Diabetic Charcot Foot

Diabetes mellitus is a chronic disease that is becoming more prevalent worldwide. Diabetes causes high blood sugar, which is harmful to health in many ways.

As of 2015, 30.3 million people in the United States, or about 9.4 percent of the population, had diabetes.

Unfortunately, more than 1 in 4 people with diabetes don’t know they have it. Having undiagnosed diabetes increases the risk of diabetes-related complications such as kidney disease, heart disease, amputations, and more.

Many people also have prediabetes, a condition where blood sugars are slightly elevated but not high enough to be considered diabetes. Having prediabetes is a significant risk factor for eventually developing type 2 diabetes. The U.S. Centers for Disease Control (CDC) estimates that up to 30% of people with prediabetes will develop type 2 diabetes within five years of their prediabetes diagnosis.

The majority of people with diabetes have type 2, which typically affects older adults and can be related to multiple known risk factors, including race, weight, and some lifestyle factors.

Type 1 diabetes is more rare as it’s an autoimmune disorder. Diabetes type 1 usually occurs before age 18, so it’s also referred to as juvenile diabetes. Type 1 diabetes affects about 2-5% of the world’s population or about 1 in 300 American adults before the age of 18. 

Having diabetes for a long time, especially if blood sugars aren’t controlled, can cause many health complications. High blood sugar damages blood vessels, causing them to weaken over time.

Weak blood vessels can cause reduced blood flow, reducing the amount of oxygen and other nutrients needed for the healthy functioning of all of the body’s organs.

People with diabetes often have issues with their feet due to reduced blood flow and impaired nerve function. Diabetic foot ulcers are very common and a leading cause of foot amputations. Another foot compilation in people with diabetes is a condition called Charcot’s foot.

What is Charcot’s foot?

Charcot foot, also called Charcot arthropathy or Charcot neuropathic osteoarthropathy, is a serious disease that affects the foot’s bones, joints, and soft tissues. It most often impacts people with peripheral neuropathy. 

Peripheral neuropathy occurs when nerves outside of the brain and spinal cord are damaged, causing weakness, numbness, and pain. It usually impacts the hands and feet but can affect other body parts as well.

Diabetes is one of the most common causes of peripheral neuropathy. When someone who has diabetes develops peripheral neuropathy, it’s often called diabetic neuropathy. It occurs when high blood sugar damages the nerves, leading to a loss of the limbs’ sensation. It usually starts outward with the hands and feet.

Some of the symptoms of peripheral neuropathy include:

• Gradual onset of numbness, prickling, or tingling in your feet or hands, which can spread upward into the legs and arms.
  
  
• Sharp, jabbing, throbbing, or burning pain.
  
  
• Extreme sensitivity to touch.
  
  
• Pain during activities that shouldn’t cause pain, such as foot pain while bearing weight or feet under a blanket.
  
  
• Lack of coordination and falling.
  
  
• Muscle weakness.
  
  
• Feeling as if gloves and socks are being worn, but they aren’t.

Charcot foot usually doesn’t develop from a single incidence. It usually begins with an injury, such as a foot ulcer, that goes unnoticed. People with nerve damage don’t notice wounds because they don’t sense pain due to their nerve damage from peripheral neuropathy. However, some people with Charcot’s foot don’t recall an injury or trauma to the area.

The wound or trauma to the foot then causes uncontrolled inflammation, which leads to a condition called osteolysis. Osteolysis refers to a condition where the bone is gradually destroyed. As the bone is destroyed, it loses calcium, making the bones soft and causing them to become degenerate and lead to fractures.

Someone without neuropathy would usually feel pain and reduce the weight-bearing load on the injured foot. In the case of diabetic neuropathy, the person continues to use their injured foot, causing repeated trauma. The body releases cytokines, which continue to cause inflammation and destruction of bone cells. This leads to bone resorption, which is when bones are broken down, and the minerals (such as calcium) are released into the bloodstream.

Some risk factors for Charcot’s foot include long history (greater than 10 years) of diabetes, history of diabetic foot problems, age less than 60 years with neuropathy, the presence of nephropathy and retinopathy, and a hemoglobin A1c greater than 6.5%.

Charcot foot has various presentations, but a common trademark is a “rocker bottom” foot. This results from the loss of bone and collapsing of the joints in the foot and ankle. The foot can also appear very swollen, red, and be hot to the touch. People with Charcot’s foot will be advised on how to alter their gait (how they walk) to avoid putting unnecessary pressure on the impacted joint(s) to allow it to heal.

Can there be any complications or risks?

