Charcot Foot

Diabetic Charcot foot is a chronic and progressive (it gets worse over time) joint disease following the development of neuropathy (the loss of protective sensation in the limb); it occurs in about 1 percent of neuropathic patients.1

Causes

Charcot foot had been documented to occur as a consequence of various peripheral neuropathies (lessened ability to feel sensations in the limbs); however, diabetic neuropathy has now become the most common cause. The interaction of several factors (diabetes, sensory-motor neuropathy, autonomic neuropathy, trauma, and metabolic abnormalities of bone) results in acute, local inflammation, which may lead to varying degrees and patterns of bone destruction, dislocation and deformity.1

Symptoms

The hallmark deformity associated with this condition is midfoot collapse, described as a “rocker-bottom” foot, although the condition appears in other joints and with other presentations. Pain or discomfort may be a feature of this disorder at the active (acute) stage, but the level of pain may be significantly diminished when compared with individuals with normal sensation and equivalent degrees of injury.1

Diagnosis

An X-ray will confirm a diagnosis of Charcot foot.

Treatment options

The Charcot foot can be managed with physical therapy, braces or casting, pain medication and surgery. For severe deformities that cannot be treated in a brace, osteotomy (the surgical cutting of a bone or removal of a piece of bone) and some sort of fixation device can help to reverse foot and joint deformities, aiding support and strength. Arthrodesis (fusion of the joints) and finally amputation are other treatment options, depending on the severity of the condition.

Complications

Left untreated, Charcot foot leads to pain and difficulties walking, which decreases everyday activity levels and, in turn, adversely affects quality of life with further deteriorating mobility. Foot wounds, foot fractures and more severe deformities of the foot and ankle may also occur. It is important to remember that the underlying conditions, such as diabetes, should be managed over the long-term, even after Charcot foot is treated in the “active” stage.

Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth disease (CMT) is a group of inherited neurological disorders involving the peripheral nerves — that is, those that are outside the brain and spinal cord, and govern the motor and sensory capabilities in the limbs (such as walking).2 Its estimated prevalence in the general population is 1 in 2500 (.04%).

Causes

CMT is caused by congenital mutations in genes involved with the structure and function of the nerves governing the feet, legs, hands and arms. There is no single faulty gene and there are many varieties of CMT caused by different genetic faults.

Symptoms

Usually develop between 5 and 15 years but may develop later. Foot deformities may occur, and the lower legs may have an “inverted champagne bottle” appearance as muscle bulk is lost. As the disease gradually progresses, weakness and loss of fine motor skills may occur, with pain ranging from mild to severe.2

Diagnosis

Examination by a neurologist will raise the possibility of the disease, which will be confirmed by nerve conduction studies, electromyography to measure the electrical activity of your muscles, and sometimes in uncertain cases by nerve biopsy.

Treatment options

Although CMT cannot be cured, it can be managed with physical therapy, braces, pain medication and surgery.2 Osteotomy (the surgical cutting of a bone or removal of a piece of bone) and treatment with an external fixation device can help to reverse foot and joint deformities, aiding support and strength.2

Complications

Left untreated, CMT leads to pain and difficulties walking, which decrease everyday activity levels and in turn, adversely affects quality of life and further deteriorates mobility. Foot wounds, foot fractures and more-severe deformities of the foot and ankle may also occur.

Pes Cavus

Pes cavus foot is another name for a high-arched foot. Prevalence in the population is estimated to be 8–15 percent.3

Causes

Severe pes cavus can be caused by progressive neurological disorders (e.g., spinal trauma, muscular dystrophy, hereditary neuropathy), static neurological disorders (e.g., stroke, cerebral palsy) and other causes, such as foot trauma.3

Symptoms

The shape of the foot may range from a slight high arch to a severe deformity actually causes a patient to walk on the outside of the foot.

Diagnosis

An X-ray will confirm a diagnosis of pes cavus and its severity.

Treatment options

Slight high arches are usually corrected or managed with specially designed footwear (orthotics) and severe deformity may require surgery to achieve realignment. Osteotomy (the surgical cutting of a bone or removal of a piece of bone) and external fixation can correct a severe deformity, thus reducing pain, improving function, and reducing the incidence of deformity-related injuries, such as ankle sprains and broken bones.4 However, realignment through external fixation must be supplemented with soft-tissue–balancing procedures, such as tendon transfer and orthotic management, in order to maintain the correction.5

Complications

Left untreated, pes cavus causes foot pain — and, potentially, knee, hip and back pain — that limits mobility. People with pes cavus may also be more prone to broken bones in the lower legs.

Pes Planus

The foot must act as a reliable landing point when putting the foot down, usually heel first, and as a rigid taking off point when walking or running. There are medial and lateral arches that run the length of the foot and are supported by ligaments, one of which is called the spring ligament. The arches are supported by a combination of the shape of the bones, the integrity of the ligaments and the function of the supporting muscle system, which is regulated by feedback from the nerves supplying the foot. Problems with any of these mechanisms may lead to loss of longitudinal arch shape and flat foot.

Pes planus is more commonly known as flat-foot. Both children and adults may be flat-footed and it’s estimated that the prevalence of pes planus in the general population is about 20–30 percent. In fact, normal arch development in children does not typically occur until between 3 and 5 years old.6 Slightly-lowered arches are usually symptom-free. Adult Acquired Flatfoot Deformity (AAFD) may develop from a normal foot in adult life.

