Who you choose for treating your foot wound can mean the difference between keeping your foot and amputation!

Caring for a diabetic foot wound can be extremely challenging.

That is where we come in.

ABOUT US

Established in 2002, The  Center for Ankle and Foot Care has a solid reputation and is respected as foot doctors who care about their patients outcomes.  With a shared vision, our doctors started the company with the intent of providing ethical and superior services, and that is exactly what we do.

MORE THAN JUST WOUND CARE

As surgically trained podiatrists, the Center for Ankle and Foot Care doctors truly understand the diabetic foot, how ulcers are formed and how to treat ulcerations.  Dr. Michele McGowan was trained in Pittsburgh, Pennsylvania and was the diabetic foot fellow.  "My time as the Diabetic Foot Fellow encompassed 2 years of surgical training dedicated to the treatment of the diabetic foot wounds and the complications associated with the wounded foot, " Dr. McGowan explains.  " Sometimes patients waste so much time being under treated by doctors who do not understand the pathophysiology and biomechanics of the diabetic foot.  There are so many studies that show the better outcomes are associated with timely intervention by a skilled physician." 

If you are diabetic and have a wound on the your foot, it is time to call our office.  Dr. McGowan has made treating the diabetic wounds her passion.  "I believe preventive care is paramount, many patients we treat that are diabetic are not aware of all the benefits that insurance covers for them to stay wound free."  At our office we work hard on helping you treat your diabetic foot wound, we work closely with other doctors like vascular and infectious disease, as the team approach is needed many times in the diabetic foot. 

" I love helping patients with wounds get better.  There is no other part of my profession that I enjoy more.  It takes a lot of hard work on the doctor and patient side to help heal a wound.  I am a big fan of tough love and make my patients be an active part of their care. Patients need to know how important it is for them to be invested in their outcome.  Wound care is not a passive patient treatment, patients come in to our office and if they really want to be healed we can help them.  Sometimes I have to get a patient to a vascular doctor to restore blood flow, or an infectious disease doctor for IV antibiotics, sometimes patients have to wear an annoying boot they don't want to wear.  But I take the time to explain all of this to a patient. Sadly, sometimes a patient comes into the office after delaying care for so long and I have to be the person who tells them that it is too late for their limb."  If you have been struggling with a wound for a long time on the foot, it is time to call us at The Center for Ankle and Foot Care and make an appointment with Dr. McGowan.  Call now 352-242-2502. 

Dear Patient, I Can Help You Heal....But I can not cure you!

A story on why Diabetic Foot Ulcers continue to recur and the painful truth on why it continues to happen.

 

Dear Patient,

You are not alone.  After the last 17 years in private practice and the 4 different wound care centers I have seen patients, there are literally thousands of people just like you. I have personally met many people just like you.  They all have some pretty similar stories.  There is the patient who was first seen by his primary care physician who saw the wound on the bottom of your foot and your doctor decided to try to treat it.  Maybe the doctor was trying to make your life more convenient, to not have to go to more than one doctor.  Or maybe your doctor did not realize the urgency there is to diagnosis and start treatment for these types of wounds.  Whatever the reason may be, there was a delay in the care of the wound most likely until you were referred to a foot doctor, or podiatrist.  A Podiatrist is a doctor who is skilled and trained to treat conditions below the knee.  After completing 4 years of post graduate training, your podiatrist will most likely have completed a 2 or 3 year surgical training dedicated to the disease processes related to below the knee.  Many podiatrist have extensive training in diabetic limb salvage.

Over the last couple of years, I have had many other doctors and patients comment at how good I am at treating the wounded foot.  I have worn that hat very proudly, until this past Monday.  I was seeing patients at one of the wound care centers that I work at, when I over heard the patient speaking to the nurse and his exact quote was, " This is all of that doctor's fault that I have this wound again!" I immediately got defensive in my own brain. How dare he say that, it's not my fault his ulcer recurred again.  He has bad luck, bad protoplasm if it were, I healed him fair and square.  He re-ulcerated on his own. I had worked myself up that by the time I had got in the room I was ready to let him have it.

An interesting thing happened when I went in the room.  Right away I looked at this man, who I had treated for months and finally healed after he had the problem for about a year before I met him.  I can honestly say it took us a good 6 months before he had healed.  He had to have IV antibiotics, a special shoe that took pressure off of the area where the wound was located, as well weekly debridements on the wound until he was healed.  Debridement is when the doctor uses an instrument like a surgical blade to remove all of the dead tissue within the wound.

I opened the treatment room door, took a deep breath and then I said, "I can help heal you again, but I can not cure you!" The patient became very agitated by this news.   I will admit that I am very good at giving  advice on how to not get another wound.  I know that before I discharged this particular patient from the wound care center, that I explained to him how important it is to see a foot doctor regularly.  I explained to him that a foot doctor can shave down a callus that could potentially become a wound.  I discussed with him the importance of daily foot inspections and for special shoes to offload the problem area. But, I can honestly say, when he heard the words "you are healed" a couple months ago he assumed this was cured.

