The longer you have diabetes, the increased chance you have of developing neuropathy. Some people with mild diabetes can have severe neuropathy. …
FOOT ULCERS AND THE TOTAL CONTACT CAST
The diabetic foot is prone to major problems This is because the foot is
the organ that expresses many of the underlying effects of diabetes
These are 1 neuropathy, 2 vascular disease, and 3 diminished
response to infection
As a result of the neuropathy, the foot can become deformed This happens
through two routes or reasons The first is that the neuropathy causes
paralysis of small muscles in the foot, which results in clawing of the
toes Clawing of the toes causes prominence of the metatarsal heads on the
bottom of the foot as well as the knuckles on the dorsum or top of the
foot The neuropathy also causes diminished sensation As the prominent
metatarsal heads on the plantar or bottom of the foot are subjected to
increased pressure, the skin will begin to hypertrophy and become callused
The callused skin can be subjected to shear forces The forces will cause
a separation between the layers of the skin, which will fill with fluid,
which can then become contaminated and infected The pressure can also
cause primary breakdown of the skin in these areas and the result is a foot
ulcer Once the initial
breakdown and contamination occurs, the foot then
can go on to significant problems because of infection
The second route to deformity is through the process known as the Charcot
foot In this situation, because of the neuropathy or lack of protective
sensation, bones in the foot subjected to microscopic trauma will actually
fracture and disintegrate The foot, then subjected to the stresses of
ambulation, will become deformed Often, this is in the shape of a rocker,
causing prominence of bone in the middle portion of the foot rather than
the metatarsal head The prominence in the middle portion of the foot is
then prone to cause ulceration along the same mechanism that has just been
described
The total contact cast is a casting technique that is used to heal diabetic
foot ulcers and to protect the foot during the early phases of Charcot
fracture dislocations The cast is used to heal diabetic foot ulcers by
distributing weight along the entire plantar aspect of the foot It is
applied in such a way as to intimately contact the exact contour of the
foot; hence, the designation total contact cast
By relieving the bony prominent areas of pressure, the ulcers are permitted
to heal
if the cast is applied in such a way that the patient can remain
ambulatory during the treatment of the ulcer The principle involved here
is that the cast is intermittently molded to the contours of the foot from
the back of the heel through the arch region, in the region of the
metatarsals, around them and even to the toes Pressure is expressed in
terms of force or pounds over the area per square inch Therefore, if the
weight-bearing area is enlarged the pressure per unit of weight-bearing
area diminishes In this way the pressure which has been concentrated on
the bony prominence is distributed over the entire plantar bottom aspect
of the foot , allowing reversal of the mechanism that caused the ulcer to
occur
Foot Ulcers and the Total Contact Cast cont
For the Charcot foot, the total contact cast is used in two ways In the
initial treatment of the Charcot foot when the breakdown is occurring and
the foot is quite swollen and reactive, the cast is applied to control the
movement of the foot and support its contours In this instance the
patient is often asked not to bear weight on the foot In the second
instance when the foot has already become deformed and ulceration
has
occurred, the principle using the cast is the same as described for the
foot that has become deformed due to paralysis of the small muscles
The total contact cast, when used for the just described applications, is a
very effective treatment A prerequisite is that the foot must have an
adequate blood supply and therefore, the foot must be monitored quite
carefully The cast must be applied by someone who has experience with the
applications and use of this cast The cast must be changed at regular,
short intervals of a week or two The reason for this caution is that
the diabetic who has insensitive feet runs the risk of having other sores
or areas of irritation occur under the cast
The cast is applied in a different fashion than normal casts It is common
to have the patient lie on his stomach on the casting table with the leg
pointed straight up The ankle should be bent to a neutral position if
possible In this way the doctor applying the cast has access to the sole
of the foot which is the all-important area A thin dressing is applied
over the ulcer A thin layer of stockinette is applied and protective cast
padding applied between the toes Cast padding is applied
very thinly up
the limb and then secondary foam padding is applied over the toes at the
bony prominences on the inner and outer side of the ankle and often times
up the sides of the cast and front of the skin Once this has been
accomplished, the plaster undercoat is applied very carefully and smoothly
to the foot and leg, completely encasing the toes and going up the leg
The sole of the cast is quite carefully and intimately molded to the
contours of the sole of the foot These valleys are then filled in with
plaster of Paris or other material so that the sole of the cast is flat
The cast is often at this point reinforced by fiberglass and a special
curved or rocker-bottom sole is applied to relieve the stresses of walking
if the patient is to be allowed to bear weight
These casts are then changed weekly or every other week depending on the
physician, his experience with each individual patient, and the amount of
swelling in the leg Casting is continued until the ulcer is healed and
the foot is ready for appropriate shoe wear and orthotics In the case of
the Charcot process, casting is continued until the patients fractures
heal and the foot no longer needs a cast for
protection Because of the
prolonged need for immobilization, the physician typically may convert the
treatment to a removable walking boot The total contact casting technique
is an effective treatment for ulcers and Charcot foot problems
THE DIABETIC FOOT
As someone with diabetes, you need to take care of your feet Once
diabetic foot problems develop, their treatment can become difficult
This brochure answers basic questions about diabetic foot problems and
offers information on a day-to-day care to help prevent them For more
details or answers to related questions, please ask Dr Paul Kupcha
Neuropathy - the loss of feeling
Q: What is neuropathy?
