Do not ignore an open wound on your foot!!!

Today we are continuing our series on when to actually go to see your podiatrist. Today we discuss the different types of wounds we see in the office.  Again we want to keep you out of the hospital and urgent care centers where all the sick people are going!

For All wounds,  good advice:

• If you notice drainage on your sock go see your podiatrist
• If you know your sensation is poor, you should be checking your feet daily
• If you have a new area on your foot that is open go see your podiatrist
• Blistering and leaking fluid from your legs and feet, go see your podiatrist
• Extreme pain in the foot and an open wound go see your podiatrist
• anything out of the ordinary on your foot or ankle, go see your podiatrist

Diabetic wounds:

• Usually associated with lack of protective threshold(poor sensation, so you do not feel pain and discomfort) 
• The simplest thing, like wearing a shoe that is even just a little too small can cause a serious wound and problem
• Do not ignore your problem, if it looks bad but you can't feel it, that does not mean it is OK
• The best thing you can do is get in to see your podiatrist, there are sometimes very simple solutions that can save you from limb loss

Venous wounds:

• Usually, these patients present with swollen legs with fluid leaking from small or sometimes big blisters
• This is another wound type that can get serious fast, many times if you see a doctor who does not treat these types of wounds they send you to be admitted to the hospital, we are trying to keep you out of the hospital
• Sometimes simple advice, like elevate the legs can be the difference between going to the hospital or not
• There are many simple ways we can mange this in the office as well

Arterial wounds:

• Sometimes patients do not have blood flow, meaning their arteries are not getting blood to where it needs to go
• These wounds can be more complicated, as without blood flow no wound will heal
• Our job is to keep you from getting infected and help coordinate care with the vascular doctor
• We do not debride these wounds, as they can get bigger, unless there is infection with a chance of wound causing sepsis
• So take home point, go see your podiatrist before the wound gets to that point

So like all of you, we are struggling with all the new responsibilities we have had thrust upon us over the last couple of weeks. Yes, it is the worst to be cooped up at home, but it always could be worse.  We are travelling back and forth every day to our office to home with our 3 children, who now have to home school, this is not the easiest task even if you have good kids! We are small business owners who understand having to work hard to make sure everything goes smoothly, or at least try to make things go smoothly! We love what we do and our very happy to help our patients and friends stay out of the hospital.  

Our website has always had a dedicated page for our wounded patients. Check us out here: https://centeranklefootcare.com/wound-care.html

Stay safe everyone and remember to wash your hands and keep your distance from others.

Michele McGowan DPM and Timothy Henne, DPM

The Center for Ankle and Foot Care

3190 Citrus Tower Blvd Ste A

352-242-2502

Don't ignore your ingrown nail, especially if you are diabetic!!

Trying to keep our patients out of the ER 

• There are problems that all of your specialist can handle right now to keep you out of the emergency room
• We treat many foot and ankle emergencies right in our office
• Many podiatrist have on-sight X-ray so they can diagnosis and treat your broken bone 
• You should never ignore bruising, swelling or unexplained redness on the lower extremity

Today we are discussing ingrown toenails

• If you have a toe that is red, and swollen like the picture to the right, you should not be trying to ride this out
• Ingrown nails are typically painful, but in our diabetic patients with neuropathy (unable to feel pain from an infection is one example of neuropathy)
• If left untreated this can be a much bigger problem, infection in the worst case scenario can lead to an amputation of a toe
• Treatment is a simple in office procedure

The Video below is an ingrown nail procedure

Ingrown nail surgery:

• The toe is anesthetized with 1% Lidocaine
• The offending border is freed from the nail bed 
• An instrument is used to only cut out the ingrown border
• After the bad part of the nail is removed, a topical medicine is used to stop the border of the nail from growing again
• If the patient does not have good blood flow, this procedure can not be performed but your podiatrist can most likely alleviate some of the problem and place you on an antibiotic
• The video above is us removing an ingrown nail on a patient

Not sure if you need to be seen in the office?  You can reach out for a Telehealth visit first at:
https://centeranklefootcare.com/telemedicine-request.html

Curbside check-in for patients during COVID-19 in our podiatry office

Dr. Michele McGowan and Dr. Timothy Henne from the Center for Ankle and Foot Care sharing their experiences during their transition back from Spring Break 2020 walking into the Pandemic COVID-19 seeing patients, helping facilitate kids virtual learning and keeping patients, staff, children and selves safe.

Virtual school
First, we have to say our children's school has been amazing during this time. They had let all parents know before spring break that they were going virtual after the break.  As promised, Monday they were up and ready to go.  The teachers are also hitting it out of the park.  Lesson plans seem back on track and having kids in elementary, middle and high school all at the same facility, it is amazing to see how well they teachers and school are pulling it all together.

Forced Family Fun Time or FFFT
Forced family fun time, our children would tell you is not new for our family during the Coronavirus.  We have been practicing FFFT for quite sometime.  Once our older children got cell phones we have been vigilant that they do not become phone zombies.  We think they like hanging out with us but we still every day have planned or on the fly activities that we make all 3 children participate, even if it's just a movie. (I know that is still a screen but we are looking at it together at least.) And this isn't a parenting blog but we also sit and have dinner together as a family every night.  It is always fun and entertaining but I think really important now more than ever to just sit with your kids and discuss the day and how they are feeling.

Curbside check in
So we had no real idea if curbside check in would actually work.  It is going really well.  I think almost every one has a cell phone. Our older patients are figuring things out pretty easily.  We really did just make up things as we were going, using common sense really comes in handy sometimes!

Curbside check-in benefits:

• Decreases people congregating in a waiting room setting
• Gives staff and doctors the ability to control flow of getting patient in a clean room
• Limits patient contact with other patients in hallway and check out desk
• Gives patients the confidence that we are going above and beyond to keep them safe

Cleaning the office

We did find it weird that some of the other doctors offices started to reassure patients that they were taking special measures to keep things cleaner when the COVID-19 became apparent it was going to have an impact on us all.  What?? Didn't they clean their offices before? Listen, your doctors office should always have been cleaning treatments rooms between patients with supplies that are meant to kill germs, bacteria and different flu strains.  It is a doctors office, there is no confidence in an office that states, "Now we are cleaning thoroughly." That wouldn't be a sell for me as a patient.  

Employees dedication

I can not begin to thank my employees enough.  If you have been to our office you have met Diana and Reshanda.  In these uncertain times, we understand and respect employees taking off time to be with their families, socially isolate, self quarantine and stay home.  I think these measures are important to help decrease the spread of the coronavirus.  That all being said, we are happy to have people that are helping us in the trenches.  It makes our lives and our patient lives so much better.  We just wanted to publicly acknowledge that we truly appreciate you!!!!

Be prepared as a patient when you go to the doctor

• If you are new, have your insurance cards ready, or email prior to visit
• If you have a copay, have it ready decreasing your time and interaction with others
• Use the million of different types of hand gel and foams we have around the office
• Don't steal supplies from the doctors offices, like gloves, we need them

What not to touch in public

• I am a germaphobe, do DON'T TOUCH ANYTHING
• Avoid pushing elevator buttons
• Avoid door handles 
• Common sense prevails always, wash your hands and use hand sanitizer
• DON'T TOUCH YOUR FACE!!!!!!!
• DON'T TOUCH YOUR SHOES!!!!

Lastly, we are busy parents and doctors, we are filming these little videos, obviously not editing them:)It is a first take scenario and what you see is what you get, LOL.  This video is what our kids would say was our "OK BOOMER!" moment.  Our light went out so we were done. I hope some of our information is either helpful or slightly entertaining.  Stay safe everyone!

Telehealth and Bunions: When to go to see your Podiatrist during the Coronavirus Pandemic

So we are knee deep into day 2 of seeing patients after getting back after our kids spring break.  It has been day two and it feels like, I don't know, maybe a month!!

 Goal #1:  Stay Out of the Hospital -  Day 2    I had to go to the Villages Hospital for emergent surgery. So we love what we do and love limb salvage and helping patients keep their toes, feet and legs.  It really is very gratifying to offer options for patients when others just offer below the knee amputation.  It was incredible to just call the hospital and be able to add a case whenever I wanted or was able to do so.   But it also was ominous,  the effect of the coronavirus on the medical community.

Goal #2: Keep non-emergent non-medically necessary patients out of the office- Day 2  We had at least 5 patients show up with non-emergent problems like bunions and hammertoes. 
So if you have a bunion or hammertoe, don't go see your podiatrist right now in the light of a pandemic aka the coronavirus.  Maybe do a Telehealth visit with your podiatrist if you are not sure after watching this. Yes it will suck for a doctor to tell you, buy bigger/wider shoes, but it could save someone else from getting sick!

Goal #3: Keep kids well stocked with supplies during the time of virtual learning- Day 2 The oldest child complains about not having "fancy mechanical pencils"  We have a box of a 150
pre-sharpened pencils available to the children.  Back in my day pre-sharpened pencils was a luxury!!

Goal #4 Forced Family Yard Time ( Like prison getting a little exercise) - Day 2 ended short when 8 year old fell off scooter and blamed Mother Nature for her pants getting wet.  Sprinkler was broken and she landed in the only puddle of water on the driveway.  

So we are all in this together! Stay safe, wash your hands, try to laugh when you can:)  

Red, Hot and Swollen in the foot is bad...Especially if you are diabetic!

RED, HOT AND SWOLLEN IS BAD!!!!! SEE YOUR DOCTOR!!!!!!

So while keeping yourself safe from Coronavirus don't let yourself go on to limb loss.  These are crazy times we are currently living in, but we still need to maintain our health of our total body.  We pride ourselves on limb salvage and helping our patients keep their limbs at all cost.  Before you ignore the red swollen toe, foot or ankle think again.  Diabetic foot infections happen quick. You should be checking your feet daily and inspect for anything abnormal.

Diabetic Foot Facts:

• Podiatric medical care in people with history of diabetic foot ulcer can reduce high level amputation from between 65% and 80%  Gibson, et al, Int Wound Journal, 2013
• Diabetes kills more people annually than breast cancer and AIDS combined. American Diabetes Association, 2009
• Chronic wounds affect some 8 million Americans each year. That’s one wound every 3.8 seconds in the USA, alone.
  Harsha , 2008 and Tomic-Canic 2010
• Diabetic foot ulcers double mortality and heart attack risk while increasing risk for stroke by 40%
  Brownrigg, et al, Diabetologia, 2012
• Every 30 minutes a limb is lost due to a landmine, Every 20 seconds, a limb is lost due to diabetes. Bharara, Mills, Suresh, Armstrong, Int Wound J, 2009
• 
  The relative 5-year mortality rate after limb amputation is 68%. When compared with cancer – it is second only to lung cancer (86%).  (Colorectal cancer 39%, Breast cancer 23%, Hodgkin’s disease 18%, Prostate cancer 8%) Armstrong, et al, International Wound Journal, 2007
• Diabetes contributes to approximately 80% of the 120,000 nontraumatic amputations performed yearly in the United States.  Armstrong et al. Amer Fam Phys 1998
• 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
• Up to 34% of those with diabetes will develop a foot ulcer. Armstrong, Boulton, Bus, New England Journal of Medicine, 2017
• 60-70% of those with diabetes will develop peripheral neuropathy, or lose sensation in their feet.  Dyck et al.  Diabetic Neuropathy 1999
• The estimated annual US Burden of Diabetic Foot Ulcers is at least $15 Billion Rice, et al, Diabetes Care, 2014

My feet are killing me and I do not want to go to the doctor for my heel pain!

We are trying to give some simple real world advice on heel pain and how to stay out of the ER and Urgent Care centers while the Coronavirus is a part of our daily life for now.  Dr. Henne and I know that some of this information is very common sense.  But honestly, simple things work all the time for minor foot and ankle problems.

In this video we discuss rolling the ice bottle on the foot:
This is simple to do. If you think you have plantar fasciitis or heel pain get rolling! I have had heel pain a couple times and this simple step makes it feel very good right away. Rolling the ice bottle, not only stretches the plantar fascia but it serves as a nice natural anti-inflammatory.

We also discussed stretching the calf muscles which will also in turn stretches out the plantar fascia or arch.  See below my homemade diagram of stretching the fascia because I didn't want to get sued for copyright infringement, so here is my art skill level and why I am a podiatrist!

Next we talked about good support on the foot, even when you are walking around the house you should not go barefoot!!! We like Oofos, spenco, vionic recovery flip flops even a pair of Crocs around the house is better than nothing! Just don't go barefoot and if it is plantar fasciitis, you will feel better.

Obviously, we are human and after watching I thought about a couple things that also we tell patients.  Good shoes with good support obviously.  A good pair of sneakers can help a lot, especially if you have to be on your feet a lot!

If the Shoes need a little more arch support I recommend a Powerstep full length arch support.  Sometimes just a little more support, along with the stretching and icing make all of the difference.

I always tell people that is the pain in the morning is persistent, consider purchasing a posterior night splint as shown below, you can buy it on Amazon.  Even if you can't wear it while you are sleeping, wear it while you are Netflix binge watching during the Quarantine of 2020.

Finally, if you do all these thing and you are not better call your podiatrist office, just make sure they have policies in place to protect you from getting sick!

For more info about heel pain or plantar fasciitis click here: https://centeranklefootcare.com/heel-pain.html

To Fix or Not To Fix My Bunion!!!! The Real Deal On Bunion Surgery!!!!

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 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, stay away from constricting leather.  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 just do it. Yes your foot is going to hurt after, but just wear good shoes after that! 

 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 http://centeranklefootcare.com/services.html
Michele McGowan DPM
Center for Ankle and Foot Surgery @2014

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

Open letter to Primary Care Doctors who tell elderly patients Medicare should cover the cutting their toenail(This is not true, most of the time)

Though I am trained in foot an ankle surgery, I must admit my favorite patients are my elderly patients that just come in to the office for routine foot care.  I see them every couple of months, we talk about their grandchildren, my kids and life in general.  We establish a fantastic long term relationship that is full of amazing conversation, while performing a task they are unable to perform themselves.

