss the impact of some shoe styles, especially for women, on feet? What percentages of foot problems in women are self-imposed due to their shoes? What about women who wear sensible shoes and still have problems?

Women are their own worst enemies when it comes to foot problems. Dress shoes, in particular, cause the most problems for women. Trust me, I know, since I too love beautiful shoes. The most beautiful shoes are not necessarily the ones that are the best for our feet. The problem with most women’s shoe styles is that they all are more narrow than a bare foot, and the front of the shoe is tapered, which forces the toe joints to buckle. Over 90% of foot problems in women are self-imposed and related to footgear. At least 85% of elective surgery for bunions, hammertoes, and neuromas are performed on female patients. Most women will squeeze their foot into a shoe that is too small. For example, as a person ages, their feet continue to get longer and wider. It also loses the fat pads that provide cushioning. All of these factors lead to a change in shoe size as one gets older, yet most people continue to buy a standard size forever. Think about it. When was the last time you measured your foot before you bought a pair of shoes? I find that most women will buy a shoe that does not fit comfortably, simply because they like how the shoe looks on the foot. Shoes don’t let joints move normally in the toes and don’t let the muscles work to full advantage. Of course, there are cases where those women will wear sensible shoes and still have problems, but this is less likely. I try and educate all of my patients to wear the shoes that are suited for their needs.

You mentioned that there are diagnoses that differ between men and women. Can you give some examples and perhaps expound on the reasons behind them?

Certain conditions are more prevalent in one gender versus the other, but these conditions can occur in anyone. For example, I see hammertoes are about six times more in females than in males. This is a function of ill-fitting shoes, and is really not as common in people who go barefoot all the time. Neuromas, which are a thickening and irritation of the sheath that surrounds a digital nerve and affects that nerve to cause burning and tingling sensation in shoes, are also more common in females. I definitely operate on more women than men with respect to elective procedures.

I find that men will have more problems with tendon tears and fractures. Men are diagnosed with ruptured Achilles tendons about five times more often than females. This likely is a result of "weekend warrior syndrome." I have found that osteochondroma, which is a growth of bone under the toenail that grows outward and causes pain, is also seen more in young males.

Diseases such as diabetes and lupus can have negative effects on the feet of men and women. Are there any gender differences in how these types of diseases present themselves in the feet?

Feet are often the place where health warnings can be found. They are often where the first signs of circulatory disorders, diabetes, arthritis, and other systemic diseases are seen.

Systemic lupus erythematosis (SLE) is an autoimmune disease and forms antibodies that attack components of the cell nucleus. It is common in black women. Often, symptoms show up in the feet and sometimes the foot is the only site of the condition. For example, a woman may present with coldness and discoloration of the feet with swelling. Or skin changes may occur, including thinning of the skin. Burning and tingling may be felt in the toes and feet. New-onset joint pain with increased flexibility of the joints can be seen. I like to work with a rheumatologist when I diagnose lupus because I strongly believe in teamwork among physicians.

Even though I work with the lower extremities, I am aware of the whole body. This is especially important in diabetes mellitus, which is multi-systemic. A lot of times I will be the first to diagnose this disease because a patient will lose sensation in their feet or develop a sore that does not heel. In this sense, women are more likely to present to the office earlier, and be more diligent in controlling their blood sugars.

What can a patient do on his or her own for fungal infections of the toenails, and when should he or she visit a doctor?

Fungus naturally lives on the protein keratin, which makes up skin, hair, and nails. If a person has fungus in the toenails, it may be able to be removed by cutting the effected piece of toenail. This can work if only the distal edge of the nail is involved. Applying a topical antifungal cream or lacquer around and under the toenail may prevent recurrence.

A patient should go to see a podiatrist if one toenail is completely infected with fungus, or if more than one nail is involved, or if there is pain. Also, if a patient has medical conditions, such as diabetes or poor circulation, I recommend that they have their feet checked regularly by a podiatrist. Fungal toenails will be thicker, brittle, and discolored. A lot of times, there will be dry skin around the nails or the bottom of the feet, which does not respond to regular moisturizer.

I treat fungus toenails, or onychomycosis, with a course of oral antifungal medication, thinning the nail plate, removing the nail plate, or a combination of therapies.

Are bunions hereditary? If your mother and your grandmother suffered from bunions, is there any way that you can avoid them?

Just as your eyes and nose are inherited, to a certain extent, foot type is inherited. Bunions are hereditary, but they can get aggravated when trendy shoes and heels are worn. When I see a teenager with bunions, I know that her mother and grandmother have this problem too. Several factors can lead to bunions: Athritic conditions limit joint motion, biomechanical problems such as excessive pronation, and genetic syndromes have hypermobility as a component, such as Ehlers-Danlos syndrome.?