A: Neuropathy is the gradual loss of nerve function in the feet and legs
due to diabetes The most common and significant change is loss of
feeling or, touch sensation
Q: How do I know if I have neuropathy?
A: Neuropathy usually comes on slowly You may not notice it at first
because it is the absence or reduction of sensation It is hard to be
aware of something you cannot feel A physical exam by your doctor and
sometimes special tests can help in making the
diagnosis
Q: If neuropathy causes loss of feeling, why do my feet sometimes hurt
or tingle?
A: Neuropathy can cause the nerves to go haywire, or transmit impulses
that you experience as numbness, tingling, shooting pains, burning
sensations, pins and needles, electric shock sensations or any
combination of the above
Q: Do all diabetics get neuropathy?
A: The likelihood of getting neuropathy increases with age The longer
you have diabetes, the increased chance you have of developing
neuropathy Many cases are mild, but some are more severe The
severity of the neuropathy does not necessarily correspond to the
severity of the diabetes Some people with mild diabetes can have
severe neuropathy
Q: Does neuropathy affect only the feet?
A: Neuropathy mainly affects the feet, but can also involve the ankles,
legs and at times, even the hands It tends to be more severe in the
foot than in the lower leg In other words, it affects the toes more
than the lower leg Neuropathy of the legs seldom goes above the knee
Q: What can happen to my feet if I have neuropathy?
A: You can injure your feet without knowing it For
example, a person
with neuropathy may let a cut or sore of the foot get out of hand simply
because it does not feel painful, and they do not realize it is there
|THE DIABETIC FOOT |Page 2 |
Q: What other ways can neuropathy hurt my feet?
A: If you wear a pair of poorly fitting shoes, blisters or open sores
ulcers can form in less than an hour At first these can cause small
problems, which can snowball into more serious ones
Q: Does this mean I should call the doctor even if I have a small foot
injury or a minor infection?
A: Yes All too often a patient notices an area of swelling or redness,
but fails to seek attention because it does not hurt Later, she/he can
lose all or part of the foot
The most dangerous thing about neuropathy is the absence of feeling,
because this allows the injury to go unrecognized
Circulation - a key to healing
Q: How does diabetes affect circulation?
A: Diabetes can contribute to narrowing of the arteries, and decreased
circulation in the upper and lower parts of the leg However, as
discussed above, neuropathy, not circulation, is
the main cause of most
diabetic foot problems
Q: Does poor circulation affect healing?
A: Your skin and other tissues depend on good blood circulation for both
oxygen and nutrition Poor circulation can result in skin breakdown and
cause minor cuts, bruises, burns and other injuries to heal poorly
Paying close attention to your feet, primarily by inspecting them twice
a day, is the key to preventing serious problems
Infections - red alert
Q: Why do infections cause foot problems?
A: Infections may spread quickly in the foot, giving little warning
Minor injuries can become open sores, and then develop into an abscess
deep infection Once an infection becomes deep-seated, or gets into
the bone, you will usually need surgery in addition to antibiotics
Q: What should I watch out for?
A: Several sneaky signs should lead you to suspect infection
Unexplained temperature rise or fevers coupled with open sores or
blisters on your feet may signal an infection Other warning signs may
include too much sugar in the urine, or blood sugar that is difficult to
control and requires a higher insulin dosage Again, inspect your feet
regularly to prevent serious problems
Prevention - a mirror of your sole
Q: How do I prevent foot problems?
A: Good care requires daily vigilance Close visual inspection must
substitute for the feeling you have lost in your feet Look for
reddened skin, sores, blisters, inflamed nails, bony prominences, and
changes in the shape of your foot
|THE DIABETIC FOOT |Page 3 |
Q: What daily care should I do?