He was struggling to argue with me, because he knew that we had discussed wearing the diabetic shoes.  We discussed all of the preventive measures he should take, but he was healed.  He just didn't get it, I could tell by the very confused look on his face.  So I blurted out "When my husband had colon cancer in 2015, the doctor cut out the part of his colon that had cancer and for all intensive purposes he was healed and cured. Yes he could have recurrence but for now he is still cured." I explained to the patient that diabetic wounds on the bottom of your foot are a much poorer prognosis than my husbands colon cancer. Most patients are just not aware of the fact that Diabetes kills more people annually than breast cancer and AIDS combined. American Diabetes Association, 2009. This patient, like the majority of patients with diabetes, do not know that every 20 seconds someone has a non-traumatic amputation as a complication from their diabetes.  Armstrong, et al, Diabetes Care 2013

Patients living with diabetes often do not know that 60-70% of those with diabetes will develop peripheral neuropathy, or lose sensation in their feet. Dyck et al.  Diabetic Neuropathy 1999. This neuropathy, or lack of sensation is why this patient continues to ulcerate or have an open wound develop.  Every time he gets out of bed in the morning to brush his teeth and he doesn't put special shoes on, he starts the road back to ulceration.  Every time he decides to get up in the middle of the night to go to the bathroom he starts the pathway back to ulceration.  He just doesn't understand, once the skin is healed, it does not make him cured.  He will struggle the rest of his life to not be a statistic! Up to 34% of those with diabetes will develop a foot ulcer. Armstrong, Boulton, Bus, New England Journal of Medicine, 2017.  More than half of all foot ulcers (wounds) will become infected, requiring hospitalization and 20% of infections result in amputation. Lavery, Armstrong, et al.  Diabetes Care 2006

There is a shroud of denial that many of these patients wear.  They don't want to hear the words that might just save their limb.  I will continue to push and be an advocate for my wounded patients. But if you are diabetic you need to play a role in your care and then it continues into your prevention. It takes so little effort for someone to re-ulcerate.  It takes great efforts to stay healed.  When this patient re-ulcerated he did not go into remission, there is no current cure for what he has. He has the perfect storm of neuropathy(no sensation on his feet to feel pain), poor bony architecture that causes him to put more pressure in certain spots leaving him vulnerable to developing a callus and ambivalence to the role he has to play in his own care.

So dear patient, if you have just healed from having a wound, you need to do some pretty basic things to keep from having a wound again.  

1. You have to check your feet everyday
2. You have to wear diabetic shoes with inserts that have an offload, to take pressure off of the area where you had a wound before
3. You need to see a podiatrist every couple months
4. You have to not be in denial that only you can keep you ulcer free. 

Number 4 is really the hardest. I liken it to when a Type 2 Diabetic is first told by the doctor that "you need to change your diet, cut out your big carbs like your rice, bread and pasta."  But next thing you know there you are in Olive Garden eating your bread sticks and having your pasta. You know you shouldn't be there but you tell yourself tomorrow you will be good.  The reality is that the diet, if you try a little harder each day you can move in the right direction. Your feet are not the same! The day after you just healed an ulcer and you do not wear the shoes that offload the area  where the ulcer was, you are on the path to re-ulcerating or opening your wound again.  I have seen patients on a Friday with a healed toe wound that come back in on a Monday after going to a wedding over the weekend and end up getting a toe amputation from wearing dress shoes that were too tight for eight hours!

So, dear patient, though you actually fall in my favorite patient category to treat, I can not cure you.  I have no other part of my profession as a podiatrist that I find more fulfilling than helping someone heal a wound.  Especially the people who had a relative like a mother or father that lost a limb, and the patient fears that this is some type of genetic legacy to lose a limb.  The technology, advance re-vascularization procedures that the vascular surgeons can perform, the materials available to offload the wounds, the advances in topical medications to help some of these wounds heal were not available years ago.  People back in the day would go to the hospital with a toe wound and leave with a below the knee amputation.  This is not what typically happens anymore.  

Below is a patient who healed a wound in September. He presented back to the office in late December, after being on his feet during the holidays and not in good shoes.  The first picture is what he looked like about 3 weeks ago and then yesterday.  In 3 weeks of taking pressure off of the area and good local wound care he is almost completely healed.  I decided to leave with this image and order because I want patients to know healing is possible, but you have to be willing to accept the responsibility of staying healed and all of the preventive measures that go along with that responsibility.