Causes

In pathological flatfoot the arch of one foot or both feet has either not developed normally, or an injury or condition, such as rheumatoid arthritis, stroke or diabetes has produced it. It may develop as a result of degenerative changes in joints and / or ligaments; this will tend to be in older patients and people who are very heavy. It may also occur as a result of trauma to the bones and / or ligaments. An increasingly common cause seems to be neuropathic problems secondary to diabetes, as an early manifestation of Charcot foot.

Symptoms

The arch of the foot is lowered or flattened out, depending on the severity. Issues such as discomfort and chronic pain can arise if, for example, there is a minor injury, changes in the work environment (such as long periods of standing), sudden weight gain, poorly-fitted footwear, and excessive standing, walking, jumping or running.6

Diagnosis

Diagnosis is usually by clinical examination. In young people the flat foot that is apparent when standing disappears when they stand on tip toe, and the normal arch appears. This is flexible flat foot, is usually symptomless and requires no treatment. Adults with AAFD will normally have a rigid flat foot that does not correct on tip toe. X-rays may be helpful when there is a history of injury, but may not be necessary.

Treatment options

Management in less-severe cases generally consists of wearing spacious, comfortable footwear with good arch support, possibly supplemented by padding or orthotics, in order to balance and cushion the foot.6 The object of treatment is to restore anatomy and function as much as possible. Surgery sometimes with osteotomy (the surgical cutting of a bone or removal of a piece of bone), may be necessary if the deformity is fixed.7 Bone grafting to replace lost bone may be necessary.7 Each case is different and there are many types of treatments; it is best to discuss your treatment in detail with your specialist rather than attempt to summarise the options here.

Complications

If not treated, certain cases of pes planus can result in severe deformity and early onset of arthritis of the foot and ankle, causing severe pain and significantly reducing the ability to walk, even when wearing orthotics. Even after surgery, you may need to wear orthotics for the rest of your life.

Ankle Arthritis

Ankle arthritis is a stiffening of the joint that restricts mobility and use. There are 50,000 new cases of ankle arthritis in the U.S. every year.8

Causes

Wear and tear over time and swelling in the joint (often due to other causes, such as diabetes or cardiovascular disease), as well as trauma and immune conditions, can lead to stiffness, pain, and a reduced ability to move, walk and even stand.

Diagnosis

Diagnosis of arthritis involves a physical exam, evaluation of the patient’s medical history and imaging such as X-rays, MRI or CT.

Treatment options

When more conservative treatments (such as pain medication, steroid injections, activity modifications/limits, walking aids, cushioned and specially designed footwear, and stabilizing braces) have failed, ankle arthrodesis may be performed.8 The goal of the procedure, commonly known as ankle fusion (as the tibia, fibula and talus are fused into one bone), is to relieve pain and maintain or improve function by eliminating motion in the arthritic joint. In younger more active patients ankle debridement, distraction arthroplasty and supramalleolar osteotomy (in near normal ranges of movement) are all options which aim to attempt to conserve the joint surface, and may be effective in selected cases. Arthroplasty (joint replacement) may also be offered in some cases.

As part of the fusion procedures, osteotomy (the surgical cutting or removal of a piece of bone to alter alignment) may be performed in the lower leg, with the use of external fixation. This procedure stabilizes the operative site, allowing the bones to heal together. In case of infection or very damaged soft tissues, external fixation is the preferred treatment.9

Complications

Even after ankle fusion, patients may still have pain and may require further surgery if infection of the incision site or loosening of the bones arises.8 Left untreated, patients will continue to lose motion in the ankle and experience an increase in pain that restricts mobility and everyday activities.

  1. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123–9.
  2. National Institute of Neurological Disorders and Stroke. Charcot-Marie-Tooth Disease: Fact Sheet. Bethesda, MD: National Institutes of Health; 2015. http://www.ninds.nih.gov/disorders/charcot_marie_tooth/detail_charcot_marie_tooth.htm [Accessed October 2015].
  3. Ball T, Butler M, Parsons S. Pes cavus: Not just a clinical sign. Diagnosis, aetiology and management. Adv Clin Neurosci Rehabil. 2013;12(6):16-9.
  4. American Orthopaedic Foot and Ankle Society (AOFAS). Cavus foot surgery. Rosemont, IL: AOFAS. https://www.aofas.org/footcaremd/treatments/Pages/Cavus-Foot-Surgery.aspx [Accessed October 2015].
  5. Paley D, Lamm BM. Correction of the cavus foot using external fixation. Foot Ankle Clin. 2004;9(3):611–24.
  6. Healthwise. Flatfoot (pes planus). Atlanta: WebMD; 2014. http://www.webmd.com/a-to-z-guides/flatfoot-pes-planus-topic-overview [Accessed October 2014].
  7. Miller MD, Thompson SR, Hart JA. Review of Orthopaedics. Philadelphia: Saunders/Elsevier Health Sciences; 2012.
  8. Gallagher B. Treatment for end-stage ankle arthritis re-evaluated. Nashville, TN: Vanderbilt University Medical Center. http://www.mc.vanderbilt.edu/documents/orthopaedics/files/Gallagher%20-%20f-a%20NMN.pdf [Accessed December 2015].
  9. American Orthopaedic Foot and Ankle Society (AOFAS). Ankle arthrodesis. Rosemont, IL: AOFAS. http://www.aofas.org/footcaremd/treatments/Pages/Ankle-Arthrodesis.aspx [Accessed October 2015].