A: Use gentle cleaning routines Wash your feet in lukewarm water,
never hot Because you cannot rely on your feet to warn you that the
water is too hot, test the water temperature with your elbow Wash with
a soft cloth and mild soap
Q: What else should I do?
A: Dry thoroughly but gently between the toes Use a moisturizing
lotion for dry skin, but do not put it between the toes Keep dry skin
soft and pliable
Q: How should I trim my nails?
A: If you have good vision and can reach them easily, trim nails
straight across with a nail clipper Do not round the corners
However, it is safest to file the nails down frequently with a simple
nail file or emery board If you
have difficulty or are uncertain, you
should have your nails trimmed professionally
Q: Are corns a problem?
A: Yes Corns are hard calluses that form on the top of the foot,
especially the toes, almost always due to the pressure of shoes Corns
indicate that your shoes are too tight and you need to be professionally
fitted
Q: How should I treat calluses on the bottom of my feet?
A: Calluses can be reduced with gentle daily rubbing with a foot file or
pumice stone If you are uncertain or unable to trim calluses, consult
your physician
Q: What kind of footwear should I choose?
A: Choosing good footwear that allows plenty of room can help prevent
foot injuries Shoes should have cushioned soles with uppers made of
soft, breathable materials such as leather, not plastic Professional
shoe fitting is advised Consult your orthopaedic surgeon for a
referral
Q: What about sandals or thongs?
A: Sandals and thongs can concentrate pressure between or on the toes
The loose fit can also allow the foot to shift and slide leading to
abrasions and ulcers
Q: What kind of socks should I wear?
A: Cotton or wool socks
provide the best padding Avoid synthetic
materials Avoid holes, wrinkles and lumpy stitching Do not use socks
or stockings with garters or elastic tops that can cut off your
circulation Synthetic Teflon socks are available and can greatly
reduce friction
Q: Should I check my shoes every time I put them on?
A: Yes Always look inside the shoe for foreign objects Make sure the
shoe is in good repair and free of loose seams, loose heels, and nails
Break in new shoes gradually Wear them one or two hours at a time
before you check your feet in the mirror for reddened areas
|THE DIABETIC FOOT |Page 4 |
Q: What kind of shoes should I wear if I have neuropathy?
A: The best shoes for neuropathy are extra-depth shoes with custom-
molded insoles
Q: Should I wear arch supports?
A: Patients with neuropathy should use specially custom-molded insoles
to help cushion the foot These are shaped to the foot Patients with
neuropathy should avoid over-the-counter, rigid, and hard plastic
insoles
Bone Injury
Q: What is a Charcot foot?
A: Fractures or dislocations of the foot or
ankle which occur as a
result of minor injury or no injury at all are called a Charcot
pronounced sharko foot
Q: What causes a Charcot joint?
A: A Charcot joint or Charcot foot sometimes occurs for no apparent
reason It often appears as unexplained swelling, sometimes with pain
Q: Can Charcot joints be seen on X-ray?
A: With time, Charcot joints are seen on X-ray, but the swelling can
sometimes precede X-ray changes for two weeks to two months
Q: How is the Charcot joint treated?
A: Charcot fractures and dislocations are treated by applying a cast or
brace for lengthy periods of time Most Charcot joints heal without
surgery, but on occasion require surgery to remove bony prominences or
even realign the bones
Q: Are Charcot joints serious?
A: Yes These are one of the most serious problems of the diabetic
foot The Charcot process can lead to collapse of the arch flat foot
and dramatic changes in the shape of the foot Charcot joints usually
occur in diabetics with relatively good circulation
Q: How are casts used to treat diabetic foot ulcers?
A: Broken bones are not the only reason to apply a cast Doctors use
a
carefully molded total contact cast or healing cast to help diabetic
ulcers heal
Q: How do total contact casts work?
A: The casts distribute the weight over the entire surface of the foot
thereby decreasing the concentrated pressure that causes open sores
|THE DIABETIC FOOT |Page 5 |
Q: What are the advantages of total contact cast treatment?
A: Total contact casts allow you to continue walking while you heal
The cast may seem inconvenient, but it can be very effective and much
less expensive and risky than surgery
Q: Can antibiotics treat infections?
A: Yes Antibiotics are important But if you have poor circulation,
antibiotics may not reach the infection
Q: What can be done to improve circulation?
A: Vascular surgeons can sometimes surgically increase circulation to
the foot and leg, helping ulcers and sores to heal
Q: Can foot wounds be removed or sewn shut?