Sincerely,

Michele McGowan, DPM
Center for Ankle and Foot Care
3190 Citrus Tower Blvd STE A
Clermont, FL 34711

A common pathway to ulceration...the anatomy of a diabetic foot ulcer.

To the left, you see two pictures of the same foot.  This is a common presentation of the neuropathic diabetic foot. Neuropathic refers to the patient's inability to feel pain and the appropriate signals that would help a patient seek care sooner.  A patient has no sensation, they continue to develop callused skin in one area. After enough pressure from a callus develops a wound starts to form under the callus.  The patient could go for a very long period of time with the ulcer getting larger and possibly infected due to their lack of sensation that is often associated with long standing diabetes.

One of the most critical factors in a patient's successful outcome, is having a skilled physician involved in their care.  If you know someone or you yourself has a wound on the lower extremity, you need a doctor who has a passion for limb salvage.  Limb Salvage is a term that has been coined in reference to preserving the diabetic foot or a foot with an open wound.  Doctors who are trained in limb salvage have been specially trained.  As the diabetic limb salvage resident at West Penn Hospital in Pittsburgh, I spent two years diagnosing, treating and preserving limbs of many patients.  I can honestly say that no other part of what I do as a podiatrist is more gratifying than helping a patient prevent an amputation.  I have practiced in Clermont, Florida since 2002 and happy to say that I have helped save many limbs.  If a patient has a wound below the knee, I can help them!  My favorite place to treat wounds is at one of the two wound care centers that I see patients: Leesburg Regional and The Villages Regional wound care centers, but I also see people in Clermont in my office.

Dr. Henne and myself have had many conversations about our patient outcomes.  The most interesting part about our patients in our practice that are diabetic, is that they are not usually the patients that we have to perform amputations on or have to put them in the hospital for a debridement.  Debridement is a term used describe what a doctor does in order to remove dead or infected tissue from a wound. It could be superficial or down to bone depending on the severity and depth of the wound. What Dr. Henne and I take very seriously is the role we play in preventive care in the diabetic foot.  When we meet a patient who is diabetic for the first time in our office we explain the role we play in prevention of future foot problems, by means of At risk foot care. At risk foot care is the term used by insurance companies for visits to the podiatrist for care of the feet.  These visits are ways for early detection of foot problems that could lead to ulceration and possible infections. These visits are meant to put out fires before they start.  What we offer in our office is the patient is always seen by the doctor and only the doctor performs these services in our office.  There is no medical assistant trimming calluses in our office, only the doctor.  These visits do not seem like a huge deal to our at risk patients because they don't develop problems, just by keeping up with a good foot care regimen.

If you are diabetic you should be following some very simple rules:
1. Check your feet daily, and if you can not see or reach your feet, have someone else check them
2. Always wear protection on your feet
3. Avoid soaking your feet, unless otherwise instructed by your doctor
4. Do not wait to seek treatment for something suspicious on your feet

If you have an open wound or you have a loved one who has an open wound, and they have not had any improvement you need to think about seeking out a higher level of care. Look for a doctor who is passionate about limb salvage.  If you are in the Central Florida area, we would be more than happy to evaluate you.  Sometimes when patient's require more complex care, I see patients at the wound care center in Leesburg or The Villages. Call our office today if you would like an evaluation of your wound 352-242-2502.

Our office is located in Lost Lake Professional Village
Michele McGowan DPM
3190 Citrus Tower Blvd Ste A
Clermont,FL 34711.

Diabetic and don't have a foot doctor? Quickly three reasons why you need a foot doctor!!

If you are diabetic, you can not avoid the thought in the back of your brain of someone who had a limb amputated due to diabetes.  Everyone has a story of an uncle, aunt or grandparent who suffered with an amputation due to complication of diabetes.  Every 20 seconds someone loses a limb due to diabetes according to Armstrong, et al, Diabetes Care 2013.

Top 3 reasons why you need to see a foot doctor:

1. Peripheral Neuropathy

• when seeing a foot doctor at least quarterly your sensation will be assessed and evaluated.  The doctor can perform a simple in office test to make sure your protective threshold is still intact
• More than 90% of people with diabetic peripheral neuropathy are unaware they have it, according to Bongaerts, et al, Diabetes Care, 2013
• So if you do not know your sensation is not intact, you run a much higher risk of ulceration and/or limb loss

2. Ulceration

• According to a study in the Journal of American Medicine in 2005: up to 25% of those people with diagnosed with diabetes will develop a foot ulcer. More than half of those have the risk of becoming infected and 20% of the infections will go on to amputations according to Lavery et al Diabetes Care 2006.
• Seeing your podiatrist quarterly, they will inspect your feet, identify any pressure spots that could predispose you to an ulceration and offload these spots to prevent the calluses from forming that often develop wounds if not routinely debrided in the diabetic patient.

