Charcot joints occur when the ability to sense deep pain is lost or diminished. As a result of the inability to sense pain, small fractures begin to develop in areas of stress such as the arch of the foot. The normal response to a fracture is swelling and increased blood flow (reflex vasodilatation) to the affected area of bone. The increase in blood flow tends to 'wash away' calcium from the fracture site, resulting in weakening of the bone as well as more fractures. In the event that the normal defensive device, pain, remains absent, a cycle of increasing fracture activity starts with progressive collapse of the supporting bone.
The description of Charcot joints dates back to be able to 1703 when neuropathic osteoarthropathy was first described by W. Musgrave. Charcot is credited regarding his work in 1868 for describing gait anomalies of patients with syphilis (tabes dorsalis). Jordan, in was the first to describe a relationship of diabetes to neuropathic arthropathy.
- The most frequent area of the foot to be effected by a Charcot joint is the mid arch.
- Charcot joints can also develop in the rearfoot and ankle but are much less common.
- Probably the most common cause of Charcot joints of the foot is peripheral neuropathy due to diabetes mellitus.
The progress of a Charcot joint may be rapid and is determined by a number of variables. Any ability to perceive pain may lead to a more prompt diagnosis because of patient's concern regarding their abilities to complete an average day. Total loss of deep pain sensation may delay early diagnosis. Charcot joints are easily confused with osteoarthritis, which can be treated much less aggressively than a Charcot joint.
1966 Eichenholz proposed a category of Charcot joints which is broken down into three distinctive stages. Stage one, or the development stage, shows debris surrounding the joints on xray. Stage one can develop over a period of days to weeks and it is radiographic change that occurs in response to unperceived trauma. Stage two is the coalescence stage. In stage two, the bone actually starts to heal with absorption of debris and healing of large fracture fragments. Stage three, often called the reconstruction or reconstitution stage, note a reduction in bone turn over and reformation of stable bone structure. Stage 0 had been added in 1999 by Sella and Barrette to include patients who exhibit clinical the signs of Charcot arthropathy but have yet to show radiographic changes.
- The classification proposed by Brodsky in 1992 includes the location of the Charcot joint which is commonly used in clinical practice today.
- Brodsky's classification is as follows;
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Type 1 - Lisfrank's joint - 27-60% of all Charcot joint deformities of the feet.
Type 3A - Ankle joint - 9% of all Charcot deformities.
Type 3B - the Posterior Calcaneus.
Type 4 - Multiple instances of the base and/or ankle.
Type 5 - the Forefoot.
Charcot joints are often not diagnosed until they create another problem that impacts a patients normal activities. These may be as simple as a great inability to fit into shoes, or as severe as an infected ulceration of the foot. By this stage, the Charcot deformity has in all likelihood progressed to a point where there is massive displacement of the bones and joints together with several displaced fractures.
- Any situation that plays a role in the loss of sensation of the foot may be considered a cause for a Charcot joint.
- Some of the people conditions include;
Diabetes mellitus Tabes dorsalis (neuropathy caused by syphilisHansen's Disease (Leprosy) Tumors of the spinal cordDegenerative change with the spinal cord or peripheral nerveAmyloid Familial-hereditary neuropathies including Charcot-MarieToothe Disease, Hereditary sensory neuropathy andDejerine-Sottas Condition Pernicious Anemia.
Injectable and systemic use of steroids PhenylbutazoneIndomethacin Vincristine
Other factors that may contribute to producing neuropathy, and subsequently, Charcot joints include;
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Alcoholic neuropathy Congenital insensitivity to pain Pott'sDisease (tuberculosis of the spine)
The most common complicating factor of a Charcot joint of the foot is the prominence that evolves on the bottom of the foot, referred to as a 'rocker bottom' foot. Treatment plans occurs as the bones of the arch collapse. In an advanced rocker bottom foot, the inability to feeling pain will become a complicating factor for the skin. As the bone places more pressure on the skin, the skin begins to ulcerate and becomes contaminated.
X-rays will be the single most useful tool in diagnosing Charcot joints. Bone scans are helpful in the early phases of Charcot joints and are sensitive indicators of hyperemia (increased blood flow to the area of the fracture). Surface skin temperature is probably the most reliable indicator of the activity of the fractures. Most doctors do not keep the necessary equipment to be able to measure skin temperature but merely measure with direct touch to be able to sense the presence or lack of warmth.
