What is Charcot?

The French neurologist Jean Martin Charcot, although not the first to describe the disease, gave his name to the neuropathic osteoarthropathy by linking it to the underlying neurological abnormalities of tertiary syphilis.

Charcot, J.M. Sur quelques arthropathies qui paraissent dependre dune lesion du cerveau ou de la moelle epiniere. Arch Physiol Norm path 1868; 1: 161.

Sella, E.., and Barrette, C. Staging of Charcot nueroarthropy along the medial column of the foot in the diabetic patient. Journal of Foot and Ankle Surgery. 38:(1) 34,1999.

Who is at risk for developing Charcot?

Charcot arthropathy is most common in patients with Diabetes with a prevalence as high as 13% in high risk patients. Additionally, it is also associated with alcoholism, Hansen?s Disease, Spina Bifida, congenital insensitivity to pain, syringomyelia, and peripheral nerve injuries.

Sella, E.., and Barrette, C. Staging of Charcot nueroarthropy along the medial column of the foot in the diabetic patient. Journal of Foot and Ankle Surgery. 38:(1) 34,1999.

Armstrong, D.G., Todd, W.F., Lavery, L.A., Harkless, L.B., Bushman, T.R. The natural history of acute Charcot?s arthropathy in a diabetic foot specialty clinic. 1997, 14:357.

What are the clinical characteristics of Charcot?

Patients with Charcot often present with a warm, red, swollen foot, bounding pedal pulses, decreased or loss of protective sensation, and absent tendon reflexes.

Nube, V.L, McGill, M., Molyneaux, L., Yue, D. From acute to chronic: Monitoring the progress of charcot?s arthropathy. Journal of the American Pod Med Ass. 2002, 92(7):384.

Armstrong, D.G., Peters, E.J. Charcot?s arthropathy of the foot. Journal of the Amer Pod Med Ass. 2002. 92: (7)390.

What is the classification system for Charcot?

Two classification systems exist for Charcot: the Eichenholtz Classification System published in 1965 and the Sell and Barrette Classification System published more recently based on clinical examination and radiological findings.

Classification by Eichenholtz

Classification by Sella and Barrette

Eichenholtz, S. N. Charcot Joints, Charles C. Thomas, Springfield, IL. 1966.

Sella, E.., and Barrette, C. Staging of Charcot nueroarthropy along the medial column of the foot in the diabetic patient. Journal of Foot and Ankle Surgery. 38:(1) 34.

What are the underlying etiologies of Charcot?

Several theories exist which attempt to describe the etiology of Charcot, but it still unclear why Charcot develops. Autonomic neuropathy results in decreased sympathetic tone to vessels, vasodilation, and increased blood flow to tissues and bone. Increase in blood flow leads to a higher resorption rate resulting in weaker bones and susceptibility to fracture and trauma. Sensory neuropathy leaves patients with desensitized joints and unaware increased pressures on the plantar aspect of the foot. Collapse of the midfoot often results due to the combined effect of autonomic and sensory neuropathies. Collapse of the midfoot is most common at the tarsometatarsal and talonavacular/calcaneocuboid joints.

Jude, E.B., Boulton, A.J., Medical treatment of Charcot?s arthropathy. Journal of the Amer Pod Med Ass. 2002, 92:(7) 381.

Armstrong, D.G., Peters, E.J. Charcot?s arthropathy of the foot. Journal of the Amer Pod Med Ass. 2002. 92: (7)390.

Pinzur, J.S., Sage R., Stuck, R. Kaminsky, S. Zmuda, A., A treatment algorithm for neuropathic (Charcot) midfoot deformity. Foot and Ankle. 1993, 14:(4), 189.

How do you treat Charcot?

Treatment is dependent on the stage at which the patient presents. Off-loading and immobilizing the patient, most commonly done with a Total Contact Cast, is appropriate during the stages of development and coalescence. Immobilization usually lasts 3-6 months and allows the affected limb to become less red and swollen and begin the stage of reconstruction. As the joints and bones begin to fuse and swelling and temperature decreases, treatment should revolve around accommodating for the new deformity and avoiding ulceration.