A: Most of the time foot ulcers and wounds are treated with dressing
changes A total contact cast may be used Open sores are usually
allowed to gradually close in on their own to prevent recurring
infection
Q: When is surgery necessary?
A: Surgery is sometimes required to clean out infected or poorly healing
tissues An orthopaedic surgeon is most qualified to carry out such
procedures Your orthopaedist can do superficial wound cleaning
debridement in the office, but larger procedures should be done in a
hospital operating room In some cases, surgery can help prevent
collapse of the foot caused by Charcot joint
Q: How many doctors do I need to treat one foot?
A: Treatment of the diabetic foot is a team effort Internists or
family doctors, orthopaedic surgeons, vascular surgeons and plastic
surgeons often work together to treat and reconstruct the legs and feet
Special studies may involve a radiologist, pathologist and neurologist
A good nutritionist, diabetes nurse specialist, and social worker often
help provide total care Some clinics provide all these services under
one roof
Be an Optimist
Care of the lower extremities in diabetics has improved in the last
decade But the key to success is prevention The key to prevention is
you taking responsibility for good hygiene, sensible shoewear, and
careful
daily inspection of your own feet
If you have any thoughts, concerns or questions you would like to discuss,
please mention them to us If you would like to schedule an appointment
with Dr Kupcha regarding your feet, please call 633-3555
SHOES AND ORTHOTICS FOR DIABETICS
Proper footwear is an important part of an overall treatment program for
people with diabetes, even for those in the earliest stages of the disease
If there is any evidence of neuropathy, or lack of sensation, wearing the
right footwear is crucial By working with their physician and a foot-wear
professional, such as a certified pedorthist, many patients can prevent
serious diabetic foot complications
Objectives
Footwear for people with diabetes should achieve the following objectives:
1 Relieve areas of excessive pressure Any area where there is excessive
pressure on the foot can lead to skin breakdown or ulcers Footwear
should help to relieve these high pressure areas and therefore reduce the
occurrence of related problems
2 Reduce shock and shear A reduction in the overall amount of vertical
pressure, or shock, on the bottom
of the foot is desirable, as well as a
reduction of horizontal movement of the foot within the shoe, or shear
3 Accommodate, stabilize and support deformities Deformities resulting
from conditions such as Charcot involvement, loss of fatty tissue, hammer
toes and amputations must be accommodated Many deformities need to be
stabilized to relieve pain and avoid further destruction An addition,
some deformities may need to be controlled or supported to decrease
progression of the deformity
4 Limit motion of joints Limiting the motion of certain joints in the
foot can often decrease inflammation, relieve pain and result in a more
stable and functional foot
Shoes
If you are in the early stages of diabetes and have no history of foot
problems or any loss of sensation, a properly fitting shoe made of soft
materials with a shock absorbing sole may be all that you need It is also
important for patients to learn how to select the right type of shoe in the
right size, so that future problems can be prevented The excessive
pressure and friction from the wrong kind of shoes or from poorly fitting
shoes can lead to
blisters, calluses and ulcers, not only in the
insensitive foot, but also in feet with no evidence of neuropathy It is
highly recommended that shoe fitting for patients with any loss of
sensation be done by a professionally trained shoe fitter or Board
Certified Pedorthist People with insensitive feet tend to purchase a shoe
that is too tight; the size that feels right is often too small
Shoes and Orthotics for Diabetics cont
In achieving proper shoe fit, both the shape and size of the shoe must be
considered You should try to match the shape of the shoe to the shape of
your foot This means that you should be sure your shoes have adequate
room in the toe area, over the instep and across the ball of the foot, and
there should be a snug fit around the heel When considering your correct
shoe size, remember that the width is just as important as the length The
proper shoe size is the one where the widest part of the foot, which lies
across the foot at the base of the toes, is the widest part of the shoe
There should also be 3/8 to 1/2 -inch between the end of the shoe and the
longest toe In addition, a shoe with laces is recommended to provide the
adjustability needed
for any swelling or other deformities and to allow the
shoe to be fit properly without any danger of slipping off
Prescription Footwear
Many patients with diabetes need special footwear prescribed by a
physician Prescription footwear for patients diabetes includes:
1 Healing shoes Immediately following surgery or ulcer treatment, some
type of shoe may be necessary before a regular shoe can be worn These
include custom sandals open toe, heat-moldable healing shoes closed
toe, and post-operative shoes
2 In-depth shoes The in-depth shoe is the basis for most footwear
prescriptions It is generally an oxford-type or athletic shoe with an
additional 1/4 to 1/2 -inch of depth throughout the shoe, allowing extra
volume to accommodate any needed inserts or orthoses, as well as