3. Amputation

• Again, every 20 seconds someone loses a limb due to complications of diabetes
• Diabetes contributes to approximately 80% of the 120,000 nontraumatic amputations performed yearly in the United states, according to Armstrong et al. Amer Fam Phys 1998
• Podiatric Medical care in people with a history of diabetic foot ulcer can reduce high level amputation between 35% and 80%, Gibson, et al. Int Wound Journal, 2013
• Insituting a structed diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality Weck, et al. Cardiovascular Diabetology, 2013

Learn more about diabetes and your feet at:http://centeranklefootcare.com/diabetic-feet.html

Diabetics should see a podiatrist to keep their feet healthy(or just to keep their feet!)

Good foot health does start with the toenails! As foot and ankle surgeons, we never take lightly the role we play in helping our diabetic patient's feet stay safe and from harm by performing what we call "at risk foot care" for them. Just because the title surgeon is in our job description does not mean we are too good to trim toenails. These patients come into the office and have a thorough exam of their feet followed by having the doctor trim their toenails and calluses if needed. Most insurance companies consider this a covered benefit if the patient has certain class findings in addition to the diagnosis of diabetes. I always tell patients that their insurance company does not give a hoot about their toenails. Their insurance is looking for the easiest way to save money, and visits to the podiatrist help keep the cost of hospital admissions for diabetic foot infections, ulcers, and worse yet amputations way down! Insurance companies cover these services to help reduce the risk of ulcerations and amputations to the foot or ankle.

The estimated annual U.S. Burden of Diabetic Foot Ulcers is at least $15 Billion Rice, et al, Diabetes Care, 2014. Proper foot care helps prevent such problems in many diabetic patients. In the last 14 years of private practice, a week has not gone by where I have not had to remove a foreign object, glass, a splinter, or an insulin needle from the bottom of someones foot who was just coming in for foot care. These patients are usually totally unaware of their brewing infection on the bottom of their foot secondarily to their neuropathy. We fix the problem right then and there, no need for the operating room or intravenous antibiotics in a hospital bed, in most cases.  

It has been proven time and time again in peer reviewed literature, that these patients who have diabetes that visit the podiatrist are much less likely to have an amputation of an extremity. Podiatric medical care in people with history of diabetic foot ulcers can reduce the the high level amputation between 65% and 80%. Gibson, et al, Int Wound Journal 2013.  When the primary care physician makes the referral to the podiatrist for at risk foot care, they are playing a huge roll in helping decrease the amputation rate as seen in the study by Weck, et al, in Cardiovascular Diabetology, 2013. Instituting a structured diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality. The inverse was also proven by Skrepnek, Mills, Armstrong, Diabetes Care 2014, in which they saw that when foot care is removed from a population, there is a 37% increase in hospital admissions for limb threatening wounds and 45% increase in individual patient charges.

I tell my new diabetic patients I meet in the office for the first time that I rarely have to amputate anything on my established diabetic foot care patients.  The numerous amputations I have performed over the last 14 years have been consults from the hospital when I am on call.  These patient usually have never seen a podiatrist, and have a wound or infection that will require multiple debridements(cutting away dead or infected tissue) with no guarantee of limb salvage.  

If you are not diabetic why should you care? Well caring for our fellow human beings should be innate human response some people are all about the dollars and cents. So here we go: the cost of diabetic foot ulcers is greater than that of the five most costly forms of cancer. Barshes, et al, Diab Foot Ankle 2013.  The Diabetic Foot Ulcer patients are twice as costly to US Medicare as to those with Diabetes alone. Rice, et al, 2014.  But maybe more importantly, you should care because according to the American Diabetes Association, 2014 there are approximately 86 million people to be considered pre-diabetic and you might be one of them!

Every 20 seconds a limb is lost to diabetes according to Bharara, et al, Int wound J, 2009. So in the time it took you to read this blog many limbs have been lost to diabetes. There should be a call to action for anyone who took the time to read this blog. It is undeniable that you know someone with diabetes an aunt, uncle, parent, niece or co-worker.  Pass this information along to them.  Have them see a podiatrist and just be established as a patient.  If you are diabetic and have no class findings the podiatrist may suggest you come in maybe once a year for a foot check. This is a painless process that takes minutes to check your sensation and arterial pulses.  As you may have gathered the overwhelming theme here is prevention.  Prevention is the key to good foot health and decreased medical bills due to diabetes.   

 Help save a limb today and pass it on! I would much rather cut your toenails than have to take you to the operating room to amputate part of your foot.

Thank you for taking the time to read our blog.  You can find more diabetic foot facts at our website at: http://centeranklefootcare.com/id7.html 

Michele McGowan DPM

Center for Ankle and Foot Care

3150 Citrus Tower Blvd Suite B

Clermont, FL 34711

352-242-2502