Diabetic patients have to think about so many things - controlling blood sugar levels being the most pressing thing. Patients see multiple doctors and have multiple blood tests monitoring everything. Diabetes affects so many systems of the body, and so many things have to be monitored. It ranges from going to the eye doctor once a year or more for monitoring, to making sure their kidneys are functioning, to controlling cholesterol levels and trying to keep their blood pressure and heart healthy.
In our practice, we focus on the foot and ankle and how this affects our diabetic patients. Our office educates our diabetic patients on how to perform daily foot exams and this is a key in preventing complications. Often complications occur from neuropathy to open wounds with bony prominences causing sores. Sometimes our patients come in with concern about a red hot swollen foot. If this sounds familiar, then the cause could be diabetic neuropathy causing a condition called Charcot arthropathy or Charcot foot.
What Is Charcot?
Charcot is a condition that affects patients with neuropathy. Due to the inability to feel, there may be an injury that would cause a person without neuropathy to stay off the foot and let the injury heal. However when a patient cannot feel the injury due to the affected nerves in neuropathy, the person keeps walking on the injury and further damages the bone. There can be a series of fractures and joint dislocations that result from this condition and those can have long term effects.
How Do I Know If It Is Charcot?
If the foot appears red and swollen with no history of trauma and no reason to suspect an infection, then Charcot may be in play. The foot presents as warm to touch, swollen, with no ascending redness and no open wound. There may or may not be a history of trauma or fracture of the bone and the redness and swelling to not subside with icing and compression and elevation like one would imagine in a trauma situation.
What Should A Patient Do If They Suspect Charcot?
If a patient suspects that they may have Charcot, the first thing to do is to visit your podiatrist. This may be a better alternative than just going to the Emergency Room as they may not have as much experience with Charcot and even if they make a proper diagnosis, they will send you to a podiatrist for management and treatment. At this stage, advance testing such as an MRI is not needed; a weight bearing radiograph (X-ray) can provide all the information that is needed.
At the initial visit in our office, the patient is evaluated and a thorough history is taken. On sight at our office, we will take radiographs (X rays) that are digital and can immediately be shared with the patient to assess the foot and ankle.
If it is determined that Charcot arthropathy is in play, then the most important thing to do is to immobilize the foot. The sooner the foot is immobilized, the better are the chances for least damage to the bones and joints. Immobilization allows the bones to heal and not progress further. Immobilization on the first visit may consist of a below knee cast in some cases or in most cases a CAM (controlled ankle movement) walker.
The CAM walker is removable and if the foot is too swollen, the air bladders inside the CAM walker are desirable so that it is not too tight. However, the CAM walker is only temporary until a more long term solution is solved with a CROW boot (Charcot Restraint Orthotic Walker). This must be custom made by a pedorthist after a prescription from your podiatrist. A pedorthist specializes in fabricating and dispensing custom and over the counter prosthetics and orthotics for the lower extremity; everything from an ankle brace to a custom shoe and insert. The CROW boot is a total contact boot that covers the toes, past the ankle, up to the midcalf or below the knee. It is fabricated by taking a mold of the lower extremity and fashioning a walking boot that ends up being total contact when wearing. This total contact type of casting and fabricating allows even distribution of weight when walking. This sufficiently immobilizes the foot and ankle and protects the bones and joints from further dislocation and slows down the process. A patient can expect to be in the boot for several months until the body goes through all the phases of Charcot and eventually on to healing.
What Are The Phases of Charcot?
There are 3 main phases that the body goes through in Charcot Arthopathy before healing: they are Acute, Subacute, and Chronic.
-Acute (Stage 1) - this is when it first occurs. The foot and ankle are red, swollen, and sometimes painful or uncomfortable to walk. There is often no noticeable open lesion and the redness does not continue to spread up the leg as if in an infection. Sometimes it happens after an injury, but not always. It can happen out of the blue, and usually happens in patients with neuropathy or lack of feeling. The bones continue to fragment and may end up with multiple fractures and dislocations of the joints.
-Subacute (Stage 2) - In this stage, the fractured bones and dislocated joints begin to come together. Sometimes the bones come together in positions that end up in unwanted bony prominences or protrusions and the joints may start healing but in a dislocated position. The foot is no longer red and hot and swollen and there is no longer any discomfort to the foot and ankle.
-Chronic (Stage 3) - At this time, the bones have healed and the destruction has halted. The foot may take a different shape and look nother like the opposite foot as the bones settle into their new positions. If the bones of the midfoot are affected, the midfoot may drop and the foot may appear to have a rocker bottom instead of an arch.
After the foot is no longer acute and now it has become chronic, it is important to obtain proper shoe gear that will accommodate any bony deformities. This may need another visit to the pedorthist as the patient will need custom molded accommodative orthotics with lots of appropriate cushioning in the shoe.
The reason is because the foot may have healed with joints out of place and new bony prominences, particularly to the arch. If the neuropathic patient, who can't feel much pressure to the bottom of the feet, walks on the new bony prominences, then this could lead to an open sore and an ulcer. So even after the Charcot is not no longer active, it is very important to make sure the the patient has the correct shoe gear to prevent further complications. If the bony prominences do cause an area of pressure that open up into a sore or ulcer and the shoes cannot accommodate the pressure, then surgery may be needed to correct the deformity and close the sore. Then even after surgery and the wound is healed, special shoes and accommodative orthotics will still be needed to continue to deweight any other abnormalities. In addition, the podiatrist may insist on regular foot checks in the office in order to make sure there are no further complications that need to be addressed.
Any patient with neuropathy is susceptible to Charcot arthropathy. There are other reasons why a person can have neuropathy, but in our office, most of our patients with neuropathy happen to be diabetic. Even if diabetic patients control their blood sugars, check their feet, and are very vigilant about their health, there is always a risk of a Charcot foot. This is why it is of the utmost importance for patients to check their feet every day for any signs of worry. And if there is a question about anything having to do with the foot or ankle, it is important to be seen by your podiatrist sooner than later. If you do make an appointment with your podiatrist, it is important to follow explicit directions. Without a thorough treatment plan, more chances that the healing will not go as planned, and then you may have to face surgery. So examine those feet every day, and seek expert advice if you think you may have a question!