Charcot foot represents a rare special form of diabetic foot. It involves softening of the bone, which eventually breaks even under normal stress.
What is Charcot foot?
Charcot foot or Charcot arthropathy primarily affects diabetics. Thus, 95 percent of all patients are people who have diabetes mellitus. Charcot foot is considered a rarely occurring special form of diabetic foot. In this disease, one or more bones of the foot become increasingly softened, which eventually leads to bone fracture, although the foot is merely subjected to normal stress. The French neurologist and pathologist Jean-Martin Charcot (1825-1893) served as the eponym of Charcot’s foot. However, the first describer of the condition was the British physician Herbert William Page in 1881. Other names for Charcot foot are neuroarthropathy or diabetic neuropathic osteoarthropathy (DNOAP).
Causes
The exact way in which Charcot foot develops has not yet been determined. The loss of pain sensitivity in the feet is considered a prerequisite for neuroarthropathy. The disease is usually triggered by a traumatic injury to the skeleton. There are two theories regarding the origin of Charcot foot. These are the neurovascular as well as the neurotraumatic theory. According to the neurovascular theory, there is increased blood flow due to nervous dysfunction, as well as more extensive bone loss. The neurotraumatic theory, on the other hand, believes that repetitive minor injuries form on the joint surfaces due to overuse, because there is a lack of perception of pain. This leads to increasing bone destruction. Almost always, those affected by Charcot foot are diabetics. In rare cases, however, the condition may have other causes. These include congenital or acquired neuropathies in which there is impaired pain perception, as well as diseases such as syringomyelia, leprosy, syphilis or spina bifida.
Symptoms, complaints, and signs
The symptomatology of Charcot foot includes several stages. First, there is an accumulation of fluid in the foot. This edema is noticeable as a swelling or reddened area. However, the patient rarely feels pain, which is due to the damage to the nerves. If the patient succeeds in relieving the Charcot foot at this stage, the bone softening regresses, which takes a period of two to three months. After six to twelve months, the Charcot foot has completely regressed. However, if normal stress on the foot continues, this causes bone loss to continue. Eventually, the bone breaks down completely. If the bone fracture shows up in the metatarsus, this initially leads to the development of a flat foot. In the further course, a rocking foot forms. If the ankle joint is affected, there is a risk of complete dislocation. The patient then moves along on his inner or outer ankle. The malpositions in turn result in pressure points, which then lead to blisters or open sores. This poses the risk of germs entering the body, resulting in serious infections. In severe cases, this can even put the patient’s life in danger. In extreme cases, painless spearing of bone fragments through the skin can be observed. Charcot foot rarely occurs in either foot.
Diagnosis and course
Because affected individuals do not notice Charcot foot at first, they are late in seeing a physician. The physician first makes a thorough inspection of the foot, which is usually already swollen and inflamed. However, an infection such as erysipelas is usually not present. Often the foot is deformed, reddened and heated. It is not uncommon for the doctor to see open wounds on the protrusions of the bones. If purulent wounds are present, they can usually be painlessly examined with surgical instruments. Several examination procedures are available to the physician for accurate diagnosis. These include X-rays, a computed tomography (CT) scan, and a magnetic resonance imaging (MRI) scan. Leukocyte scintigraphy may also be required to rule out osteomyelitis (inflammation of the bone marrow).If circulatory disorders are suspected, supplementary vascular examinations take place. A Charcot foot can have serious consequences for the patient because he or she does not initially notice the bone fracture. If the patient is no longer able to walk, there is a risk of complications such as open ulcers. Even after successful healing of a Charcot foot, the affected person must undergo medical checkups for the rest of his or her life, because there is a risk of neuroarthropathy again at any time.
Complications
With Charcot foot, the affected person can suffer a fracture in the foot even with very light exertion. This results in extremely severe pain and restricted movement. Usually, the fracture does not occur directly. At first, the foot only shows swelling and redness and may also be painful under certain circumstances. In some cases, the pain may be completely absent due to damage to the nerves. Furthermore, there is progressive degradation of the bone and increasing pain. Likewise, the patient can no longer exert heavy loads on the foot. This has a negative effect on the quality of life. Treatment is primarily aimed at relieving the foot. This can lead to considerable restrictions in everyday life. In severe cases, a plaster cast is also placed around the foot. Furthermore, a causal treatment must take place, which treats the diabetes. This usually does not result in any particular complications or discomfort. Diabetes can be treated relatively well. In the worst case, the Charcot foot comes must be amputated if the damage is no longer reversible. Life expectancy itself is not affected by Charcot foot.
When should you see a doctor?
