Jerusalem at your feet

Is the capital in step when it comes to foot care?

ome of us are sufficiently fortunate, patient and daring to travel Jerusalem's streets by car, bus and motor bike, but for the majority of Jerusalemites, the capital is a walk in progress. Our feet are intimately acquainted with Katamon's hills, Har Nof's staircases and the Old City's hard stone. The health benefits of walking aside, this daily foot pounding is creating a plethora of podiatric problems that extend beyond the ingrown toe nail. Foot deformities such as bunions, heel spurs and hammer toes are just a few of the ailments that plague the patients of American trained podiatrist Dr. Richard Jaffe. Jaffe moved to Israel after practicing podiatry in California for 13 years. "You see far more foot injuries here both because people walk so much more and the sidewalks are not in very good condition," he explains. More than half of his patients suffer from heel problems, particularly heel spurs which develop from calcium deposits in the heel creating bony protrusions and irritation of the ligaments that make walking and standing painful. The pain from these injuries can be exacerbated by the rock hard floors traditionally found in Israel's buildings. Nonetheless, Jaffe points out, "A hard floor is a benefit to a person with a normal foot, but it is less forgiving for people with an abnormal foot; anything that is not right will be amplified by a hard floor," he said. If the rickety sidewalks, hard floors (not to mention the old stone sloping and unstable surfaces in some pre-State houses) aren't reason enough to make you feel unsteady on your feet, then the fungus-infected, bruised and swollen feet of an Israeli soldier who has not removed his boots in over two weeks will certainly make your toes curl. Podiatrist Hillel Gluch regularly sees soldiers whose feet are suffering from prolonged marches under the weight of heavy equipment, poorly designed boots and insufficient pre-enlistment preparation. Like the cardiovascular system, which requires time and training to be in top shape, he explains, foot bones also need to be built up. "Foot bones become denser with training, but before they get denser, they become softer," he says. Gluch recommends that soldiers start getting their feet in shape over a year before they join the army. Soldiers, like runners, also tend to suffer from the biomechanical condition to "overpronate" (an excessively inward roll of the foot when walking or running) that can affect not only the lower leg, but also the entire body. For one entrepreneurial soldier neither the over-the-counter options nor the custom designed orthopedic insoles were able to relieve the pain brought on by his army boots. "My feet were starting to lose feeling and my toes were turning purple, especially after long marches," recounts Jerusalem-based Shlomo Friedbauer. After months of seeing various doctors and experimenting with different solutions, Friedbauer discovered an orthotic from the United States which employed the latest technology to create a do-it-yourself custom insole. Like the heat-produced professional custom insoles, this malleable insole adapts to the shape of one's foot merely after being heated in the oven for two minutes. Freidbauer was so enthralled with the product that he introduced it to his army unit and after witnessing their enthusiastic reception, started a business selling the insoles in Israel after he left the army. The technology for dealing with foot pain has advanced significantly in recent years, although the simplest solution might be to buy a new pair of shoes, which are generally well made in Israel according to Jaffe. "People tend to wear out their shoes here more than in America, and sometimes when people complain of feet problems, all you have to do is look at their shoes," he says. Surgery is the most common solution for physical deformities such as bunions and hammer toes and the procedures today are vastly improved from the formerly painful, partially debilitating ordeals. Jaffe, who has been performing corrective surgery for 32 years, notes that today you can "operate on both feet at the same time and still walk out of the office right afterwards without a cast and crutches." In the past 10 years, the orthotics industry in Israel has started to catch up with the treatments in the United States. Customers can choose from an abundance of devices that improve arch support, correct foot alignment, offer support and cushioning or even provide relief from back and leg pain. For those with more serious problems with their arch or gait, custom-made insoles, in which a trained specialist creates a cast of your foot to fashion an individual insole, are also available. Perhaps no one understands orthotics better than Peretz Eisler, whose family owns a three-generation orthopedics store in Nahlaot. Eisler's father imported the store 30 years ago from Hartford, Connecticut. Eisler has seen people with every kind of foot pain and problem imaginable from "holes on top of their feet" to "overzealous Jewish grandmothers" convinced that their grandchildren aren't walking straight. Although he makes custom insoles in his store, he often tries to discourage his customers who come in without a prescription from their health-care provider from buying the pricy devices - which can range anywhere from NIS 600 to 2,000. "Most people have a lot of heel pain and just need various types of arch support," he says. For people who need professional care beyond their local foot store, however, finding a qualified podiatrist in Israel presents an entirely new set of challenges. The question of who can legally be called a podiatrist has erupted in a fierce debate that has traversed both the court and the legislative systems and has generally pitted American trained podiatrists against the rest of the Anglo community from the UK, South Africa and Australia. The debate centers around the level of training received by podiatrists in America versus that of their Anglo counterparts. Americans receive a Doctor of Podiatric Medicine degree after first earning a bachelor's degree at a four-year undergraduate institution. They then progress to podiatry school where they often engage in extensive fellowships in foot and leg bone surgery, allowing them to perform the same duties as many orthopedic surgeons. By contrast, in Europe and South Africa professionals usually enter directly into their respective professional studies from high school without first receiving an undergraduate degree. In addition, the podiatry training is exclusively non-surgical, although it includes all the other elements of foot care. Since Israel offers no formal podiatric training, the Ministry of Health has traditionally had no legal guidelines on podiatry certification and has given out licenses based on a subjective set of credentials. Although it might seem like a semantic issue, to Jaffe and many of his American colleagues the number of years and the level of training they have received is significant. Jaffe has worked to establish a set of guidelines that would allow the Ministry of Health to hand out podiatry licenses exclusively to medical professionals with the American level of training. Medical professionals from other countries with non-surgical training would be called chiropodists, defined as a foot care specialist. British-trained podiatrist Daniel Weisz objects to such stringencies. Everyone with foot care training, he argues, should be allowed to be called a podiatrist. Those with surgical fellowships would receive an extra certificate detailing their surgical qualifications. In response to Jaffe's attempts to establish a distinction between podiatrists and chiropodists at the Ministry of Health, Weisz sued the ministry. After seven years of litigation, the courts ruled that the ministry had to establish a law that would lay out official guidelines determining who can be called a podiatrist and who will be called a chiropodist. The law is currently being debated in the Knesset and is leaning toward American podiatrists, of whom there are only 11 in the whole country. Not everyone finds the complexities of podiatry or the streets in Jerusalem to be so daunting. Maurice Benlezrah's doctor in Toronto actually recommended Jerusalem's hills to help Benlezrah's knee heal from recent surgery. "I walked a couple of hours every day uphill and downhill, and it really worked to strengthen my leg," Benlezrah says.