Diabetic Charcot foot is a rare but serious complication of diabetes. People with bone deformities are more likely to develop pressure wounds (ulcers) on their feet from bones pressing against the skin. These wounds are slower to heal in people with diabetes for many reasons, such as:

• Immune response in people with type 2 diabetes: Inflammation can be a useful protective mechanism used by the immune system. Inflammation helps the body fight off things that might harm it, such as infections, injuries, and toxins. When something causes a threat to cells, such as a wound, the immune system releases chemicals to trigger this immune response. When inflammation is prolonged, wound healing can be delayed. 
  
  Researchers have found that people with type 2 diabetes seem to have an altered immune response. One study found that people with diabetes had lower levels of a gene responsible for wound healing present in their foot ulcers. People with type 2 diabetes are generally thought to have an altered immune response, making them more susceptible to illness, infections, and other conditions where pathogens invade the body.
  
  When the immune system can’t fight off things like bacteria, wounds are more likely to become infected. Infected wounds are more complicated and take longer to heal.
  
  
• Poor circulation. Blood flow can be altered when the lining of the vessels become damaged from chronic hyperglycemia. When part of the body has reduced blood flow, it has reduced access to healthy blood containing oxygen and nutrients responsible for healing. Damaged tissue that doesn’t have adequate blood flow will be slow to heal and can even die.
  
  Circulation in the legs tends to be negatively impacted more severely than other body parts, which is one of the reasons ulcers tend to appear on the feet. Another main reason foot ulcers occur is from diabetic neuropathy, which inhibits a person’s ability to feel the pain from the wound, which often delays treatment. Native Americans, African Americans, Hispanics, and older men are more likely to develop foot ulcers, as well as those who are overweight and/or use tobacco.
  
  Peripheral artery disease (PAD) is common in people with diabetes and occurs when arteries are blocked by plaque, which restricts blood flow. The term for arteries narrowing from plaque is called atherosclerosis and is another cause of poor circulation. It’s similar to how heart disease occurs from blocked arteries around the heart, which can lead to a heart attack. In fact, people with PAD are at much higher risk of having a heart attack and stroke due to the narrowing of the arteries.
  
  When wounds are slow to heal, they can become infected. Sometimes an amputation is required when the skin and tissue dies off due to infection. Diabetes is thought to be the leading cause of leg amputations worldwide. Depending on the severity of the wounds, the toes, feet, or entire lower limb (leg) may be amputated.

How is it treated?

There are different stages involved in diagnosing Charcot foot, which can be determined using radiographs (X-rays). With acute Charcot foot, these radiographs can be normal. During later stages of Charcot foot, bone abnormalities may be shown on the radiograph.

Treatment for Charcot foot depends on which stage it’s in:

• Stage zero: The patient is advised not to bear weight on the affected limb. A total contact cast or a prefabricated pneumatic walking brace may be used. The total contact cast is a specific casting technique used to heal diabetic foot ulcers and protect the foot during the early vulnerable phases of Charcot fracture-dislocations. The cast is used to heal diabetic foot ulcers by distributing weight along the foot’s entire sole.
  
  
• Stage one: Use of a total contact cast with minimal weight-bearing.
  
  
• Stage two: Use of total contact cast followed by a Charcot restraint orthotic walker (CROW), which is a rigid boot designed to accommodate and support a Charcot’s foot.
  
  
• Stage three: Possible surgery to remove bony prominences.

Surgery may be indicated if the bones of the foot are severely impacted. Surgeons aim to reconstruct the impacted bones of the foot and ankle, which can become dislocated during the process of developing Charcot’s foot.

A common surgical procedure to treat Charcot foot is internal fixation, which stabilizes and joins fractured bones’ ends with mechanical devices such as metal plates, pins, rods, wires, or screws. Arthrodesis is the term for surgical immobilization of a joint by fusion of the adjacent bones, which is accomplished through internal or external fixation.

External fixation doesn’t involve surgery but instead uses devices such as splints and casts to set the joint to help it heal. The Charcot restraint orthotic walker (CROW) and total contact cast are examples of external fixation.

How can it be prevented?

The best way to prevent Charcot’s foot is to encourage healthy blood sugar levels and practice good foot and skin care. There are many ways people with diabetes can accomplish this, which will help prevent Charcot’s foot.

Regular foot checks. It’s recommended that all people with diabetes take time to inspect their feet each day to check for blisters, wounds, or other red flag warning signs. This is especially important for people who also suffer from neuropathy. The American Diabetes Association recommends an annual comprehensive foot exam for all people with diabetes. This can involve checking pulses in the feet and testing for neuropathy using a microfilament test. 

