Charcot Neuropathy in the Diabetic Foot:
Incidence, Causes, Symptoms and Diagnosis
Charcot Neuroarthropathy (CN) is a condition that can occur in people with diabetes who have significant neuropathy. If left untreated, CN may lead to foot deformity, ulceration, infection, amputation, disability and possible premature death. Timely diagnosis and treatment could prevent amputation and long-term disability. Increasing awareness is fundamental to improve CN management and reduce its complications.
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HOW SERIOUS
IS CHARCOT FOOT AND
ANKLE DISEASE?
WHAT DOES CHARCOT FOOT
LOOK LIKE AND WHY DOES
IT OCCUR?
HOW IS CHARCOT FOOT
AND ANKLE DIAGNOSED?
THE IMPORTANCE OF
A MULTIDISCIPLINARY
APPROACH
HOW TO PREVENT CHARCOT
FOOT AND ANKLE
CHARCOT
DEFORMITY
ULCER
INFECTION
AMPUTATION
INACTIVITY
POSSIBLE PREMATURE DEATH
WHO ARE MORE LIKELY TO DEVELOP A CHARCOT NEUROARTHROPATHY?
Charcot patients are more likely
to be men
Over 50 years
as average
is the incidence rate of Charcot in
patients with diabetes
How serious is Charcot Foot and Ankle disease?
According to the International Diabetes Federation (IDF), diabetic foot and lower limb complications are an important cause of morbidity, affecting 40 to 60 million people with diabetes worldwide.
Complications from diabetic feet, including ulceration and Charcot Foot and Ankle, are a leading cause of hospitalization, resulting in high disease burden, poor quality of life, and increased healthcare costs.
- Diabetes is the seventh leading cause of death in the USA
- 0.3 to 7.5% of diabetic patients may develop a Charcot Neuroarthropathy
- Almost 100,000 patients with diabetes will suffer an amputation each year in the USA
- Worldwide 85% of leg amputations are a result of a diabetic foot ulcer
- With Charcot Neuroarthropathy, a minor injury can lead to amputation
- Up to 80% of diabetic patients are more likely to die within 5 years of having a limb amputation
Still, with timely diagnosis and appropriate treatments, it is possible to prevent 4 out of 5 amputations. Understanding the diabetic foot and taking the appropriate measures to detect and treat complications as soon as they arise go a long way in the prevention of limb amputation in patients with diabetes.
What does Charcot Foot and Ankle look like?
The name “Charcot Foot” comes from Jean-Martin Charcot – a French neurologist often referred to as one of the world’s pioneers of neurology – who described this condition in 1868.
Charcot Neuroarthropathy is a condition causing weakening of the bones and ligaments in the foot and the ankle that can occur in people who have significant nerve damage (neuropathy), most often related to diabetes. Patients’ ability to feel temperature, pain or trauma decreases.
The bones are weakened enough to fracture and/or dislocate and, with continued walking and weight bearing, the foot eventually changes shape.
As the disorder progresses, the joints collapse and the foot takes on an abnormal rocker bottom shape.
The natural course of Charcot Neuroarthropathy encompasses active and inactive disease phases, which relate to an inflamed or stable disease, respectively. After the consolidation phase, there is a 23% risk of “re activation” of the inflammation phase, which leads to a progressively worse condition.
Charcot Foot and Ankle patients need immediate treatment, as they may develop severe foot and ankle deformity, foot ulcers, infections, disability, gangrene and (worst case scenario) require amputation of the foot.
Why does Charcot Foot and Ankle occur?
Charcot patients are more likely to be men, over 50 years as average
age, with a long history of diabetes, nerve damage to their feet
(diabetic neuropathy) and poorly controlled blood sugar levels.
Lifestyle, such as long-term alcohol, smoking or other substance
abuse, can also increase the risk of developing Charcot Foot Disease.