If you have swelling or reddened areas on your foot, you may have Charcot foot. If these symptoms have not subsided after one week at the latest, medical advice is needed. If movement is restricted or the bone is broken, a doctor must be consulted immediately. If no medical treatment is given by then at the latest, painful pressure points, malpositions and infections may occur – medical emergencies that must be treated immediately. After hospitalization, depending on the stage of the diabetic foot, lengthy physiotherapeutic therapy may be required. Those who suffer psychologically from the sudden restriction of movement can additionally consult a therapist. Charcot foot predominantly affects diabetics as well as patients with neuropathies, leprosy, syphilis or diseases of the spinal cord. If you belong to these risk groups, it is best to have the above-mentioned warning signs clarified immediately by the doctor in charge and treated directly on the spot. In addition to the general practitioner, a diabetologist or a specialist for the respective symptom can also be consulted. In the event of a severe course, the emergency physician should be alerted in any case.
Treatment and therapy
Acute Charcot foot is classified as a medical emergency. Therefore, treatment requires inpatient care by a specialist who will perform complete pressure relief. In the early edema phase, complete decompression takes three months. In the case of minor collapses, the application of special shoes may be useful. Relieving walking apparatuses such as clamshell orthoses are also sometimes used, so that the bone strengthens again and no malpositioning occurs. After the acute phase, the foot receives an adapted plaster cast or a rigid plastic bandage. A special orthotic shoe is then worn. It is also important to normalize the sugar metabolism by treating the diabetes appropriately. In some cases, surgery or even amputation of the affected foot must be performed. In this case, the patient receives a lower leg orthosis that can be worn with an orthotic shoe.
Outlook and prognosis
In most cases, Charcot foot can be treated well if treatment is performed early and the affected person changes his or her lifestyle. This is especially necessary for the treatment of diabetes, since Charcot foot is triggered by this underlying disease. The Charcot foot itself is treated on an emergency basis. In this case, patients rely on various prostheses or soles to alleviate the symptoms. In severe cases, amputations or other surgical interventions are also necessary. In this case, the course of the disease strongly depends on the exact manifestation of the disease.Therapy should therefore begin very early to avoid possible complications. If Charcot foot is not treated, the foot may die off completely, with other areas of the body usually affected by inflammation and infection as a result. For the affected person, this disease always results in severe movement restrictions and a significantly reduced quality of life. However, regular examinations by a doctor can prevent Charcot foot. If the affected person changes his diet and possibly reduces excess weight, there may be a positive course of the disease.
Prevention
Since Charcot foot is mostly triggered by diabetes mellitus, prevention is not easy. Regular check-ups with a physician are considered important.
Follow-up care
Once the primary treatment by the doctor is completed, to avoid further complications in the future, the patient with a Charcot foot should not only adhere to the rules of conduct of his treating diabetologist, but should actively participate in the aftercare and also preventive care of his medical problem. Especially the good blood sugar control is essential to avoid further symptoms of the disease. If the deformation of the foot is very severe, it is possible for the patient to get special orthopedic shoes (custom-made). These protect the foot from further damage (costs must be clarified with the health insurance company beforehand). The opinion of a Charcot foot specialist should also be sought. As a further aftercare measure, the patient should always keep a close eye on his feet during daily care in order to be able to notice and react to any changes at an early stage. Special attention should be paid to pressure points and injuries. Good blood circulation to the feet can be achieved if the affected person performs barefoot “foot gymnastics”: standing up, walking around, turning the feet and putting weight on them. Furthermore, it should be considered to use the services of a professional foot care. The money invested here is worth it, because the trained professionals not only care for the feet optimally, but also recognize with a trained eye, whether and if so what changes have occurred in the feet.
What you can do yourself
Acute Charcot foot is a medical emergency and must be treated immediately by a specialist. It is imperative that affected individuals go to a hospital immediately. One of the most important self-help measures is to discover the disease in time and have it treated. At the beginning of the disease, there is usually only a seemingly harmless accumulation of fluid on the foot. The affected person often notices no more than redness or swelling. If the disorder is recognized and treated at this stage, the bone softening usually disappears completely over a period of eight to twelve weeks. Members of risk groups should therefore always consult a doctor promptly if they notice edema in the foot area, even if it appears harmless. Diabetics in particular belong to the risk groups. In rare cases, however, a Charcot foot also forms after infectious diseases such as syphilis. Diabetics help themselves best by fighting the underlying disease. In the case of type 2 diabetes mellitus, this usually means a complete change in lifestyle. It is important to reduce existing excess weight. In addition, a change in dietary habits and the integration of sport and regular exercise into the daily routine is almost always necessary. In the case of an acute illness, all measures to relieve the foot, which the treating physician has ordered, must be strictly observed. Only in this way is there a chance that the softened bones will recover and the foot will become healthy again.
