Sunday, November 23, 2014

Should I have foot surgery? To fix or not to fix my bunion or hammertoe?

If you have just left your doctors office and they have told you that surgery is your best option for your foot deformity, you may want to read this and listen to our latest podcast above first before going through with the surgery.  Now full disclosure Dr. Henne and myself are Board Certified in foot surgery and perform surgery weekly.  That being said we will be the first people to try and talk you out of having unnecessary surgery.  More importantly we make sure you fully understand the post operative course (how bad it really is).  We never SUGAR COAT anything.

Many people come into the office with a bunion or a hammer toe and want it fixed.  But unless they pass a very strict set of criteria to be a candidate for surgery, we turn them away.  I will jump right into the nitty gritty here folks.  Number one reason to not have surgery is NO PAIN!  Yes the old adage if it ain't broke don't fix it still stands. If you do not like the way your feet look, surgery is never the answer! Feet are for function not for entering beauty pageants.  If you want pretty feet, foot surgery will give you pain and may never guarantee a beautiful foot.

When do I operate on someone? The answer is simple: if they have pain that has not improved with a normal course of conservative care and I know that there is a great chance their foot will feel better after surgery.  I never tell someone that their foot will look so much better only that their foot will feel better. I believe the unrealistic expectation that your foot will look better after surgery plays a huge role in why some people are very unhappy after foot surgery.

Bunions are a great example of the type of deformity a lot of people have but do not have a lot of pain with it.  They present with the big bump on the side and want their foot to look thinner but have no pain.

A bunion is a enlarged bump on the inside of the foot at the base of the big toe.  A bunion, in its simplest definition, is a imbalance at the 1st metatarsal phalangeal joint(the big toe joint). A contracture of the lateral side of the joint and stretching of the  medial side of the joint further contributes to the bone getting more deformed.
Over time a bunion can become a progressive deformity that can lead to other deformities like hammertoes, blisters and more. But if you have no pain other than the bump being irritated in some shoe gear, then do not have surgery. The fix for the non-painful bunion is really an adjustment in shoe gear.  Go for a wider toe box and get a mesh sneaker like the one pictured here.  The mesh will give unlike a leather or pleather material. The less pushing you have on the big toe the better to prevent any further progression of the deformity. Also if you just have to wear those fabulous shoes for the day then we have some suggestions on how to cheat the system below!

Hammer toes are a very similar situation to bunions as far as a guide to when to fix and when to just wear a more suitable shoe for your foot type. The hammer toe that is most common is the 2nd metatarsal joint(joint at the base of the 2nd toe) hammer toe.  People often come in and complain of a contracted toe that rubs on shoe gear on the top of the toe.  After a thorough examination, if they have no pain but just the nuisance of shoes that they want to wear not fitting right, I tell them to get new shoes.  I explain that the pain they will have after surgery and the aesthetic result they want to have may not line up to what they expect in their mind.   There are many instances where people have hammer toe surgery and their toe is still kind of deformed looking and much stiffer than they would have expected.  My criteria, which if you are contemplating foot surgery please read closely, no pain in the toe means shoe gear adjustment and using gel sleeves to protect the toe with activity in enclosed shoes.  If there is real pain in the toe and the joint that is unable to be treated with conservative care, then we consider surgical intervention.  I tell all of my surgical hammer toe patients, "You may never be able to wear heels again, and all shoes will not be able to fit just because your toe was fixed."  I always explain the end result is functionality when you have foot surgery not beauty.  

Again, for hammer toes and bunions they make extra-depth and extra-width shoes, that don't look like ugly orthopedic shoes.  They just cheat the extra room where you need it in the shoe with out making the shoe look like it should be on Frankenstein!  

Now, I will tell you that I perform foot surgery weekly on people but only on those who truly need it. If you go see a foot an ankle surgeon and the first thing they offer you for your bunion or hammer toe deformity is surgery, you should run out on your non painful deformed feet and go get some new shoes.  I leave you with this last thought, feet are not pretty.  Feet are for transportation not to be entered in a beauty contest.  I have never seen the foot competition in Miss America for a reason, most people have ugly feet!

If you would like to learn more about other foot and ankle deformities visit our website at

Michele McGowan DPM
Center for Ankle and Foot Surgery @2014

Thursday, November 20, 2014

Don't let your feet take a beating this Thanksgiving Season! Keep your feet feel happy with Vionic Shoes

About a year ago I reviewed the Vionic (Orthaheel) Shoe and Sandal Line. If you know Dr. Henne and myself, Dr. McGowan, we are very skeptical individuals. Not only do we want to know something works before we pass it on to our patients, we would rather try it for ourselves before making a tried and true recommendation for something.

