Diabetic patients present with a multitude of complications. Musculoskeletal complications of diabetes can significantly impact the quality of life and the development of Charcot foot in diabetic patients is a potentially life-threatening complication. It is commonly seen in patients as early as 20s-30s and later for those patients who develop type 2 diabetes [1]. The combination of minor trauma, neuropathy, vascular concerns, and other potential metabolic issues of the bone contribute to the inflammation and eventual deformity [1].

Differential Diagnosis-

• Septic Arthritis
• Crystal-associated arthritis (Gout, pseudogout)
• Cellulitis
• Osteoarthritis
• Idiopathic Inflammatory Disorders
• Osteomyelitis
• Complex Regional Pain Syndrome
• Acute deep vein thrombosis

Clinical Features –

Patients present with a unilateral warm, swollen, and erythematous foot. This is important to manage since this is usually a common presentation of patients with long standing diabetes and can be mistaken for osteomyelitis or cellulitis. Furthermore, the most common joints that are involved include the tarsus, tarsometatarsal joints, and lastly the metatarsophalangeal joints and ankle [1].

This neuroarthropathy is also described as painless and often coexists with foot ulceration. Additional deformities include a “rocker bottom foot”, which is caused by the collapse of the medial arch and a medical convexity deformity [2].

Imaging and Staging –

On imaging, the changes are gradual and initially in the acute phase of the disease, demonstrate nonspecific changes with soft tissue swelling. As the inflammatory process progresses, the metatarsal heads may disappear which is known as as “pencil pointing” [1].

There are several stages that have been characterized, known as the Eichenholtz system [1].

• Stage 0 – Early or inflammatory – Localized swelling, erythema, and warmth
• Stage 1 – Development – Swelling, redness, warmth, fracture- subluxation, dislocation, bony debris
• Stage 2 – Coalescence – Signs of fracture healing, bony debris resorption, new bone formation
• Stage 3 – Remodeling – Fracture callus

Treatment-

• Offloading and limited weight bearing activities
  • Total contact casting = Gold Standard
    • This immobilizes the foot and is initially replaced after 3 days with a follow up weekly [2].
    • The casting is continued until the edema has resolved.
  • These include CROW – Charcot restraint orthotic walkers for hind foot involvement [1].
  • Total contact prosthetic walkers
  • Walking boot
• Short term bisphosphonate treatment, calcitonin may also be beneficial
• Surgical Correction in select patients

Prognosis –

• Overall, diagnosing this condition early on can improve healing and improve the overall outcome.

Citation –

[1]. Hordon L. Diabetic neuropathic arthropathy. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Available from http://lib.campbell.edu/cusom. Accessed March 30, 2016.

[2]. Rogers L, Frykberg R, Armstrong, D, et al. The Charcot Foot in Diabetes. Diabetes Care. 2011; 34 : 2123-2129. http://care.diabetesjournals.org/content/34/9/2123.full

Contributing author: Ahasn Mahmood MS 3 Campbell University School of Osteopathic Medicine