Charcot Foot: Clinical Clues, Diagnostic Strategies, and Treatment Principles

Valerie S. Marmolejo; Jonathan F. Arnold; Mario Ponticello; Charles A. Anderson

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May 1, 2018 Issue

Charcot Foot: Clinical Clues, Diagnostic Strategies, and Treatment Principles

VALERIE S. MARMOLEJO, DPM, University Place, Washington

JONATHAN F. ARNOLD, MD, Great River Wound and Hyperbaric Medicine Clinic, West Burlington, Iowa

MARIO PONTICELLO, DPM, and CHARLES A. ANDERSEN, MD, Madigan Army Medical Center, Tacoma, Washington

Am Fam Physician. 2018 May 1;97(9):594-599.

Author disclosure: No relevant financial affiliations.

Article Sections

Abstract
History
Physical Examination and Laboratory Studies
Imaging Studies
Treatment
References

Acute Charcot neuroarthropathy of the foot and ankle is often difficult to diagnose because of limited findings in the patient history, physical examination, imaging, and laboratory studies. Delay in treatment results in the development of rigid foot and ankle deformities, increasing the risk of ulceration, infection, and major lower extremity amputation. Acute Charcot neuroarthropathy should be suspected in any patient 40 years or older with obesity and peripheral neuropathy who presents with an acutely swollen foot following minimal or no recalled trauma and who reports minimal to no pain, particularly if radiography and laboratory markers of infection are normal. Magnetic resonance imaging or computed tomography should be performed in these cases. If changes consistent with acute Charcot neuroarthropathy are observed, prompt immobilization and/or referral to a foot and ankle subspecialist is needed to minimize sequelae. Immobilization should continue until lower extremity edema and warmth resolve, and serial radiography shows evidence of osseous consolidation. Intranasal calcitonin salmon may have a role as adjunctive therapy. Although controversial, surgery may be indicated if there is severe dislocation or instability, concern for skin breakdown, or failure of conservative treatment to obtain a stable, plantigrade foot.

Charcot neuroarthropathy of the foot and ankle is an inflammatory condition affecting the periarticular soft tissues and bone in persons with peripheral neuropathy, resulting in osseous subluxation, dislocation, and fracture, if the lower extremity is not immobilized.1 One in four cases of acute Charcot foot is misdiagnosed, most often as cellulitis, gout, deep venous thrombosis, or a minor sprain2–13 (Table 12–8,14–16), which delays diagnosis by an average of seven months.2,17–19 Without prompt treatment, the condition often results in development of rigid foot deformities (i.e., the classic rocker-bottom foot [Figure 120]), increasing the risk of major lower extremity amputation by 15- to 40-fold.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
In patients with suspected acute Charcot neuroarthropathy, early and accurate diagnosis and prompt immobilization reduce the incidence of rigid foot deformity development, which increases patient quality of life and reduces the risk of ulceration, infection, and amputation.	C	2–6, 8–11, 14, 17, 20–29
The diagnosis of acute Charcot neuroarthropathy should be considered in any patient 40 years or older with obesity and peripheral neuropathy who presents with a unilateral swollen limb and minimal or no associated pain.	C	2–12, 14, 18–20, 22–25, 29–37
Acute Charcot neuroarthropathy should be considered in patients with recurrent cellulitis but no systemic or laboratory findings concerning for infection.	C	2–14, 22, 30, 38, 42
Bilateral weight-bearing radiography is recommended to allow for comparison between both feet in persons with suspected acute Charcot neuroarthropathy. Clinicians should look for signs of subtle subluxations or ligamentous avulsion, which denote impeding osseous instability.	C	2–4, 9–12, 14, 20, 22–26, 30, 38, 39

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
In patients with suspected acute Charcot neuroarthropathy, early and accurate diagnosis and prompt immobilization reduce the incidence of rigid foot deformity development, which increases patient quality of life and reduces the risk of ulceration, infection, and amputation.	C	2–6, 8–11, 14, 17, 20–29
The diagnosis of acute Charcot neuroarthropathy should be considered in any patient 40 years or older with obesity and peripheral neuropathy who presents with a unilateral swollen limb and minimal or no associated pain.	C	2–12, 14, 18–20, 22–25, 29–37
Acute Charcot neuroarthropathy should be considered in patients with recurrent cellulitis but no systemic or laboratory findings concerning for infection.	C	2–14, 22, 30, 38, 42
Bilateral weight-bearing radiography is recommended to allow for comparison between both feet in persons with suspected acute Charcot neuroarthropathy. Clinicians should look for signs of subtle subluxations or ligamentous avulsion, which denote impeding osseous instability.	C	2–4, 9–12, 14, 20, 22–26, 30, 38, 39

The Authors

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VALERIE S. MARMOLEJO, DPM, is a freelance medical writer with Scriptum Medica, University Place, Wash....

JONATHAN F. ARNOLD, MD, ABPM-UHM, CWSP, is the medical director of Great River Wound and Hyperbaric Medicine Clinic, West Burlington, Iowa.

MARIO PONTICELLO, DPM, FACFAS, FAPWCA, is chief of the limb preservation service at Madigan Army Medical Center, Tacoma, Wash.

CHARLES A. ANDERSEN, MD, FACS, FAPWCA, is chief of wound care and a staff vascular surgeon at Madigan Army Medical Center.

Address correspondence to Valerie S. Marmolejo, DPM, Scriptum Medica, 9416 42nd St. W., University Place, WA 98466 (e-mail: vlsdpm@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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