The Orthaheel shoe line was developed by an Australian Podiatrist with already built in orthotic support. This company was recently bought by Vionic.  The whole line has the American Podiatric Medical Association Seal of Approval, which not many products have. The Vionic 44 Cascade Flip Flop I reviewed was my first choice when I first saw the line of Orthaheel/ Vionic shoes. This is a sporty but very delicate looking active sandal.  With Thanksgiving this week, a classic holiday where we stand for hours cooking, I wanted to remind you to support your feet!  Standing for hours preparing a big delicious meal can be torture to your feet.  There is probably no better brand than Vionic to support your feet during the Holidays!
Here was my review a year ago about this shoe:

I will tell you that the moment I put this flip flop on, I wanted to take back every bad thing I have ever said about flip flops! I immediately felt support that I think my feet have been lacking, even in my good athletic sneakers. Because I felt so much support I was nervous to wear them for a full day, echoing the sentiment we give when fitting an individual with custom and over the counter orthotics or inserts in their shoes. We tell them to slowly break them in a couple hours at a time, increasing it slightly each day. I don't know if this was overkill, but I think that I would recommend this before going all day in them, mainly because that is what I did and it worked great.

So I have worn these sandals for last 3 weeks. I have had no problems and my feet feel great. These shoes are touted and praised for a perfect after sports recovery sandal.
Here is what I currently think today:
I agree with all of the above and these shoes get my seal of approval:) They retail at $99, this is money well spent especially for all of my patients who refuse to wear anything other than flip flops but come in complaining of foot pain. I finally have an alternative for these patients that I feel good about.

The Vionic shoes are not just sandals or flip flops.  There are many shoes to choose from and I included a couple links that are from FootSmart, that has a huge selection of the Vionic Shoes.
Since I first wrote this blog I have purchased the Orthaheel sneakers and I absolutely love the extra support I get from such a well thought out shoe like Vionic offers.

Dr. Henne believes that my reviews are a sneaky way for me to buy all new shoes but this is science here, I want to make sure these work for our patients:) If you would like to learn more about these shoes visit us online at:

Want to get rid of your heel pain or plantar fasciits, but don't have time to get into the office?

Many people find it hard to get into the doctors office, but when your foot hurts it sometimes is unavoidable.  If you think you have plantar fasciitis or "heel pain" I would recommend seeing your foot and ankle specialist.  I recently requested a copy of this ebook :

As a foot doctor I am always very skeptical of anything titled "Cure", but I have an open mind so I requested this book to review,  The author was very accommodating and let me read his book. I loved it, it is everything I tell patients to do when they visit me for heel pain.  I wish every patient would read it before they came into the office the advice is great and very practical.

If you are experiencing heel pain and are not able to get in and see your foot and ankle specialist then I would recommend this ebook for helpful insights and advice for helping treat your heel pain.  However, if your symptoms persist, you need to make an appointment with your foot doctor!

What Is Plantar Fasciitis?

 Plantar Fasciitis is an injury sustained as the result of repetitive stress placed on the bottom of the foot. More specifically, its damage sustained on the fascia—a thin layer of fibrous tissue that protects
other tissues within your feet. Many people develop Plantar Fasciitis from long periods of standing, running, or performing various load-bearing activities.

 Plantar Fasciitis Symptoms

The most common symptom of Plantar Fasciitis is pain. This can be burning, stinging, stabbing or throbbing pain. Many people experience a dramatic amount of pain when they first get up in the morning, with the sensation lessening throughout the day. For others, the pain is consistent. The pain can be isolated to an area in the middle of foot, or it can radiate outward towards the toes. The heel is another common area for Plantar Fasciitis pain to show up. Plantar Fasciitis pain can be very stubborn and last for months or even years. Since walking and standing cannot be completely avoided in our lives, the injury can cause serious disturbances in professional and private life.