Proper-fitting shoes. People with diabetes may need special shoes that help reduce pressure in the feet, helping prevent foot ulcers. Insurance companies often cover diabetic shoes as a benefit because of the importance of properly-fitting footwear.

It’s also recommended that people with diabetes don’t walk barefoot, increasing the chances of injury to the feet. Shoes should also be checked for foreign objects before putting them on.

Good skincare. Skin complications can increase the likelihood of wounds. The American Diabetes Association recommends following good skincare habits, including:

• Keep skin clean and dry. 
  
  
• Avoid very hot baths and showers. If skin is dry, avoid bubble baths. Moisturizing soaps may help. Afterward, use a standard skin lotion, but don’t put lotions between toes. The extra moisture there can encourage fungus to grow.
  
  
• Prevent dry skin. Scratching dry or itchy skin can open it up and allow infection to set in. Moisturize your skin to prevent chapping, especially in cold or windy weather.
  
  
• Treat cuts right away. Wash minor cuts with soap and water. Only use an antibiotic cream or ointment if your doctor says it’s okay. Cover minor cuts with sterile gauze. See a doctor right away if you get a major cut, burn, or infection.
  
  
• During cold, dry months, keep your home more humid. Bathe less during this weather, if possible.
  
  
• Use mild shampoos. 
  
  
• Do not use feminine hygiene sprays.
  
  
• See a dermatologist (skin doctor) about skin problems if you cannot solve them yourself.
  
  

Promote healthy blood sugar levels. This is one of the most important aspects of diabetic foot complications. There are many ways to achieve healthy blood sugar levels, including:

• Use of medications as prescribed. Common medications treating diabetes include insulin, metformin, sulfonylureas, DPP-4 inhibitors, GLP-1 receptor agonists, among many others.
  
  
• Monitoring blood sugar levels. Checking blood sugar levels regularly at home, as well as having routine glucose screenings such as the hemoglobin A1c test, usually leads to better outcomes than people who don’t routinely monitor blood sugars. 
  
  
• Healthy eating habits. Eating a healthy diet, such as a Mediterranean diet, has been shown to improve health outcomes. An added bonus is that this eating style is associated with reduced levels of inflammation, which may help promote better-wound healing. A Mediterranean diet consists of foods like:
  • Vegetables
    
    
  • Fruits
    
    
  • Nuts and seeds
    
    
  • Legumes
    
    
  • Tubers such as potatoes, parsnips, etc.
    
    
  • Whole grains
    
    
  • Fish and seafood
    
    
  • Poultry
    
    
  • Eggs
    
    
  • Dairy
    
    
  • Herbs and spices
    
    
  • Healthy fats such as avocados and olive oil

A Mediterranean diet is also low in added and refined sugar, which should be limited to around 25-35 grams per day or less.

• Being physically active. Engaging in at least 30 minutes of moderate to vigorous physical activity most days (aiming for at least 150 minutes per week) can help promote healthy blood sugar levels. Strength and resistance training can further improve blood sugar.

Conclusion

The Charcot foot abnormality is a rare but serious complication that can arise in people with diabetes. It most commonly impacts people with diabetic neuropathy, which leads to a loss of sensation in the limbs, especially the hands and feet.

Other risk factors for Charcot’s foot include a long history (greater than 10 years) of diabetes, history of diabetic foot problems, age less than 60 years with neuropathy, the presence of nephropathy and retinopathy, and a hemoglobin A1c greater than 6.5%.

People with neuropathy are less likely to feel pain from a wound or injury, leading to excess inflammation and, eventually, bone loss. The loss and weakening of bone can cause the foot’s structure to collapse, resulting in a Charcot foot deformity. People with a severe foot deformity may need surgery or even amputation if it can’t be resolved.

Charcot foot can be treated with devices such as casts and boots, as well as with surgery to correct the bone abnormalities. The treatment will depend on the severity and damage done to the foot.

The best way to prevent Charcot foot is through promoting healthy blood sugars and practicing good foot care. Healthy blood sugar levels can be achieved through a combination of lifestyle changes and/or medication use. 

Good foot and skincare habits are also encouraged, so people with diabetes will be more likely to notice a foot wound and prevent it from becoming more serious, such as developing Charcot foot. Good foot and skincare habits include keeping the skin clean and dry, avoiding hot baths, showers, and other drying environments, preventing dry skin, and treating cuts and scrapes right away. 

People with diabetes should also have regular check-ups with their healthcare providers, including primary care physicians, dermatologists, and podiatrists.

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