deformities commonly associated with a diabetic foot In-depth shoes
also tend to be light in weight, have shock-absorbing soles, and come in
a wide range of shapes and sizes to accommodate virtually any foot
3 External shoe modifications This involves modifying the outside of the
shoe in some way, such as modifying the shape of the sole or adding
shock-
absorbing or stabilizing materials
4 Orthoses or inserts An orthosis is a removable insole which provides
pressure relief and shock absorption Both pre-made and custom-made
orthoses or inserts are commonly prescribed for patients with diabetes,
including a special total contact orthosis, which is made from a model
of your foot and offers a high level of comfort and pressure relief
5 Custom-made shoes When extremely severe deformities are present, a
custom-made shoe can be constructed from a cast or model of the
patients foot These cases are rare With extensive modifications of
in-depth shoes, even the most severe deformities can usually be
accommodated
Taking good care of your feet means making sure you have the right
footwear Whether you have been recently diagnosed or have had diabetes
for many years, proper footwear can help prevent serious foot problems Be
sure to talk to your physician about the type of shoes, modifications and
orthoses that are right for you
PATIENT INSTRUCTIONS FOR DIABETIC FOOT CARE
Understand that the loss of normal, protective sensation is the cause of
most diabetic foot problems What you
cannot feel will hurt you
Therefore, constant vigilance is required to exercise prevention, which is
the best cure
1 Inspect:
Inspect your feet twice daily
Use a mirror, or have a companion inspect the feet for you
Examine the feet for cracks, blisters, reddened spots and ulcers or
for excessively moist skin between the toes
2 Wash:
Bathe your feet daily with warm water and mild soap
Always test the temperature with your elbow, ie, an area unaffected
by neuropathy, or have someone else test it - but remember you might
burn your foot and not even feel it
Dry gently and carefully between the toes Blot, do not rub
3 Beware of burns:
Never use heating pads, hot water bottles or any other heat source to
warm your feet Irreparable damage can be done in a minute
Wear socks in bed if your feet are cold at night
4 Skin: Calluses and corns
Do not use chemical agents or medicated pads These can cause
burns
Do not do bathroom surgery with a razorblade
Use a pumice stone or foot file to gently reduce calluses at bath
time
Keep the skin moist regularly to prevent cracking by using a
gentle
skin lotion A very thin layer of petroleum jelly can be used to seal
in moisture after the bath
Do not put creams, lotions or other ointments between the toes because
excessive moisture can result
Some corns and calluses can only be removed professionally
5 Nail problems:
Trim nails straight; do not attempt to dig out the corners
Filing the nails daily reduces the frequency of clipping; avoid
rubbing the skin
Consult your doctor if the nails are too thickened or hard to trim
Patient Instructions for Diabetic Foot Care cont
6 Shoes:
Fashion is an unfortunate enemy of the diabetic with neuropathy
Many, many serious foot problems result from shoe pressure
Shoes should be long and wide enough and have enough room for the
toes, especially if the toes are clawed
Synthetic materials that do not breathe are to be avoided Leather
is still generally the best material because it shapes and stretches
Avoid shoes of hard materials, eg plastic or patent leather
Inspect the feet frequently when new shoes are obtained Wear new
shoes no more than an hour the first day
Shoes should be professionally fitted if you have neuropathy or have
had previous serious foot problems
Shop for a properly fitted shoe, not for what you remember as your
size Shoes vary and feet change in width and shape
Shop at the end of the day when your foot is largest
Never walk barefoot
Before you put on your shoes check them for pebbles, nail points, and
torn linings
7 Dressing:
Inspect the shoes and turn them upside down to detect any foreign
object each time before putting them on
Changing shoes during the day can reduce the risk of pressure
problems
Do not use hard devices or rigid orthotics in the shoe These can
produce excessive pressure on the feet
8 Stockings:
Avoid stockings with elastic tops or garters
Do not use socks or stockings with heavy seams
Wash and change stockings daily
Stockings of materials such as cotton and wool are best Blister
Guard Teflon socks reduce friction and can be ordered by calling
877 697-6257
9 Inform:
Inform all shoe fitters that you are diabetic
Have your physician examine your feet each time you
visit
10 Dont smoke It restricts the flow of blood to your feet
THE DIABETIC FOOT AND RISK:
HOW TO PREVENT LOSING YOUR LEG
1 Dont deny you are a diabetic
Anyone who has ever had an elevated blood sugar level is at risk for foot
complications It may be as simple as knowing that once in your life
even during pregnancy you have had an elevated blood sugar level If
so, you are at risk and must begin to monitor your feet
Diet-controlled diabetics, whether diagnosed as an adult or as a child,
have feet at risk of diabetic complications The simple rule: If you
have ever been told that you are at risk of developing diabetes, you need
to consider your feet and work to prevent injury
2 Dont accept that all diabetics lose their legs
It starts with daily foot checks - inspecting all sides, including the