 Causes of Plantar Fasciitis

Several different things can cause Plantar Fasciitis, which makes classifying the condition somewhat difficult. For example, bone spurs, flat feet, high-arched feet, and hard running surfaces are all very different—but each one can be a cause of the condition. Individuals in professions that require you to stand for long periods of time—nursing, for example—are at a higher risk for developing cause Plantar Fasciitis. Another very common cause of Plantar Fasciitis is the type of shoe you choose to wear. Older or poorly constructed shoes can place your feet at a higher risk for stress. Shoes that don't have adequate padding for the heel and arch can be a problem as well. Finally, overweight individuals are at a higher risk for developing Plantar Fasciitis. As you gain weight, this naturally places more stress on the tissues of your feet, and the fascia tends to bear the brunt of this.


Fast Plantar Fasciitis CureThere are a number of treatment options for Plantar Fasciitis. From special orthotic devices and splints, to stretching and strengthening the fascia itself. R.I.C.E. is a common treatment regimen, which stands for Rest Icepack application Compression and Elevation. Research has shown that 25% of individuals with Plantar Fasciitis have found that rest is the best treatment. Many people have success with dietary modifications as well. Zinc, for example, is an essential mineral that helps you repair and regenerate damaged tissue. Plantar Fasciitis can be a very debilitating medical condition if it is left untreated. The good news, however, is that there are a number of solutions available to help you overcome it. To learn more about Plantar Fasciitis and proven techniques to treat and prevent it, the best guide on the matter is Fast Plantar Fasciitis Cure™ by exercise rehab consultant Jeremy Roberts. This book provides reader with a step-by-step plan of action to overcome the pain and repair the damaged foot tissue. By following this plan, you can quickly reclaim your foot health and your quality of life.

Not sure if you have plantar fasciitis? Then got to our website at and read more!

Wednesday, November 19, 2014

Ankle Sprain!!! What do I do? Have no fear we have some advice!

It is a common scenario, you step off a curb and you feel it, your foot and ankle turn in when it shouldn't! Within seconds your outer ankle starts to swell, get red, and very painful.  If you stand up and can walk I still would recommend you see your foot and ankle specialist.  It is absolutely best to see a specialist that can take an X-ray of your foot and ankle to make sure you have not broken anything.  Your specialist can give you advice on what you need to do to get better, write for a medicine if necessary and offer you devices that may help in the aid or care of your foot or ankle injury.    The reason I stress that you should see your foot and ankle specialist is because there are 6 plus different bones you could possible break with this type of injury. Also, a well thought plan of care is going to be better than your own self diagnosis and treatment. Just "googling" your symptoms, more often than not results in sub-optimal results in your health, and taking your neighbors advice on your foot problems yields pretty terrible results!

So you see your doctor and X-ray shows no fracture, SWEET, right? Well, though I think breaking a bone is not ideal, soft tissue injuries can take some time to get better, and some people struggle for an extended duration.  Convalescence of a foot or ankle injury is very important.  If you do not treat it right, it will not treat you right!

If you have been diagnosed by your foot and ankle doctor with an ankle sprain, these are our recommendations:

1.  ICE, ICE, ICE: not for the first 24 hours but everyday, at least twice a day, for 2 weeks.  There are so many great icing products that are better than the old school ice system of the ziplock bag.

2.  Support is the next piece of the puzzle and depending on the damage, one of a couple options may be best for you. Make sure you ask your doctor about an Aircast splint versus a cam walking boot to help calm down your foot and ankle pain. If you need temporary immobilization all you may need than an Aircast splint, but if you are having difficulty putting weight on the foot than a waking cast would most likely be more suitable.

Some people struggle for months and years with ankle sprains, so choosing the right course of care can make all of the difference in the world! Most people who seek treatment swiftly, take their doctor's advice and follow through with their plan of care have the absolute best results!

If you would like to learn about any other foot or ankle pathology or problems after injury visit

Wednesday, November 12, 2014

Does my nail polish matter? And Pedicures are Safe, Right???

Why 3 Free Nail Polish?

Simply put, beauty should not come with a price tag of harmful chemicals. The beauty industry has a great divide that has developed over the last several years. The consumer now has access to information right at their fingertips to help them make an informed decision on their purchasing choices.  Nail polishes that are 3 Free do not have Formaldehyde, Toluene or Dibutyl Phthalate(DBP). These chemicals at one time were used to help with the consistency and longevity of a nail polish, but they also have potential draw backs linked to in utero development issues, cognitive function decrease, skin allergies and dermatitis.

Many popular nail polish companies still have some of these chemicals in their polish.  So this leaves the consumer in the very familiar buyer beware situation.

Now that more advances have been made in the development in nail polish, you don't have to have
exposure to these harmful chemicals but still enjoy a nice coat of polish! In our medical spa in our podiatry office our nail technician only uses 3 free nail polish that we have developed and bottled, or she uses Dr.'s Remedy nail polish for a small upcharge.