Jude, E.B., Boulton, A.J., Medical treatment of Charcot?s arthropathy. Journal of the Amer Pod Med Ass. 92:(7) 381, 2002.

Armstrong, D.G., Todd, W.F., Lavery, L.A., Harkless, L.B., Bushman, T.R. The natural history of acute Charcot?s arthropathy in a diabetic foot specialty clinic. 1997, 14:357.

Pinzur, J.S., Sage R., Stuck, R. Kaminsky, S. Zmuda, A., A treatment algorithm for neuropathic (Charcot) midfoot deformity. Foot and Ankle. 1993, 14:(4), 189.

What diagnostic modalities should be ordered?

In addition to the clinical diagnosis, X-Rays should be ordered. MRI can be ordered to differentiate between Charcot vs. osteomyelitis.

Classical signs and symptoms of Charcot may lead to a clinical diagnosis. However, baseline X-rays should be taken at the time of initial presentation and progressively throughout the disease. They may often appear normal in the early stages, but will useful in monitoring the extent of bone deformity and involvement. Eichenhotlz was the first to monitor and stage the disease, according to radiographic findings.

Eichenholtz, S. N. Charcot Joints, Charles C. Thomas, Springfield, IL. 1966

Nube, V.L, McGill, M., Molyneaux, L., Yue, D. From acute to chronic: Monitoring the progress of charcot?s arthropathy. Journal of the American Pod Med Ass. 2002, 92(7):384.

Armstrong, D.G., Peters, E.J. Charcot?s arthropathy of the foot. Journal of the Amer Pod Med Ass. 2002. 92: (7)390.

When is the charcot foot considered to be resolved?

The Charcot foot is considered resolved when radiographic signs indicate the bones and joints have fused and when erythema, and edema are absent and temperature has equilibrated between the two feet.

Nube, V.L, McGill, M., Molyneaux, L., Yue, D. From acute to chronic: Monitoring the progress of charcot?s arthropathy. Journal of the American Pod Med Ass. 2002, 92(7):384.

McCrory, J.L., Morag, E., Norkitis A.J, Barr, M.S., Moser, R.Pl, Caputo, G.M., Cavanagh, P.R., Ulbrecht, J.S. Healing of Charcot fractures: skin temperature and radiographic correlates.

Armstrong, D.G., Lavery L.A., Monitoring healing of acute Charcot?s arthropathy with infrared dermal thermometry. Journal of Rehab Research. 34:(34), 317, 1997.

When is surgery indicated in patients with Charcot?

Surgery is indicated only at the end of the stage of reconstruction when deformities exist which can not be accommodated for and will certainly lead to ulceration.

Pinzur, J.S., Sage R., Stuck, R. Kaminsky, S. Zmuda, A., A treatment algorithm for neuropathic (Charcot) midfoot deformity. Foot and Ankle. 1993, 14:(4), 189

Armstrong, D.G., Peters, E.J. Charcot?s arthropathy of the foot. Journal of the Amer Pod Med Ass. 2002. 92: (7)390.

Is there a temperature measuring device that can screen for Charcot?

The inflammatory mechanisms which occur in Charcot?s osteoarthropathy lead to increased temperature in the effected extremity. Handheld infrared dermal thermometers can be used to monitor skin temperature increases and thus be used as a screening device for risk of ulceration or development of acute stage of Charcot. Although no well-established criteria exists, some studies suggest that increases of 3-4 degrees F between the affected and the contralateral lower extremity is predictive of an active phase of Charcot. "Foot cooling" as the inflammation subsides has also been a useful tool in the treatment process.

Armstrong, D.G., Lavery, L.A., Liswood, P.J., Todd, W.F., Tredwell, J.A., Infrared dermal thermometry for the high-risk diabetic foot. Phsical Therapy. 77:(2) 169,1997.

Armstrong, D.G., Lavery L.A., Monitoring healing of acute Charcot?s arthropathy with infrared dermal thermometry. Journal of Rehab Research. 34:(34), 317, 1997.

McCrory, J.L., Morag, E., Norkitis A.J, Barr, M.S., Moser, R.Pl, Caputo, G.M., Cavanagh, P.R., Ulbrecht, J.S. Healing of Charcot fractures: skin temperature and radiographic correlates.