Charcot Foot typically develops over time and requires a number of
factors to occur. The triggering event for an active stage of Charcot
Foot and Ankle in a susceptible patient can be a sprain, a twisted a
nkle, or even just the load of weight-bearing (especially if the
individual is obese). This starts an inflammatory process, leading to an
osteolysis that is indirectly responsible for the progressive fracture
and deformity.
The role of other factors, such as the reduction of calcitonin
gene-related peptide caused by nerve damage and pre-existing
low bone mineral density, may also be relevant in the
development of Charcot Foot and Ankle.
How is Charcot Foot and Ankle Diagnosed?
Timely and accurate diagnosis is key
The natural course of Charcot Foot and Ankle is characterized by four stages, and the patient can cycle through them in a pattern resembling active and inactive phases, resulting in high morbidity and accentuated foot deformity.
Making an accurate Charcot Foot diagnosis in the early stage of the disease might be difficult, since the acute symptoms can be similar to other conditions, such as cellulitis, gout, or deep vein thrombosis.
Notably, less than one-third of physicians recognize the signs of diabetes-related peripheral neuropathy and diabetic foot problems, even when the patient is symptomatic. The best safeguard is a high index of suspicion, especially in any diabetic patient with a swollen, red, warm foot in the presence of somatic or autonomic neuropathy.
When dealing with Charcot Foot Disease, a timely diagnosis is crucial to improve patient outcomes, facilitate treatment and decrease long-term disability.
What to ask your patient
- Do you have a history of diabetes?
- If yes, do you regularly check your glycemic levels?
- Do you have a history of diabetic foot pathology?
- Did you have prior angioplasty, stent or leg bypass surgery?
- Do you feel any leg or foot pain and discomfort at rest?
- Have you noticed a loss of your leg sensation?
- Has your foot lost the ability to feel pain, heat and cold?
- Do you smoke?
- Do you drink alcohol?
What to look for
- Warm, swollen, red foot and/or ankle (Active Charcot)
- Higher temperature of 2°C or 4°F of one foot compared with the contralateral one
- Interdigital maceration
- Skin lesions, ulcers and open wounds
- Hypertrophic calluses or corns
- Discolored, ingrown nails
- Crepitant cellulitis
- Fungal infection
- Bone deformities
- Loss of foot sensitivity
- Limited range of joints motion
- Absence of Achilles Tendon reflex
- Vascular compromise, with sudden absence of dorsalis pedis and posterior tibial pulses
- Peripheral arterial disease
- Diabetic gangrene and necrosis
- Previous amputation
What to teach your patient
- Have a preventive foot evaluation every year
- Examine foot skin and nails daily and have a regular expert podiatric care
- Report any swelling, redness, lesions and skin discoloration
- Choose appropriate footwear
- Do not walk barefoot
- Replace orthotic shoes every year: they should fit perfectly
- Report absence of pain when it should be felt (e.g. touching hot water)
- Stop or reduce smoking
- Reduce alcohol
Proper surgical procedure is the responsibility of the medical professional. This information is furnished as an informative guideline. Each surgeon must evaluate the appropriateness of a technique based on his or her personal medical credentials and experience.
When is time for a specialist?