The Dr.'s Remedy nail polish is very nice and has the great features of being free of the bad chemicals and has the added benefit of being enriched with Tea Tree Oil and Wheat Protein.  This is the polish I always recommend for the patient that is experiencing the white dots and drying of the nail.  I explain to patients that those white dots can be the start of damage to the nail from polish and can lead to nail fungus down the line.  If they insist on painting their nails, I tell them the Dr.'s Remedy polish is the best option,  Plus, this is really nice polish.  It is safe for kids, patients under going chemotherapy, pregnant women and people who care about the health of their nails in general. We sell this polish in our office or it is available through our Amazon Store:

Pedicures are Safe, Right? 

Our little intimate spa is very different from the run of the mill strip mall joint.  We take your safety and luxury very seriously.  Every thing in our Natural Nail Spa is single use and all of our instruments are autoclaved(sterilized), even the nail polish goes home with you. Currently, there are only two states that require instruments to be autoclaved or sterilized in the nail spa industry: Texas and Iowa.  Since these are a long commute from Florida and maybe the state you live in, I wanted to give you some advice from one girl(who happens to be a foot doctor) to another girl!

If you do not live in Texas or Iowa, you need to really re-evaluate the place you are getting your bi-monthly pedicure.  Yes it feels great to close your eyes and get pampered having someone take care of your feet.  You can live your life saying what all people say before bad things happen, "That won't happen to me".  Or you can pull your head out and really look at the environment around you.

I wanted to give you 5 Truths(whether you want to hear them or not!) about the "treat" of pedicures:

1. Fancy does not = Clean: When looking for a place to get you nails done, do not be fooled by a nice imported tile floor from Italy, this will most likely mean they are skimping somewhere else to pay for the floor expense.  Ask where their autoclave is!

2. Just because they keep your instruments in a box and say "it's yours", does not mean they do not use it on someone else! Yep, you can not trust this 100%.  There are countless stories I have heard right out of the mouths of patients who have witnessed this first hand.  Also, I have several patients who have got nail fungus from places who claimed to have never used their instruments on someone else.  TAKE YOUR STUFF HOME EACH TIME.  Also, ask them where the autoclave is!

3. In the water you are soaking your feet in, there is most likely tiny pieces of other people's dead skin! This is really one of the grossest truths I know.  Unless they are using a pipeless tubeless spa pedicure chair and cleaning it appropriately, you are most likely putting your feet into a pool of tons of DNA samples.  Don't put your feet in the water!

4. Liners for the tub do not protect you from the DNA samples discussed above: Just because they put a liner in the tub, does not protect you from the a whole lot of anything.  Once the tub is full the water in the liner is contiguous, or touching, the water on the other side of the liner.  That being said, we use liners in our pipeless tubeless spa chairs in our spa, but I think this may be out of peer pressure:)

5. Most nail salons use the cheapest nail polish, multiple times: When researching nail polish for our spa, I found several cheap alternatives, but they involved putting the client at risk.  The cheap alternatives were shipped from China and were not three free and most likely the cancer rate in the factory where it is bottle is at 99% or higher.  Many salons take advantage of such cheap offers because they are only charging $25 for the service so they can not spend more than 10 cents on the bottle.  Now remember, when you go to the salon you pick your color and then it goes back on that wall to be reused.  I have several patients that go for pedicures and they have fungal nails.  They are not turned away from these fancy salons, even if they do not have an autoclave to kill the fungus on the instruments they just used! Again, ask to see their autoclave!

Check out our link here for our best suggestions available on Amazon for an awesome at home pedicure!

Yes, I do take time out of my day to beat up the pedicure industry.  This has a lot to do with all of the damage I have seen to peoples feet from pedicures.  If you have ever had to cut someones toe off after a terrible aggressive bacterial infection that someone got from a pedicure, you too may be a little more intense on the subject matter.  Below is a repeat broadcast of "2 Pods and a Microphone: Is Your Pedicure Killing You?"

Sunday, November 9, 2014

Week 10 NFL Fantasy Football Ankle and Foot Injury Report

Week 10 in the NFL:

All is quiet in the NFL ankle and foot front for the most part this week.  This week we discussed Reggie Bush, Michael Vick, Calvin Johnson, Harry Douglas, Andre Ellington and even Percy Harvin's freak accident in practice this past Wednesday.  If you have any of these players they all will most likely play but how many points they get you for your fantasy football team is a different story.
We discuss Steve Smith and his season ending injury that he had  foot surgery for this week, as well.

