Charcot Foot (Severe Foot Deformity)
We treat a lot foot and ankle problems for our patients, but the ones associated with diabetes are especially alarming. The concern is that there can be a loss of sensation from chronic elevated glycemic levels. This can lead to a collapse of the foot called a Charcot deformity. This would be like driving your car and the mid portion is dragging on the ground. Instead of sparks coming from the frame of the car we have bones pushing through the bottom of the foot.
In the case of a Charcot foot, diabetes has damaged the nerves to a point where they no longer provide the gift of pain. Although it may not sound like a gift but the loss of sensation is the Loss Of Protection (called LOPS). A foot without sensation is as dangerous as a smoke detector without a battery. Although diabetes is responsible for the majority of this problem, anything that blocks sensation can lead to a Charcot foot.
This may sound like a Rube Goldberg cartoon without the amusing entertainment. There is a long series of events that occur before the spectacular ending. Repetitive micro damage occurs in a foot with faulty mechanics like a flat foot. The ligaments that hold the joints together slowly begin to stretch and tear. An inflammation cycle begins which is part of the natural healing process. Normally pain increases with the degree of damage or injury. If the pain is too great we limp or just stop walking and this stops the cycle. The person without protective sensation keeps on walking…and walking…and walking. Every cycle of micro injury keeps escalating the inflammatory cycle.
In an effort to heal the area, the body increases local blood flow. After months or years the bones become washed out (osteopenia) and weakened like an old pair of jeans. And since there is little or no sensation there is no alarm. The ligaments around the weakened bones start to tear or stretch. The bone either break, crumble or dislocate. For people with neuropathy there is no pain and continue to walk on a compromised foot. This would feel like a truck had run over your foot IF you had normal sensation.
The cycle continues until a foot is severely misshapen and is called a rocker bottom foot. The end stage is skin break down/ulceration around the boney enlargements. Open wounds go to infection and that could lead to amputation.
If you have diabetes and/or realize you’ve developed this serious condition, please give us the chance to do everything we can to protect and hopefully save your feet. Either call our Indianapolis office at (317) 545-0505 or connect with us online to schedule an appointment.
It is pretty easy to recognize a Charcot Foot.
You may have heard that if you lose one of your senses another will increase. When sensation is lost you must rely on vison for protection. An early complication from diabetes will be visible long before it is painful.
More than half of individuals that have diabetes for more than 5 years have a decrease in sensation.
Please read this sentence again.
So a simple visual inspection on a daily basis can prevent disaster. This powerful 20 – 30 second habit will decrease the chance of losing a body part by 90%. If the person that has LOPS also has vision problems then it is still critical that someone else monitor the foot. It is pretty common for my new patients to ask if they REALLY have to look at their feet every day. My smart alec response is “NO, but there may not be any feet to look at if you don’t”.
I wish I did not have to say this but….If a problem develops it need immediate attention. This would be like having a smoke detector alarm go off in the middle of the night and calling 911 a week later. I hear “I have been watching this hole in my foot for 2 weeks now and it is not getting better” too often.
This is what you are looking for:
- Swelling (especially when there wasn’t an obvious injury or explanation for it)
- The swelling can be significant
- Warm to the touch
- Redness Consider this a red flashing light in a fire drill.
- Physical deformity A foot that rolls inward (flat foot) is a primary cause of Charcot collapse.
- Drainage This will typically come from under a callus.
- WARNING – a callus is an ulcer waiting to happen
- Discomfort By the time there is detectable pain, it is already a 3 alarm fire.
These are also the same symptoms of an infection. Charcot collapse and infection can go hand in hand. Both are significant threats.
Early diagnosis and treatment are crucial for reducing your risk of amputation. If you recognize any of these symptoms or know you have a high risk, schedule the earliest possible appointment with our office so Dr. Leibovitz can evaluate the situation and create a plan for you.
What kind of treatment options are there?
Treatment for the condition depends on a variety of factors, including the stage and severity of the deformity. Other factors that affect treatment are glycemic levels, additional medical issues such as obesity, blood flow, heart disease, nutrition, and use of nicotine. To be blunt; I do not expect to save a Charcot foot in the presence of nicotine.
Conservative treatment methods are simple but critical:
- Immobilization – During early stages, the ankle and foot are especially fragile. The foot must be protected. The goal is to prevent further collapse. the weakened bones have a chance to repair themselves, NO WEIGHT should be put on the foot. Since there is no pain this can be a difficult message to understand. Walking on this foot would be like walking on a bag of light bulbs.
- Keeping all the weight off the foot is a big challenge. The options are Crutches (a pair), Knee cart, Walker, wheel chair, or hiring minions to carry you around.
- After the swelling and inflammation is controlled, a removable boot may be used (possibly along with a wheelchair or crutches). How quickly (or slowly) the initial phase is controlled will determine when partial weight bearing begins.
- Bracing and custom shoes – After the initial fire is out, the position of the bones is assessed. Daily activities can resume if bones have healed in a functional position. Shoes with special inserts might be used to support the foot. This will help prevent ulcers, amputation, and even recurrence of the Charcot foot. More aggressive bracing may be required if there is significant change in the foot and ankle.
- Activity modification – In order to prevent repetitive trauma in both feet, activity levels will need to be modified.
The BIG IF
If there is significant collapse of the foot and ankle, if this is a reoccurring problem, and if the health status is reasonable then reconstruction can be considered. This involves rebuilding the foot like Steve Austin. only without the neat sound effects. The challenge is that the bones are not very strong. A combination of surgical screws, plates , pins, or external fixation are used to hold the bones together so they fuse/heal. Reconstruction is the last treatment option. It can only be considered after the inflammatory phase (swelling) is complete.
Can Charcot foot be prevented?
To prevent a Charcot foot, we encourage patients to practice diligent diabetic foot care, including:
- Conducting thorough daily foot inspections
- Regularly coming in for check-ups with our office
- Monitoring and managing blood glucose levels to reduce the progress of neuropathy
- Always contact us immediately if anything is out of the ordinary.
- When we consider a medical issue like this, it is simply best to prevent it from happening in the first place. We can help by working with you to create a diabetic foot care plan based on protection and proactive measures to keep you safe.
- After prevention, early care is the next best option.
As soon as you recognize the warning signs of Charcot foot, schedule your appointment with us right away. Contact our Indianapolis podiatry office for all of your diabetic foot care needs by calling (317) 545-0505 or fill out our online form today to schedule your appointment.