If there is a history of bunions in the family, I recommend early examination by a doctor in order to determine if orthotics (custom or prefabricated supports for feet) may help provide arch support and prevent pain from occurring. It is essential that wide, soft leather shoes be worn to avoid irritation to the area around the first metatarsal. I try to determine the cause behind the bunion in order to be able to control or correct it. Often I will surgically correct the bony deformity and educate the patient for early detection in children.

What exactly are plantar warts? How do you know if you have them, and what should you do?

A plantar wart is a benign tumor that is caused by a virus. Plantar warts grow into the skin. When the virus gets into the skin, it starts multiplying and starts to develop small blood vessels around the area. If you look closely at a plantar wart, you will notice several things. You will see a loss of skin lines where the wart is located. In its place, you will see an area that looks like the head of a cauliflower and may have little red dots in it, where the blood vessels are close to the surface.

The wart often is painful but does not have to hurt. If you have plantar warts, I recommend going to see a doctor for care. They often spread and it is much easier to get rid of solitary wart. I know that there are over the counter methods, but they are best used under the active care of a podiatrist because it is easy to chemically burn the skin. I may remove the wart completely, or try and disrupt the blood supply to the wart.

Should men and women have routine check ups with a podiatrist? If so, how often would you recommend?

Yes. Most people take their feet for granted. Foot related problems have kept one in five people from taking part in sports, work, and/or leisure activities. Most people are not educated in proper foot care. Feet are out of sight and therefore out of people’s mind. When summertime comes and people are barefoot or in sandals, then the number of people who present to the office increase because their feet are actually exposed to other people. I believe strongly that taking care of your feet is vital because if you cannot walk comfortably, it will affect all of your activities. Once I have educated my patients, they are more self-aware and will be more likely to take care of themselves.

Foot pain is not normal. Anytime that your feet have persistent pain, you should have your feet checked by a podiatrist. If painful feet are left untreated, it can lead to chronic problems and loss of mobility. Problems start becoming more distinct as one gets older; for that reason, the American Podiatric Medical Association recommends a yearly check-up starting at 50 years old. Since we are living longer and more active lives, it is important that our feet stay in good condition. I feel that if there are any concerns about your feet, you should have a complete examination and have all your questions answered by a podiatrist. It is equally important for men and women to consider the cost of not being able to walk functionally.

I see patients with diabetes annually from the time of diagnosis in order to prevent serious foot problems from occurring. At least 15% of patients with diabetes will develop foot problems, many of which can be prevented. Depending on the situation, I may increase visits to as often as four times per year.

How far up the leg do podiatrists go? Does their care include the ankle?

Each state has a specific definition of the scope of practice for podiatric medicine. Scope of practice may include the foot; the foot and related/governing structures: the ankle; the leg; the muscles and tendons of the leg governing the function of the foot; the lower leg; the soft tissue of the lower leg distal to the tibial tuberosity.

For example, in New York State, a podiatrist cares for the foot. In New Jersey, a podiatrist cares for disorders of the foot, ankle, and lower leg. One of the most important things to remember is that a podiatrist are trained in all aspects of the lower extremity and that the state in which he or she practices sets the scope.

What different advice would you give to men and women about caring for their feet?

For women, I would emphasize the need to stay in comfortable shoes that fit. Women should vary the kinds of shoes that they wear. Early signs of poor foot care include corns, calluses, toenail pain, foot fungus and swelling. Women should be cautious with respect to pedicures to avoid infections. I recommend bringing a set of your own instruments. I specifically highlight care of the feet during pregnancy when the entire posture changes and there is laxity in the connective tissues.

For men, I would highlight the need to replace your shoes on a regular basis. A person can get tendonitis from repetition of motion with loss of cushioning in shoes. If you are going to exert yourself on weekends, please stretch your legs and feet. It is important to maintain proper hygiene by keeping feet clean and dry.

In what ways can the Partnership for Women’s Health help in getting information to your specific patients?

The Partnership offers a wonderful forum for doctors to become more educated on all aspects of gender differences in a medical sense. It offers the opportunity to educate physicians to be more sensitive in discerning another important variable of diagnosis of disease, which in turn will lead to more focused handling of the conditions involved. For this reason, I believe that presenting the information found in this web site needs to be done through educational forums such as lectures and round tables. I believe that interdisciplinary collaboration is the way of the future. Working together, we can educate patients to be sensitive to their own needs.

Is there anything you would like to add?

I believe that men and women differ not only in some medical conditions, but also in the way that they communicate and in their expectations of outcomes. I tend to focus on each patient as an individual and care for them as individuals. The more I know about a person, the better I can care for them. I look forward to sharing the knowledge gained from interaction with the Partnership to both my patients and fellow practitioners.

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