Wednesday, November 5, 2014

Marathon runners to one mile a day runners are coming into the office in droves as the temp falls. Why? SHIN SPLINTS!!!!!

It is the time of year, that as the temperature falls the running injuries rise. One of the most common injuries that seems to be walking into the office lately is Shin Splints.  If you have ever had a shin splint you may be reaching down just to rub the front of your lower leg remembering the pain you used to have.  This is not a nice injury, especially if you are training for a marathon.

First of all, you might be asking yourself "Self, what is a shin splint?" I will explain.  A shin splint is inflammation on the front of the lower leg.  The culprit is usually from the repetitive micro-trauma that occurs when one is running on a consistent basis. The anterior tibialis muscle belly becomes strained and starts to pull on the tibia bone causing the most common anterior shin splint.  The inflammation occurs on the bone and on the attachment of the muscle to the bone.  The repeated stress, can over time lead to stress fracture of the tibia if ignored and not addressed.

How you get shin splints becomes an important question as well. If you want to treat anything you have to understand the root cause.  Some people get shin splints from a very simple culprit, shoe gear. Many times patients will explain that they run at least 5 miles a day and two big races over 10 miles a quarter.  Then they whip out their shoes that are missing all of the tread pattern on the bottom as well as holes in the toe box.  Bad shoes do not belong in the world of runners! Especially if you are running more than 3 days a week.  Big miles and bad shoes = all kinds of foot problems!  If you are a runner, you know shoes are your friends but they still will need to be changed out more than an average active person.  We tell the average person to change their shoe gear every 6 months.  I tell all of my runners that it is better to change your shoes every 300-400 miles and that buying two pairs of your favorite running shoes at the same time will at least increase the interval of time that you need to replace your shoes if you are rotating your shoes daily.  I created a little combo of some of my favorite running shoes that are great for support and stand up for long distances a little more than the average shoe for runners who are serious. These shoes are all available at FootSmart online.

Next, if your calf muscles are tight and you are not properly stretching you can get shin splints.  We are all born with more muscle in the back of our lower leg and less in the front.  The biggest problem with this is that these muscle groups are antagonist, they work against each other.  If your calf muscle is really tight you are going to hit the ground with the foot in a more plantar flexed orientation, meaning the foot is going to strike the ground with the foot more pointed down and pressure on the ball of the foot instead of a heel strike.  This breaks up your runners stride more awkwardly and causes you to have more strain on that front of the lower leg, especially when you push off on the next stride.  So stretching is key for runners to take the strain off of the front of the lower leg when they are prone to shin splints.  I have included my world famous stick figure drawings for stretching for your perusal.

There are other reasons that one may get shin splints but they are not as prevalent as the two main ones we go over above: bad shoe gear or warn out shoe gear and insufficient stretching are more often than not the main issues.  Look to these first before making any other big changes.

Treatment for shin splints is pretty straightforward, change shoes and stretch of course.  Also, your doctor may want to put you on a medicine by mouth to help with the inflammation associated with the shin splints.  I recommend icing and a period of rest in cases where there is a lot of pain associated with the shin splints.  Many of my runners are crazy and if you are a runner you may also fall under the crazy umbrella.  It is hard to get a runner to stop running, especially if they are a serious runner putting on serious miles.  I try to explain to all of my runners that if they give the injury rest and convalesce this correctly they will return to running with less of a chance of struggling for months and years on and off with shin splints.

I leave you last with the suggestion of using the compression type sleeves while running and putting on these big miles. Compression sleeves are not a treatment for shin splints or any other lower leg disorder but they have been proven in recent studies to increase blood flow to the most important areas while you are running.  Compression sleeves are a graduated compression from the ankle to up past the calf muscle itself. These types of sleeves help decrease the amount of swelling that may be occurring on long runs where gravity starts to help us keep more fluid in the ankles. These sleeves in a nutshell help the body with the venous return of our deoxygenated blood back to the heart.  The by product of this is also a decrease in muscle soreness and quicker recovery due to the lactic acid build up being more efficiently cycled through the body.  Even though the compression sleeve is not a treatment for shin splints, I do believe they can help stabilize that tibialis anterior muscle and may be able to decrease some of the shear force this muscle has with running on the anterior tibia bone.