bottoms, which can be done best with someones help or with a mirror
During a foot check, any changes in the foots shape or color, sense of
feeling/sensation, painful areas of skin integrity need to be evaluated
With shape, any new bunions, calluses or corns need to be identified
and if known, shown to a physician The overall shape could change due
to a bone fracture that would also need the attention of a physician
Stress fractures are very small breaks in the bone that will not usually
change the shape of the foot but may cause pain or bruising The color
of the foot is important as it helps show any changes in blood flow to
the foot Darkening or loss of hair may indicate that the blood supply
has decreased Less blood to the foot can mean slower healing of cuts
and scrapes Bruises indicate injuries Especially important are the
bruises or cuts found during a foot check that the person was not aware
of at the time of injury Any bruises within calluses are particularly
important to show to a physician
To monitor sensation, a feather or facial tissue can be used to brush the
foot and test its ability to feel light touch It is important to be
sure the foot can sense the differences between hot/warm and cold water
also Shower water can be first tested with the hand and then with the
feet to identify any loss of temperature sensation Testing for any
change in ability to feel with the feet is important
because diabetics
can hurt themselves and not be aware of the injury or its severity By
checking their feet daily, they can see any new wounds and monitor
healing areas Diabetics can also wear more protective shoes, not
sandals, to prevent any injuries to the feet and toes The top of the
foot will be the first area to lose some of its ability to feel, then
the bottom of the foot The area may not feel numb, but a progressive
decrease in ability to feel light touch, temperature or the presence of
shoes indicates a foot at risk
The Diabetic Foot and Risk: How to Prevent Losing Your Leg cont
3 Beware of Common Pitfalls
Any areas that are painful need to be examined very closely for any of
the above-mentioned changes Foot injuries that occur without the
persons knowledge can be the first sign of diabetes, especially when
accompanied with decreased sensation
Wounds need to be monitored When wounds take a long time to heal, the
foot becomes at risk for infection, ulcers and further damage to local
tissue and bone There are special bandaging techniques and ointments
that can be used to help diabetic wounds heal and concurrently
prevent
permanent damage
As with any chronic disease, history is important - both the patients and
his or her familys Diabetics who have had problems with any of the
following in the past or currently need to consider themselves at
risk: foot ulcers, toenail infections such as fungus, stress fractures
or other single fractures of the foot, slow-healing wounds, bunions,
corns and thick calluses In the family history, any amputations of
toes, feet or legs part or whole need to be shared with a physician
Other family members with known diabetes, suspected diabetes or problems
with the feet such as mentioned above should be shared with a physician
The bottom line is take care of your feet, look at them daily and see a
physician if anything is suspicious
PATIENTS WITH CHARCOT JOINTS
What is it?
In the late 1800s, a French physician, Dr JM Charcot, first described
the destructive changes in the joints of people with decreased feelings in
their legs and feet Today, the term Charcot joint is used to refer to any
joint in the insensate foot that is destroyed or dislocated The term
Charcot foot is used to refer to a
foot with many Charcot joints and which
has actually changed shape
There is usually not a single event or major injury to the insensate foot
which causes fractures or destruction of the joints, but an accumulation of
many small injuries which result in Charcot joints or a Charcot foot
The following factors will increase the chance of developing a Charcot
joint
o Loss of protective sensation
o Activities or conditions which put increased stress on the feet
o Shoes which do not provide support
What causes Charcot joints?
Feet with or without feeling, experience injury or trauma everyday as a
normal part of walking The difference between the insensate foot and one
with feeling is that injury will cause the person with feeling to stop
walking, to rest or protect the injured foot The person with insensate
feet will continue to walk, causing further injury with possible bone and
joint destruction
Muscle strength in the feet and legs of a person without sensation is
usually decreased as part of the disease process This loss leads to a
muscle imbalance affecting how a person walks and the way the foot
functions The foot will strike the ground harder during
walking,
resulting in greater impact to the bones and joints, causing greater and
more frequent injury Twists or sprains of the foot and ankle are more
common, and even though there is significant injury, the person without
sensation will continue to use the foot
Another complication occurring with the insensate foot is a loss of muscle
tone in the blood vessels supplying blood to the feet This results in
increased blood flow which can remove some of the minerals which normally
keep bones strong Weakened bones are more likely to break when stressed
Patients with Charcot Joints cont
What does this mean to you as a person with an insensate foot?