Priority
Indications
Timeline
Follow-up
Priority
Indications
- Open wounds and deep ulcers
- Pain at rest
- Active Charcot Foot deformity
(red, hot, swollen) - Vascular compromise
Timeline
- Urgent/immediate referral
- Patient needs interdisciplinary care
management, off-loading with total
contact cast devices and/or surgery,
diabetic orthopedic footwear
Follow-up
- According to specialist decision
Priority
Indications
- No sensitivity
- Ulcers
- Chronic vascular venous insufficiency
- Previous lower limb amputation
related to diabetes
Timeline
- Immediate/first available referral
- Patient needs diabetic orthopedic
footwear, preventative off-loading
and appropriate therapy
Follow-up
- Every 1-2 months
Priority
Indications
- Insufficient sensitivity
- No ulcers
- Foot deformity
- Posterior tibial pulse diminished
or absent - Foot swelling, aedema
Timeline
- No ulcers
- Foot deformity
- Posterior tibial pulse diminished
- or absent
- Foot swelling, edema
- Referral within 3 weeks
- Patient needs prescriptive footwear,
preventative off-loading and
appropriate therapy
Follow-up
- Every 2-3 months
Priority
Indications
- Insufficient sensitivity
- No ulcers
- No foot deformity
Timeline
- Referral within 1 months
- Patient needs prescriptive footwear
and preventive foot health behaviors
education
Follow-up
- Every 4-6 months
Priority
Indications
- Satisfactory sensitivity
- No ulcers
- Possible foot deformity
- No peripheral artery disease
Timeline
- Referral within 3 months
- Patient needs foot care and preventive
foot health behaviors education
Follow-up
- Once a year
Proper surgical procedure is the responsibility of the medical professional. This information is furnished as an informative guideline. Each surgeon must evaluate the appropriateness of a technique based on his or her personal medical credentials and experience.
The importance of a multidisciplinary approach
Patients with diabetes and Charcot Foot and Ankle represent a special population that may differ in the diagnosis and treatment compared to patients with Charcot Neuroarthropathy due to other reasons. The gold standard for diabetes-related foot complications involves a multidisciplinary healthcare team, where the diabetic foot specialist and the diabetologist play coordinating roles.
In multidisciplinary approaches that are built around the diabetic foot, the timely assessment and diagnosis of wounds, as well as the appropriate methods of prevention and treatment, are the keys to improved evidence-based outcomes:
Increased limb salvage,
as a result of a 68% increase
in angioplasty and 9% increase
in bypass operations
62% reduction
in major amputations
12% reduction in hospitalization
for diabetes-related foot
complications
20% reduction
in overall amputations
The team may also include:
- Vascular surgeons
- Endovascular interventionists/radiologists
- Diabetes nurses
- Pedorthists/orthotists
- Physical therapists
Timely diagnosis of Charcot Foot and Ankle is essential to proper management.
There are four domains involved in the diagnosis of Charcot Foot and Ankle:
- Clinical assessment, including a physical exam and patient history
- Peripheral neuropathy exam
- Initial imaging and laboratory values
- Pedorthists/orthotists
- Charcot Foot and Ankle stage confirmation
The imaging tests play an important role in Charcot Foot diagnosis. Among the imaging techniques
most used are Radiography, Radionuclide, Computerized Tomography, and Magnetic Resonance.
Radiography
The imaging tools, namely radiographs, are fundamental in the diagnostic process in all
stages of the disease.
Radionuclide
The use of nuclear medicine to perform bone scans with small amounts of radioactive tracers
(radionuclides) is valuable to have a functional method of diagnosis, as opposed to the purely
anatomical methods offered by other imaging tools.
Computerized Tomography
Although the use of CT scans in neuropathic arthropathy is not well investigated, this imaging
tool has higher sensitivity for early intra-articular fractures that are not readily visualized in
plain radiographs. CT can also show periosteal new bone formation and small foci of gas
within bone in a better way than MRI can.
Magnetic Resonance
The use of MRI is becoming increasingly popular for the diagnosis of Charcot Foot and Ankle,
especially in the early stage (Eichenholtz Stage 0), which is marked by inflammation. When
applied to the musculoskeletal system, MRI provides excellent soft-tissue contrast resolution
and multiplanar capabilities.
How to prevent Charcot Foot and Ankle
Since the alterations caused by Charcot Foot and Ankle may be initially elusive, it is important that they are detected as soon as possible. To accomplish this, the patient must be aware of his or her crucial role in the disease management by doing regular check-ups, carefully taking care of their feet, and promptly communicating any alteration to a member of their healthcare team.
Failing to take preventative measures and delaying treatment can result in burdensome complications, such as pronounced foot deformity, ulcers, infection, and ultimately lead to limb amputation.
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