Diabetes Mellitus is when the body is unable to keep its blood sugar levels regulated either due to the pancreas not producing insulin or the body’s lack of response to insulin that is produced. In previous blogs, the symptoms and other manifestations of diabetes have been discussed. However, as stated previously, peripheral neuropathy is an extremely common problem among diabetics. To quickly review peripheral neuropathy, it is damage to the nerves that are located in the hands and feet. Our nerves have a protective sheath over them, very similar to a rubber coated wire, and when blood sugar levels go out of control this protective layer begins to get damaged. Once the protective sheath gets damaged, the nerves may lose their ability to feel sensation, and/or burning and tingling in the hands and feet may result. Charcot arthropathy is another common pathology found in those with diabetes; the reasons for how and why of Charcot arthropathy develops is poorly understood, but is believed to be linked with neuropathy.
Charcot arthropathy is classified via the Eichenholtz classification system and is divided into 3 stages. Each stage will present with a different set of symptoms.
o Stage 1 is the acute fragmentation stage: the patient will present with redness of the foot and swelling. In addition, the patient will have increases in soft tissue, fractures, dislocations, and decreased bone density noted on x-rays. These symptoms of this stage are identical to the symptoms of infection and rheumatoid arthritis, which makes an early diagnosis of Charcot arthropathy difficult. In fact, Charcot arthropathy will not usually be diagnosed for 29 weeks after symptoms progress. This is unfortunate because stage 1 is a medical emergency, since with time the foot begins to lose stability and begins to collapse due to the fracturing, dislocations, and decrease in bone density.
o Stage 2 is the subacute coalescence stage: there are fewer symptoms in this stage, since the bone fractures are healing and redness and swelling are gradually decreasing. The fractures and dislocations will not heal in proper alignment and the foot may begin to look deformed.
o Stage 3 is the chronic remodeling stage: there will be neither swelling nor redness remaining; however, the foot will be deformed. Charcot arthropathy stage 3 is characterized by the “rocker bottom foot” appearance, which will appear football in shape. In addition to the deformity, ulcerations are common in Charcot arthropathy since there will be many pressure points on the foot due to deformity.
Early stages of Charcot can be treated by trying to stop the foot bones from fracturing and dislocating by putting the patient in a cast for several weeks. By having the foot casted and not bearing any weight, the foot will be well protected. It will also be important to decrease inflammation and prevent weakening of the bone by taking bisphosphonate medications. However, as the symptoms approach stage 3 Charcot arthropathy, the condition becomes difficult to reverse since the foot will become rigid and stay deformed. Stage 3 Charcot can be treated by non-surgical and surgical treatments. Non-surgically, it is best to make accommodative orthoses with custom molded shoes. The orthoses will cushion the foot and the custom molded shoes will allow the deformed foot to have enough room in the shoe. Another option is a Charcot Restraint Orthotic Walker (CROW) which helps minimize pressure on the foot.
In addition to non-surgical treatment, there are surgeries that can be done for Charcot arthropathy that will attempt to provide a more stable and well-structured foot.
At Boulder County Foot and Ankle and Platte Valley Foot and Ankle Clinic, we treat this condition as well as other diabetic foot conditions. We can be reached at (303) 442-2910 in Boulder and (303) 659-5950 in Brighton.