In the insensate foot, pain that would warn a person with normal sensation
of injury is not present You need to be aware of other signs that an
injury has occurred If a bone is broken or a Charcot joint has occurred,
you will have one or all of the following signs:
o Swelling mild or great
o An increase in skin temperature
o Redness in the area
o A lack of sweating resulting in dryness of the skin over the area
Some patients wait until a fifth sign appearsDestruction and Structural
change the foot
appears shorter and wider An untreated Charcot foot
develops a rocker bottom shape much like a rocker on a rocking chair
The arch of the foot collapses and joints are destroyed
Treatment
The best treatment is prevention:
o Insensate feet need special attention Visit your doctor regularly
o Insensate feet need support, protection and cushioning to help
prevent fractures an movement of the bones This includes special
footwear, extra-depth shoes, molded insoles, special custom made
shoes
o Inspect your feet daily
If prevention fails and the signs of Charcot joints appear, seek medical
attention immediately to determine the severity If a fracture has
occurred, healing will include protecting the foot from further injury
Forms of protection may involve any of the following:
Casts Crutches Wheelchair Bed
Rest
Sometimes joint destruction is severe enough to result in a permanent,
misshapen foot with bony bumps or prominences This condition will always
require special shoes Sometimes surgery to fuse broken joints or remove
bony prominences may be necessary
NEW TREATMENT
RELIEVES SEVERE FOOT PAIN
IN PEOPLE WITH DIABETES
MONTEREY - Forty percent of those afflicted with diabetes suffer a nerve
condition called neuropathy, which can sometimes cause burning foot pain so
severe it restricts a patients activity and even his or her ability to
wear shoes A new remedy using the drug Mexiletine helps relieve this pain
and allows these patients to return to their former levels of activity,
according to a study presented at the American Orthopaedic Foot and Ankle
Societys AOFAS 13th Annual Summer Meeting
Neuropathy can result in debilitating, severe, burning pain Patients
feel like their feet are on fire, explained Robert Vander Griend, MD,
Gainsville, Florida, author of this study Often this condition will
prevent the patient from working or participating in activities, and many
physicians think there is nothing that can be done beyond the use of anti-
inflammatories or pain medications However, all of the patients we
treated had some degree of response to this medicine About 50 percent
had long lasting pain relief and were able to come off the medication,
according to Dr Vander Griend
Thirty-five patients
suffering painful diabetic neuropathy were treated
with 150 mg of Mexiletine, a drug similar to the local anesthetic
lidocaine, two or three times per day The dose was adjusted based on the
response to the treatment This regimen continued for three months and
then the medication was gradually stopped If the pain returned, patients
were started back at the lowest effective dose
Thirty-two of the patients noticed a reduction in their pain, rating the
improvement at 50 percent on average Three subjects suffered side-effects
nausea with the medication and could not continue with the study
Overall about 50 percent of the patients treated had long lasting
improvement in their pain even after the medication was stopped, explained
Dr Vander Griend Most of the remaining patients who continued
Mexiletine treatment after the three month period enjoyed a reduction in
their pain as well
CHARCOT JOINTS OR NEUROPATHIC ARTHROPATHY
Charcot arthropathy, or neuropathic arthropathy, is a condition that
affects some diabetic patients with peripheral neuropathy loss of
sensation after eight to ten years Jean Martin Charcot was a French
physician who in 1868 described
neuropathic arthropathy primarily in
patients with advanced syphilis At that time, people with diabetes did
not live very long because insulin was unavailable to treat diabetes Once
insulin was available and diabetes treatable, it was in the 1930s that
neuropathic arthropathy was recognized in diabetics It may also occur
with several other diseases that affect the sensory nervous system
alcoholism, leprosy, syphilis, Charcot Marie tooth disease to name a few
In the United States, diabetes is the number-one cause
So what do all these terms mean?