Treatment of Charcot Joints
The hallmark of treatment of Charcot joints is early diagnosis and prevention. The signs and symptoms and findings of Charcot joints vary so that each case requires careful evaluation. Therapy ofCharcot joints of the feet may include rest, casting and also non-weight bearing to allow adequate time for fracture healing. Total contact casting or the use of a Charcot Restraint OrthoticWalker (CROW) tend to be popular in stages one and two. The goal is to limit weight bearing to enable progression to stage three. This kind of progression can take from many weeks as much as 6 months. Electrical stimulation, or even bone arousal, is a well known adjunct to be able to non-weight bearing or sending your line.
Surgical procedures for Charcot joints are often challenging not only due to the complexity of this condition but also due to the fact that these patients are usually bad surgical candidates due to other health problems (co-morbidity). Surgical procedure may include reconstruction of the arch and/or combined fusion. Often, surgical procedures are used to return the foot to a shape that can be accommodated by typical feet wear. Stage threeCharcot deformities often result in piles, bump as well as unusually shaped feet as a result of bone alterations. Reshaping the foot may be used to remove a boney prominence on the top or bottom of the foot.
Nomenclature: reflex vasodilitation - increased flow of blood to an area within response to inflammation
Rocker bottom foot - a dominance which forms on the sole or perhaps bottom of the foot as a result of the collapse with the arch
The symptoms of Charcot joints vary based upon the location and severity of the condition. The sign is localized edema swelling) of the joint or important joints. The actual edematous area may exhibit increased temperature change. Often, the first obvious symptom in which a patient with advanced sideline neuropathy will notice is the fact that their shoes have become tight or these people have difficulty appropriate into a pair of shoes that have fit well for some time.
The challenge in diagnosing this condition is the lack of symptoms that are due to peripheral neuropathy. Peripheral neuropathy makes it impossible for the patient to be able to speak in terms that would be understood by the general population such as 'my toes hurt'. As a result, the physician needs to rely more on testing and less on the history and physical examination.
The differential diagnosis for this condition should include;
- Bone tumor.
- Idiopathic edema
- Soft tissue tumor
Additional References Include;
Grady, J.F., et al: The use of electrostimulation in the treatment of diabetic neuroarthropathy J. Am. Podiatric Med. Assoc. 90(6): 287-294, 2000
- Sinha, S., Munichoodappa, C.S., Kozak, G.P: NeuroarthropathyCharcot Joints) in diabetes mellitus.
- Medicine (Baltimore)
Saltzman, CL, Johnson KA, Goldstein RH, et al: The patellar tendon-bearing brace as treatment for neuropathic arthropathy: a dynamic force overseeing study. Foot Ankle 13: 14, 1992
- Sticha RS, Frascone ST, Werthheimer SJ: Major arthrodesis in patients with neuropathic arthropathy.
- J Foot Ankle Surg 35:
- Eichenholtz SN: Charcot Joints, Charles C.
- Thomas, Springfield,Il 1966
- Giurini JM: Applications as well as use of in-shoe orthoses in the conservative management of Charcot foot deformity.
- ClinPodiatric Med Surg 11: 271, 1994
- Pinzur Ms, Sage R, Stuck R, et al: A treatment algorithm for neuropathic (Charcot) midfoot deformity.
- Foot Ankle 14: 189, 1993
- Lavery La, Armstrong DG, Walker SC: Therapeutic rates of diabetic person foot ulcers associated with midfoot fracture due to Charcot's arthropathy.
- Diabet Med 14:46, 1996
- Cleveland M: Surgical fusion of unpredictable joints due to neuropathic disturbance.
- Am J Surg 43: 580, 1939
- Wilson M : Charcot foot osteoarthropathy in diabetes mellitus.
- Mil Med 156: 563, 1991
- Reinherz RP, Cheleuitte ER, Fleischle JG: Identification and treatment of the actual diabetic neuropathic foot.
- J Foot ankle Surg
- Pap J, Myerson M, GirardP, et al: Save with arthrodesis in intractable diabetic neuropathic arthropathy of the foot and ankle.
- J Bone Joint Surg Am 75:1056, 1993
- Lavine LS, Grodinsky AJ: Current concepts review: electrical stimulation of repair of bone tissue.
- J Bone Joint Surg Am 69: 626, 1987
- Bassett CA, Mitchell SN, Norton L, et al: Repair of non-unions by pulsing electromagnetic fields.
- Acta Orthop Belg 44: 706,
About the actual author:Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster can also be board certified in pedorthics. Doctor. Oster is medical director of Myfootshop.com and is in active practice in Granville, Ohio.