Charcot arthropathy occurs in the presence of peripheral neuropathy and metabolic abnormalities. Today it is seen more commonly in patients with long-standing diabetes^1,2. Its pathogenesis, although still largely unknown, involves several pro-inflammatory pathways, which stimulate osteoclastic activity³.

A rapid and accurate Charcot diagnosis is essential to protect the foot and reduce the chance of further bony collapse of the foot and ankle. However, early-stage Charcot foot is often misdiagnosed, due to three main factors:

Relative rarity of the condition⁴
Absence of clear, defined signs and symptoms⁵
Little to no knowledge about the condition from non-specialists⁶

The last point is particularly relevant in the context of referrals from the general practitioners. Lisa Grant-McDonald, DPM, notes that patients with suspected Charcot are sent to many different specialties, including internal medicine, vascular surgery, and orthopedic surgery. When a misdiagnosis is made, this delays a prompt intervention. Charcot arthropathy treatment strongly benefits from attentive physicians well versed in its treatment and a multidisciplinary approach, where all specialists work together. If you would like to know more about the advantages of having a multidisciplinary health care team, and have some material to give to your patients to help them know more about Charcot arthropathy, please read the article “Charcot Foot and Ankle Diagnosis: The Multidisciplinary Approach.”

The challenges mentioned above often delay the initial treatment of Charcot arthropathy, which can then progress to limb- and life-threatening complications². In this article, we will focus on the distinguishing features of the early stages of Charcot arthropathy and its symptoms, when the radiographs may still reveal an intact osseous structure.

Early-stage Charcot Arthropathy

There are four different stages in Charcot foot, often grouped in active versus non-active disease states: inflammation, fragmentation, coalescence, consolidation⁷. Patients usually only go through one round of the different stages, but approximately 23% of them can suffer through multiple cycles (Figure 1)^7,8. An earlier classification developed by orthopedic surgeon Sidney N. Eichenholtz defined the three stages of Charcot arthropathy based on the natural history of the disease. Stage I was the development, stage II the coalescence, and stage III the reconstruction⁹.

While radiographic imaging is useful in the later stages, it is less so in the inflammatory stage of Charcot, where it often shows no alterations¹⁰. If there is a high suspicion of Charcot in its early stages, magnetic resonance imaging (MRI) and bone scans can be useful in detecting bone marrow edema and distinct bone alterations^10,11. Tagged white blood cell scans can also be used to differentiate infection from acute Charcot arthropathy¹². However, according to the feedback from our interviewed Charcot experts, MRI can be difficult to interpret, given its high sensitivity. Diagnostic imaging, while important, should always be preceded by a careful clinical evaluation of the patient to minimize the risk of misdiagnosis and delayed treatment.

Initial Signs and Symptoms of Charcot Arthropathy

Since there is no single diagnostic test that can unequivocally diagnose Charcot, physical examination is the cornerstone of staging and diagnosing the condition¹³. All patients with diabetes should be examined at least once a year for potential foot problems, and more often if they have risk factors¹⁴.

Early-stage Charcot starts with a red, hot, and swollen foot, with patients frequently complaining that their foot no longer fits into a shoe and is often painful¹⁰. The precipitating event is often trauma, such as slipping or twisting, although the patient often may not recall a specific traumatic event¹⁰. Pain may or may not be present, due to the sensorial alterations caused by peripheral neuropathy^2,15. Since neuropathy is a pre-requisite for the development of Charcot foot, it is useful to confirm its presence by Semmes-Weinstein monofilament or vibratory perception threshold¹⁶.

Although peripheral artery disease is common in patients with diabetes, Charcot arthropathy usually presents with exaggerated blood flow which, along with the inflammatory process, leads to increased temperature in the affected foot, about 2–5°C (3.6–9°F)^10,16. Some specialists, including Stephanie Oexeman, DPM, are big proponents of thermography. She uses an app to store thermal data from her patients and evaluate how temperature changes over time.

Daniel Scott, MD, MBA (Medical University of South Carolina) also highlights that warmth, redness and swelling are red flags of early Charcot and that thermography is helpful to quantify and document asymmetry in temperature. Furthermore, he mentions a helpful tip to differentiate Charcot foot from infection: in Charcot, the warmth, redness, and swelling improve with elevation, while in infection these signs remain unchanged.

The diabetic foot symptoms that clinicians should be most attentive to are summarized in Table 1.

Sign or symptom	Assessment
Unilateral erythema, ligament laxity, and swelling	Clinical observation
Peripheral neuropathy	Semmes-Weinstein monofilament or vibratory perception threshold
Increased temperature	Clinical observation or thermal mapping (more accurate)
Pain of the affected foot	Patient history

Misdiagnosis of Charcot Foot

According to a recent systematic review, more than half (53.2%) of Charcot cases involving the foot are initially misdiagnosed, leading to long wait times from symptom onset to correct diagnosis¹. Because Charcot of the foot is not at the forefront of most clinicians’ minds, it is often misdiagnosed as skin or bone infections, other inflammatory conditions, fractures, sprains, or deep vein thrombosis¹. Foot ulcers, common in diabetic patients, can also create challenges with correctly diagnosing this condition, as worsening deformity from Charcot arthropathy can lead to early ulceration¹⁷.

An untimely diagnosis of Charcot of the foot will significantly increase medical treatment costs and health care resource utilization, but most importantly, it will reduce the patients’ quality of life and life expectancy^17,18.

In conclusion, a timely and accurate early-stage Charcot arthropathy diagnosis should be a priority for every clinician caring for patients living with diabetes, so that appropriate treatment can be quickly implemented.

References

Korst GS, Ratliff HT, Torian J, Jimoh RO, Jupiter DC. Delayed Diagnosis of Charcot Foot: A Systematic Review. The Journal of Foot and Ankle Surgery. 2022/09/01/ 2022;61(5):1109-1113. doi:https://doi.org/10.1053/j.jfas.2022.01.008
Schmidt BM. Clinical insights into Charcot foot. Best Pract Res Clin Rheumatol. Jun 2020;34(3):101563. doi:10.1016/j.berh.2020.101563
Jansen RB, Svendsen OL. A review of bone metabolism and developments in medical treatment of the diabetic Charcot foot. Journal of Diabetes and its Complications. 2018/07/01/ 2018;32(7):708-712. doi:https://doi.org/10.1016/j.jdiacomp.2018.04.010
Trieb K. The Charcot foot. The Bone & Joint Journal. 2016;98-B(9):1155-1159. doi:10.1302/0301-620x.98b9.37038
Marmolejo VS, Arnold JF, Ponticello M, Anderson CA. Charcot Foot: Clinical Clues, Diagnostic Strategies, and Treatment Principles. Am Fam Physician. May 1 2018;97(9):594-599.
Schmidt BM, Wrobel JS, Holmes CM. Physician knowledge of a rare foot condition – influence of diabetic patient population on self-described knowledge and treatment. Article. Clin Diabetes Endocrinol. 2017;3(1)
Rosskopf AB, Loupatatzis C, Pfirrmann CWA, Böni T, Berli MC. The Charcot foot: a pictorial review. Insights Imaging. Aug 5 2019;10(1):77. doi:10.1186/s13244-019-0768-9
Osterhoff G, Böni T, Berli M. Recurrence of acute Charcot neuropathic osteoarthropathy after conservative treatment. