Canadian Medical Alliance for the Preservation of the Lower Extremity
This is , the website for the Canadian Medical Alliance for the Preservation of the Lower Extremity, or MAPLE. We are an organization of Canadian wound care specialists with a particular interest in foot ulcers.
The main directive of this organization is medical and public education for providers and the public, and advocacy for wound care issues.
MAPLE was founded in 2017 by Dr. S A Schumacher, a podiatric surgeon based in Surrey, British Columbia. Dr. Schumacher is a certified specialist in wound healing, and has worked in private practice and a hospital setting treating complex wounds. He is also board certified by both major boards in his profession--the American Board of Foot and Ankle Surgery and the American Board of Podiatric Medicine. His practice is based in Surrey, a suburb of Vancouver, in British Columbia, Canada.
The name MAPLE was chosen because there are few things more identified with Canada than the Maple leaf. It's on our flag, it's on our money, and it's the name of the hockey team in our largest city. However, while the website is geared particularly for Canadians, anyone with an interest in neuropathic ulcers of the foot may find this site useful.
Symbolic of the maple, what our organization tries to provide is a strong base of knowledge, rooted in science, with a perspective from multiple branches of medicine. We hope this site will offer you some shelter from the worst impact of foot ulcerations, and serve as a point of reference for discussions with your health care team.
If you are a health care provider with an interest in wounds and wish to join MAPLE, click the Join MAPLE link. If you're not a medical provider and are interested in joining as associate member, we welcome that too.
Why Does This Website (and MAPLE) Need To Exist?
This website, and MAPLE more generally, exists because there is insufficient information out there about how
to manage wounds, and insufficient access to their proper care.
A lack of information about wounds is certainly true for many Canadian patients, many of whom come into wound
care facilities with little idea of what their wounds mean and what is required to heal them.
But it's also true for medical practitioners generally. And it's true for provincial government insurance,
which tend not to cover what's most effective in treating wounds.
There may be several reasons for this lack of understanding.
First, from the patient's perspective, foot ulcerations (wounds) are
unpleasant. They're often messy and smelly, and they can be
embarrassing for some patients to discuss or even look at.
And because many of these wounds are typically associated
with sensory neuropathy (loss of the sense of touch), they
often don’t hurt. So patients may not discover a wound
until it is quite progressed.
Even if the patient is aware of the ulcer, he may feel
that something that doesn't really hurt isn't urgent
This combination may mean a delay in a patient
seeking treatment. And this is unfortunate because
foot ulcerations are serious. They can lead to infections,
amputations and premature death. The statistics are daunting.
But, truth be told, wounds are unpleasant from a physician’s
perspective as well. Besides being messy and smelly, they’re
often quite time-consuming and significantly underpaid for the
effort and skill that’s required. Additionally, wounds are often
hard to heal, especially if you don't treat them regularly. And they
have a high tendency to recur. So there are few doctors or nurses
who specialize in ulcerations, or like to deal with them.
The result is that wounds are often managed inappropriately, or are
otherwise given insufficient attention.
As an example, if a patient with an ulceration presents to a typical family
physician, a walk-in clinic, or an ER, the most common treatment is to apply
a bandage and to prescribe antibiotics. Antibiotics, however, kill bacteria;
they do not heal wounds. So, while vitally important if an infection is present,
antibiotics are not appropriate for wounds that are not infected, and patients
wounds often do not heal. Most wound specialists have seen patients
who have been on antibiotics for a year or more without healing.
Other times patients are referred from one physician to the next,
to home nursing, for tests of various sorts--often with no one
physician taking real ownership of the patient's wound.
You'll see some examples of wounds on this site that have
languished for years in this way.
Sometimes doctors conclude that because the wound hasn't healed with an antibiotic, or with a change in some other medication, or after a negative finding on an x-ray or culture, or after an unsuccessful referral or two, the patient must be unable to heal. They may conclude there must not be enough blood flow to heal. Or that a diabetic's sugar must be too high to heal. Or that the patient must be too old to heal.
And the patient is referred for amputation.
But this has profound implications. Patients who have one amputation usually end up with more. This is because even small amputations alter biomechanics. This causes no pressure sites, new ulcers, and new health risks.
Further, amputations affect a patient's health and longevity. Amputations create depression. They affect the patient's ability to work and provide for the family. They strain our social programs. They increase the costs to our health system.
But a wound's not healing is often not a result of a patient’s inability to heal. Often wounds don't heal because they are not receiving all the care they require, whether because of a lack of knowledge in how to deal with them, or because the provincial health plans simply don't wish to invest resources in proper management that are actually proven to work.
However, a little knowledge can pay huge dividends. So our aim
is to try to provide some of that knowledge.
Wound care is a medical field unto itself. Wounds require a
specialized skill set, including an understanding of how wounds
develop, and what they need to heal. They require a degree of
surgical skill, to remove the dead tissue that typically develops in
a wound, sometimes extending down to bone. And they require
an understanding of biomechanics--understanding the movement
of the foot, both normal and abnormal, and the physical forces that
cause the wound and prevent it from healing.
There are few doctors with this skill set, or with wounds as a specialty. This is even more true in a country as vast as Canada with a population spread out over an enormous geography.
Even if a patient is close enough geographically to appropriate medical care, he may not get the care he needs. For instance, podiatrists (foot doctors) have with some of the most important skills for wound healing—such as a specific specialty in the foot, extensive surgical training (appropriate in surgical debridement), and biomechanical expertise (important for effective offloading).
Yet some provincial medical plans do not insure podiatric services. And those provinces that do pay for some podiatric services to one degree or another often exclude wound care from reimbursement. The result is the nonsensical situation seen in British Columbia where the provincial government will pay to amputate, but not for the proper wound care that would save the limb.
Many extended plans do pay for podiatric services, including for wound care. But not all patients have such plans, and reimbursement rates may not always be sufficient. So, too often a patient may have to pay out of pocket, and many patients most susceptible to wounds—the elderly, minorities and indigenous populations, and those in lower income populations—simply cannot afford the care.
Those who are most at risk for amputations are those who have already had an amputation, and many of those patients are not working because of an earlier amputation, and simply cannot afford the out-of-pocket care.
Services for wound care nurses are often covered by provincial health plans, but nurses are often underfunded, overworked and inadequately supported. Further, wounds really require a multi-disciplinary approach to address the aspects of wound healing that no single health care provider can provide alone.
In addition, most provincial governments do not pay for offloading—specialized dressings, casts, boots, shoes, etc. that seek to get pressure off the wound and give it the opportunity to heal. And this is the single most important factor in most wound healing.
Because most physicians do not have the time or expertise
to deal with wounds, and because our health system has
insufficient inclination to pay for appropriate wound care,
many Canadian patients develop preventable infections and
have unnecessary amputations performed, even if the wounds
are able to be healed if given proper care and attention. This
is immensely frustrating for those of us in wound care, as we
know limbs and lives could be saved. And we'd save money in
The final reason for this website is that wound care is a billion-dollar industry. Thus, much of the information on wound care that does exist on the internet is put out by companies or individuals selling a product or treatment, and the information may be compromised by financial self interest.
So this website, produced by specialists who work in this field, seeks to give patients access to information on wound healing that they may otherwise be unable to access.
This page written by Dr. S A Schumacher
Surrey, British Columbia Canada
Unless otherwise noted, the clinical photographs found on this site are the possession of Dr. Schumacher. They may be used for educational purposes with a credit to Dr. S A Schumacher, Surrey, BC and a link back to this website, .
To return to the top of the page, click on the maple leaf to the right.
"If what I say resonates with you, it is merely because we are both branches on the same tree."
-- W. B . Yeats
"A very little key will open a very heavy door."