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Also referred to as Charcot Arthropathy, Charcot Joint, or a neuropathic joint, Charcot Foot is a serious condition of the foot and ankle that is characterized by joint dislocation, fractures through weakened bone (pathologic fractures), and deformities of the foot and ankle. It is a progressive disorder that is associated with peripheral neuropathy. It was originally described as being caused by syphilis in the 1700’s, and was named for French neurologist Jean-Martin Charcot after he gave the first neurologic description of the disease in 1868. It has since evolved to be associated with a number of different causes of peripheral neuropathy, the most common of which is in association with diabetic peripheral neuropathy.
The incidence of Charcot Foot is relatively low, with ranges of 0.15-2.5% of diabetic patients developing the condition in their life. However, the incidence in specialized foot clinics has been reported as being as high as 13%.
The way that Charcot Foot develops is not completely understood. There are two theories for its development; the neurotraumatic theory and the neurovascular theory. The neurotraumatic theory describes Charcot Arthropathy developing due to repetitive trauma to the foot, that goes unrecognized by the insensate patient. The neurovascular theory describes the development of Charcot Arthropathy as being the result of an autonomic neuropathy that decreases blood flow to the lower extremity, thus decreasing bone synthesis and weakening the bones. The most universally accepted explanation for the pathogenesis of Charcot Foot is that it is a combination of these two events. That is, the neuropathic patient does not feel the damage that is being done to their already weakened musculoskeletal system.
Charcot Foot is classified using several different systems, most of which rely on which part of the foot is effected. Most commonly, the joints effected are the tarsometatarsal joints and the cuneonavicular, talonavicular, and calcaneocuboid joints. Charcot foot may also develop in the forefoot or in the ankle, those these scenarios are less common.
The signs and symptoms of Charcot Foot include a red, hot, swollen foot with intact skin. The affected foot is often several degrees warmer than the unaffected foot, and the patient is insensate. It is common for a patient with Charcot Arthropathy to also have an ulcer, which can complicate the diagnosis. In this case, the skin has been breached and infection is likely. Tests may be ordered to search for bone and/or systemic infection.
Treatment depends on the extent of the condition. Since there are a number of factors involved, including a patient’s general health, stage of the disease, and the presence/absence of infection, there are a number of considerations to plan for. The mainstay of treatment for the acute phase is to immobilize the foot and reduce the forces placed on the foot.
Immobilization is accomplished most frequently with a total contact cast. This is a cast that covers the entire foot, ankle, and leg. Casts are changed often, and serial x-rays are taken by the doctor to monitor the progression of the deformity. Infections are treated aggressively, and forces through the foot are addressed by having the patient in a non-weight bearing status.
After the acute phase, treatment is centered on prevention of recurrence. This includes measures such as treatment of the underlying condition (such as diabetes) as well as an emphasis on foot health. Proper fitting shoes are essential, and special shoes may be ordered or custom-made to reduce forces through the foot that can contribute to the development of Charcot Foot and ulcerations.
Surgery is warranted in some cases, where the deformity can be reduced and the progression of the disease can be prevented. An acutely inflamed foot is never operated on; the resolution of the initial symptoms is required before surgery can be planned.
While it may not be an extremely common condition, Charcot Foot is something that is always considered in the diabetic patient. It can be an extremely debilitating disease, and the progression can be unrelenting in some cases. Early detection is the key to a better prognosis, which is one of the many reasons why there is such an emphasis on foot health in the diabetic patient.
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