So again, they keys to help you with your shin splints are:

1.  Good shoes: look at your shoes and changes them out if they are breaking down
2.  Stretching:  the calf muscle should be stretched several times a day
3.  Icing the injury will help with the local inflammation
4.  Compression sleeve may help improve and maybe prevent shin splints in the future
5.  See your doctor if your symptoms persist he or she may be able to put you on a medicine by mouth to help the swelling as well and they can take an x-ray to rule out a stress fracture.

Michele McGowan, DPM Owner and doctor of the Center for Ankle and Foot Care Clermont FL

If you are interested in learning more about other foot and ankle problems please feel free to visit our website at


Tuesday, November 4, 2014

November is National Diabetes Awareness Month, Knowledge is Power!!!! Read On:)

Podiatrist Play a Big role in Diabetes Amputation Prevention:

Despite being one of the most serious and costly complications of diabetes, foot complications can be effectively prevented. By implementing a care strategy that combines prevention, the multidisciplinary treatment of foot ulcers, appropriate organization, close monitoring, and education of people with diabetes and healthcare professionals, it is possible to reduce amputation rates by up to 85%.      
International Diabetes Federation (IWGDF), 2011

Diabetes doesn't have to equal amputation!
Every time I meet a new patient that has just been diagnosed with diabetes, usually Type 2 non insulin dependent due to the demographic I see, we usually have some type of conversation about limb loss.   It seems that all of these people have an uncle, aunt, parent or grandparent that has had an amputation.  So when these people are first diagnosed with diabetes their initial fear becomes the "A" word, amputation.

Sometimes doctors are not the best communicators with this type of patient.  With the type two diabetics, their should be some type of discussion about weight loss and the contribution their belly fat has to complicating this disease process.  I am always happy to discuss this with the patient when this may have been overlooked by their doctor who is trying to make sure that the patient doesn't die of something else.  

How I always describe the process of belly fats roll in the Type 2 non-insulin dependent diabetic to a patient so they can grasp what is going on in simple terms is as follows:
1. Your pancreas is working
2. When you eat, your pancreas is producing insulin
3. The insulin gets trapped in the fat cells closest to the pancreas itself
4. Since the fat cells are trapping your insulin, your blood sugars go up

I also explain the process of diabetic neuropathy to the patient, explaining what happens next, as the sugars
are not being met with the insulin.
1. Our body has a mechanism to try to counter the glucose in the absence of insulin
2. The Polyol Pathway kicks in and tries to reduce glucose but produces sorbitol
3. Our bodies are not efficient at clearing this and its other byproducts
4. The sorbitol will attach to the nerve endings and contribute over time to neuropathy symptoms

Why I explain this has a lot to do with my strong belief that if you can get the patient to understand a little they may be able to help themselves.  I am sure the patient will not go home and tell their family all about the Polyol Pathway and sorbitol. But they might just think about it, internalize it and try to help themselves.

When I have the uncomfortable conversation about their belly fat, I discuss the benefits of a simple 10 minute walk a day to start.  For some of these people, what comes along with the Type 2 diabetes and belly fat is aching joints and feet.  So exercise sometimes needs to be creative.  In Florida we have the advantage of almost year round pool usage which is great.  I encourage patients to walk in the pool or swim, giving less trauma to their already aching joints and feet.  They need to start somewhere and a little will go a long way in the beginning.  What the patient is really trying to do here is decrease their amount of insulin resistance. Exercise will help and hopefully help them loose the belly fat.

Diabetes does not have to equal amputation
This again is a topic that becomes paramount for the newly diagnosed Type 2 and Type 1 Diabetic patients.  The stigma of limb loss with diabetes is unavoidable.  But is has been documented throughout the literature, complications of diabetes to the foot and lower limb can be avoided with good preventive care.  Like most anything, at home prevention and patient mind set play an important role in patient outcomes.

I tell all of my newly diagnosed diabetic patients, that the patients that I wind up having to amputate a toe or part of their foot on are usually consults from the hospital, not current or past established patients.  The normal scenario is a patient that come through the emergency department of the hospital and gets admitted for a foul smelling wound.  The patient may have blood sugars that are regularly in the 300s and does not check their feet on a daily basis.  These two things alone are a recipe for disaster and I always stress that to my patients.

Compliance plays a huge role in whether someone I meet as a patient for the first time will actually go on to limb loss.  Obviously, if they are admitted with and infection that is so severe that the bone is infected and tissue is destroyed, they have already sealed their fate for potential limb loss.  But if the patient can follow instructions and work on improving their blood sugars and be compliant with wound care, they have a chance.