Neuropathy is a term used to describe problems with the nervous system In
diabetics this is called peripheral neuropathy and affects the sensory
nervous system to the peripheral, or farther, points ie feet and hands
causing loss of feeling or numbness Diabetic neuropathy also involves the
autonomic involuntary nervous system which controls regulation of blood
vessels and may result in increased blood flow to the limb, contributing to
swelling and osteoporosis of the bones as the Charcot process occurs
Arthropathy is a term used to describe a problem with a joint Therefore,
neuropathic arthropathy is used to describe problems with
joints related to
long-standing diabetes The joints are unable to recognize the forces put
across them and the relative positions of the various joints, sustaining
microtrauma or microfractures because the body does not adjust to these
forces and positions It would therefore be reasonable to assume that most
cases of neuropathic arthropathy would occur in the lower extremities, with
their weight-bearing functions This is indeed the case, although on
occasion other joints can be involved
When does neuropathic arthropathy occur?
Most patients who develop neuropathic arthropathy have peripheral
neuropathy after being diabetic about 10 years or longer So a patient
with juvenile-onset diabetes as a child may develop this in his 20s or
30s However, most patients with Charcot arthropathy are in their 40s or
older, as more patients have adult-onset diabetes
What are the signs and symptoms of Charcot arthropathy or neuropathic
arthropathy?
There are three states to Charcot arthropathy The first stage is a
fragmentation or destruction stage During this stage, as the process
begins, the joint and surrounding bone is destroyed The bone fragments,
the joint becomes unstable and in
some cases the bone is completely
reabsorbed This stage is clinically identified by significant swelling
often with little pain to the patient, erythema redness and warmth or
heat to the area It is easy to see why this is often confused with an
infection, especially as there is often no history of injury or trauma As
the bones and joint are affected, fractures and instability develop and the
joints can dislocate or shift the bones in relationship to each other
This can lead to severe deformity of the foot and ankle Often the midfoot
joints are affected and the result is a very flat foot which is wide where
the normal foot
Charcot Joints or Neuropathic Arthropathy cont
narrows in the arch Bony prominences often develop on the plantar
bottom surface of the foot Diagnosis and early treatment at this stage
is important to try to minimize the bone destruction and deformity This
process may last as long as 6 to 12 months
The second stage is termed coalescence During this stage the acute
destructive process slows down and the body begins to try and heal itself
The swelling and heat begin to disappear Once the acute process is
resolved and the healing on-going, the third
stage begins This is a
consolidation or reconstruction phase during which the bones and joints
heal Unfortunately, the foot is often deformed and if there has been
enough destruction, there may be residual instability Fitting shoes may
be very difficult and prescription footwear and diabetic orthotics shoe
inserts are important to help prevent ulcer formation over deformed areas
How is Charcot arthropathy treated?
Once the diagnosis is made for most patients in the first stage there are
several important treatment goals The first is to get the heat and
swelling under control The second is to support or stabilize the foot to
minimize deformity A total contact cast is applied by trained personnel
This cast has more padding than a standard cast and is often applied with
the toes completely covered to prevent foreign objects gravel, stones,
etc from getting in the cast The cast will need to be changed
frequently initially as it will get loose very quickly as the swelling is
controlled Once the initial swelling is controlled and the patient is
tolerating the casts without skin problems, the cast change interval may be
lengthened to 2 to 4 weeks Another alternative is
fabrication of custom
walking boot for diabetics The foot must be supported until all heat and
swelling has resolved This may occur in several months but more commonly
requires 6 to 12 months Minimizing weight-bearing on the affected
foot/ankle is also important Realistically this is extremely difficult
for the patient with diabetic neuropathy and should be encouraged
Assistive aides such as a walker or cast are recommended During this
period the patient will be seen frequently in the office Continued
education about diabetic foot care and Charcot arthropathy is necessary
Also, support of the various stages of anger and denial concerning this
rather profound change is necessary After the first stage is completed,
molds for appropriate diabetic footwear, orthotics and braces if needed
are made During treatment it is important to check the noninvolved foot
and protect it, as that foot is doing much more work
For patients who develop deformities that are unshoeable or bracable, or
who develop unbracable instability, surgery may be considered The timing
for this surgery is important Surgery done during stage one has a high
complication rate, often with fragmentation of any
grafting done
Sometimes, however, surgery must be done during this stage due to joint
instability Another option for severe deformity/instability is amputation
and prosthetic fitting Patients often have multiple medical problems that
must be taken into account in consideration for any surgery
Long-term management of patients with Charcot Arthropathy is important
Once the patient is stable, periodic checkups 6 to 12 month intervals
with a qualified foot and ankle specialist is important to identify early
complications, address footwear, orthotic and brace issues, and continue
patient education regarding the care of diabetic feet and the special needs
of the patient with Charcot arthropathy Patients should be counseled to
seek medical care if they develop any redness, swelling or heat in their
feet, as this could be the start of another Charcot process