But when we see many of these patients as a first encounter they are convinced that this is a covered service by Medicare.  Some people believe this because they have seen a podiatrist for years before they moved to our area and the doctor has been billing this illegally or they have seen their primary care physician and they say, "Medicare covers cutting of the toenails." This simply is not true!

It is true that if you are diabetic, meet certain class findings, and have seen your primary care physician, who is actively treating your diabetes, in the last 6 months, then yes Medicare will cover such a service. But as far as someone who just happens to be elderly with long toenails, no dice! Below is an excerpt from the medicare.gov regarding podiatry services that are covered:

"Medicare Part B (Medical Insurance) covers podiatrist services for medically necessary treatment of foot injuries or diseases (like hammer toes, bunion deformities, and heel spurs). Part B generally doesn't cover routine foot care (like the cutting or removal of corns and calluses, the trimming, cutting, and clipping of nails, or hygienic or other preventive maintenance, including cleaning and soaking the feet)."

This becomes a very big source of contention in our office on a daily basis, over exhausting our resources of our office staff having to explain to patients why this is not covered.  But many elderly people can not perform this service themselves due to: not being able to reach their feet, bad back, bad hip or even they are just too thick for them to cut.  All of these are great reasons for an elderly person to be seen by a podiatrist for this service but insurance will not cover it and the patient has to be prepared for this out of pocket expense. These patient's are given a Medicare Advance Beneficiary Notice that explains that it is not a covered service. 

Encouraging an older person to go to a nail salon can be irresponsible advice from a doctor and a big problem exposing the patient to many community acquired skin and nail infections.  There are only 2 states that require that nail salons autoclave their instruments: Iowa and Texas.  So sending an elderly person into this environment is really not a great idea.

In our office we perform the highest level of care for these patients.  They are seen by the podiatrist, not a tech or medical assistant. The podiatrist will evaluate and treat the patient professionally debriding(cutting) the the toenails and the calluses if necessary.  The patient will leave with peace of mind knowing that they are getting the best possible care and service for their feet.

What we charge for these services are below:

Trimming of toenails	$60
Trimming of calluses	$60
Trimming of toenails and calluses	$75

Sometimes these services can take up to 45 minutes when someone has very thick toenails and many calluses.  We do not rush through this exam and service because our ultimate goal is to give the patient the best possible outcome.  We see many patients for this type of non covered routine foot care and try to perform this in a way that we can space out the visits so they may only need to visit us 3 to 4 times a year.  

Most podiatry offices offer this type of service and prices range from $50-$75.  The expense may seem steep. but by having a nail care patient in the treatment room the podiatrist is possibly missing much higher revenue of a new patient or even reimbursement for a follow up for an established patient.  Like all other doctor offices we have multiple staff: medical assistants, billing company, insurance specialist, and receptionist. These people all have to be paid for their hard work.  So it really is impossible for us to perform this service for less. If the doctor is performing the service themselves this service is very well worth it for the patient and in the patient's best interest.

If you would like to learn more about our office see our website: http://centeranklefootcare.com/

No insurance should not be a reason to ignore your feet!

In the ever increasingly expensive world of health insurance, many people have opted out of the insurance exchange and for good reason, it is extremely expensive.  Some statistics show that in Florida, when the health insurance exchange officially opened, many insurance premiums went up by 40%! My own personal health insurance premium went up by $300 a month more for my family of five, we now pay over $1000 a month for health insurance we only use "in case of an emergency".
Insurance premiums have gone up and interestingly enough reimbursement to the doctors you see have gone down.  This is not meant to be a winy doctor crying poor.  It is meant to inform you that the insurance companies have the upper hand on all of us.

There are many people that have decided not to pay $1500 a month for health insurance.  When your feet hurt, you do not have to ignore them. We have put together our price list for the non insured to take the guess work out of the cost for seeing one of our foot doctors.  If you have foot pain and do not have insurance, you want to cut out the middle man.  Seeing a board certified foot surgeon instead of your primary care physician, urgent care or emergency room visit could literally save you hundreds and hundreds of dollars.

If you live in Florida near Orlando we are conveniently located in Clermont.  This is a very nice location in Central Florida.  We are only 23 miles from Disney World so even if you are on vacation and have a foot problem one of our Board certified foot and ankle surgeons would be more than happy to get  you back on your feet!

We treat ankle sprains, heel pain, ingrown nails, nail fungus, fractures of the foot and ankle, warts and many other foot related problems.  We have on sight digital x-ray, so we are able to answer many bone related problems right away.

Below is the link to our pricing for the Center for Ankle and Foot Care for non insured patients:
http://centeranklefootcare.com/cash-price-list.html