Top 4 reasons wounds do not heal
I preface this with the following, If a patient has any of the following 4 issues, it does not mean that the pressure, lack of blood supply, infection and smoking. 
wound will not heal, as I will explain below.  But having any of the following 4 as an issue and not making steps to change the situation will surely complicate the patients situation.  So the top 4 reasons wounds do not heal are:

Pressure, I always start with pressure. Since many of our diabetic patients with wounds have neuropathy, I explain this one first.  It only takes about 4 minutes of pressure for tissue necrosis and death to start to occur.  What that means is that when you are standing on an area that is callused or has an open pressure wound, after about 4 minutes we are starting the process to do further harm.  For the callus patient that can mean damaging the skin underneath the callus.  This can lead to a wound underneath the callus.  For the patient with an open wound this can lead to the wound getting bigger and deeper.  When a patient is checking their feet daily, they are more likely to notice and take care of these problems before they become bigger issues.  If they already have an established relationship with a foot doctor they can get in to the office be seen and treated.  Treatment for wounds caused by pressure revolve around offloading, an external means to remove pressure off the area.  We do this with padding, special shoes and special casting when needed.

Lack of blood flow I define as not being able to palpate pedal pulses in the office or a decrease or stenosis of blood flow that is not supplying enough blood to the foot.  Many of my diabetic patients I see for preventive foot care have this condition to their extremities but they have no open wound so it becomes less of an issue for them.  We focus at that point on prevention.  When someone walks in with an open wound and no palpable pulses the game changes.  This is the patient that needs a referral to a vascular surgeon before I can help them.  I never waste the patients precious time in this scenario.  If I can't feel their pulses and they have an open wound, I am sending them to the best vascular surgeons I know. They need blood to heal simple as that.

 is another area of the wound that must be assessed.  If there is a simple infection sometimes just an
antibiotic will do the job.  Often, though, many of these types of infections have a more significant effect on the soft tissue.   These wounds requiring multiple debridements to cut away dead tissue from the wound that
the infection has killed.  Theses are the patients that are typically admitted to the hospital, placed on IV antibiotics and have multiple trips to the operating room.  Until all of the infection is cleared it is impossible for the wound to heal.  Once we are certain that the wound is free of infection we can close the wound if there is enough soft tissue, if not we use many different wound care modalities to aid in the closure of their wound.

Smoking is the final topic I speak with my diabetic patients about to decrease their risk of complications.  Simply I state to my patients that they need to STOP SMOKING if they want to keep their limbs.  The damage that smoking does to the arteries, soft tissue and skin can make the difference between losing a limb or keeping it.

Dead horse but prevention is key
This a topic I literally try and beat into my patients.  I want patients to know that most of the terrible infections and amputation I perform are not in the compliant patient. The amputation rate in my practice for established diabetic patients, that were not seen for the first time in the emergency room or hospital, is very close to 0%.  My established patients, that are seen for regular diabetic foot check ups do not end up getting amputations.  We catch problems on these visits so that problems do not progress to a point where they get out of hand.

Below are my very generic but very effective tips on preventing foot problems when you are diabetic. I encourage patients to follow these guidelines and feel free to share them with friends or family members that also may benefit from this advice.  And I always my patients it is always better to be safe than sorry.

What can I do to better take care of my feet?

There are many steps you can take to greatly reduce the chance of major injury to your feet.
  • Visually check your feet and toes daily for any cuts, sores, blisters, bruises, bumps, infections, or nail problems, EVERYDAY.
  • Wash your feet daily using warm water and mild soap. Check the water temperature with your wrist to make sure it isn't too hot, and do not soak your feet for long periods or at all.
  • If you have dry skin, cover your feet — except between your toes — with petroleum jelly or cold cream before putting on shoes and socks.
  • Wear thick, soft, and loose-fitting socks and shoes that fit well and allow your toes to move. Rotate your shoes and do not wear new shoes for more than a few hours at a time.
  • Watch out for a thick seam in a sock, it can help cause ulcers on the tops or tips of the toes.
  • Cut your toenails straight across and don't leave sharp edges that could cut the next toe, they are too difficult to cut yourself or you have neuropathy or peripheral vascular disease, see a podiatrist.
  • Never go barefoot on the beach or anywhere else.
  • Have your feet checked at every doctor visit.
  • Do not sit with your legs crossed. Crossed legs can cut circulation to the feet.
  • Do not use tobacco products. Smoking impairs circulation.
  • check out more of our tips at:
Diabetic foot by the numbers:

  • Every 20 seconds a lower leg is lost due to diabetes globally
  • A majority of these amputations are preceded by ulcers
  • Only two-thirds of ulcers will eventually heal and the remainder may result in some form of amputation
  • Median time of healing for an ulcer is approximately six months
  • Each year, some 3.8 million adults die from diabetes-related cause
  • Diabetes is the fourth leading cause of death by disease globally
  • In 2011 it is estimated that 366 million people worldwide have diabetes
  • The number is expected to reach some 552 million by 2030
Ref: International Diabetes Federation (IWGDF), 2011  and  American Diabetes Association, 2012
2010 United States Census

Sunday, November 2, 2014

Ankle Dislocation is not a quick recovery,that being said Robert Griffin III probable in Week 9 of NFL season!!!!! We will see.

First and foremost, I do not consider myself a negative Nellie, but there is no way RG3 could have had an ankle dislocation if he is expected to play this Week 9 of the NFL.

I was sad to see the Washington Redskins, Robert Griffin III, get hurt on Week 2  against the Jaguars this season. As the MRI reports came back that week, there were murmurs of relief that nothing was broke. I challenge that notion that it may have been better to have a fracture.  When someone has a fracture their is a predictable time period in which it will take for that individual to get better.  But when someone dislocates a load bearing joint like the ankle, I believe there is much more concern for the future of their athletic career.

If you are not aware of how serious of an injury this is refer to the ankle illustration.  Notice the ligaments that are around the ankle, these tiny little ligaments have a lot of responsibility.  The anterior talofibular, calcaneofibular and the posterior talofibular are crucial to the stability to the outside of the ankle.  On the inside of the ankle we have the Deltoid ligament for medial stability.  The ligaments just mentioned above are basically, in layman terms: the connectors of the foot to the ankle.  When these connectors are disrupted with a violent force, like the one RG3 supposedly had, the recovery is long and not always very straight forward.

When you look at the ankle joint itself without the ligaments, muscles, tendons and skin, you can truly appreciate its' fragility.  It is made up of three bones: the tibia, the fibula and the talus.  For perspective sake, the talus is about the size of a 3/4 eaten apple.  It is small but does so much for ankle and foot stability.  Disrupt the ligaments attached to the talus and your suffer a pretty significant injury. One, that for a football player on the professional level, may very well be season ending and can be career ending.

This is why we were so puzzled by the rush to return to playing this season for the Washington Redskins injured quarterback Robert Griffin III.  This is an injury protocol that is setting a very bad precedent for future NFL players(Dr. Henne would argue with me that this is already set due to the amount of money on line for both team and players).  Players in the future with this type of violent injury may feel compelled to rush back only to lead to the early exit from their NFL career.

I can only speculate that if RG3 steps on that field today and is running and passing like the good old days, that he indeed suffered a very severe ankle sprain but not an ankle dislocation.  Bad ankle sprains require time off like RG3 had.  A bad ankle sprain after a period of recovery can be taped and back on the field with somewhat less of concern of re-injury compared to the diagnosis of ankle dislocation.

Treatment for an ankle dislocation with no fracture and no impingement of soft tissue is often conservative, with a period of non-weight bearing followed by gradual increase in activity is a walking boot with physical therapy.  Physiologically, 8 weeks for the ligaments to heal with a bad ankle sprain.  In the case of the ankle dislocation the question of future instability arise especially with such an early return after such and injury.

The game today of RG3's team the Washington Redskins against the Minnesota Vikings will be the most anticipated game of the day in our house.(Mainly, because we have a bet about RG3 actually playing or not)  I am excited to see RG3's return and wish him the best of luck.  He is available in my Fantasy Football league and at the first sign of him playing well I hope to be the first person to add him as my backup quarterback, I have Cam Newton and he gave me only 18 points on Thursday, so I'm desperate!  UGH!!!

If you are interested in learning more about foot and ankle injuries go to the Center for Ankle and Foot Care at We are constantly updating our webpage to better help you understand your foot and ankle problem.  We also make suggestions for devices to maybe help you foot pain but they should in no way take the place of a doctors visit if you are experiencing pain!

Michele McGowan, DPM Owner and doctor of the Center for Ankle and Foot Care in Clermont Florida and Fellow of the American College of Foot and Ankle Surgeons.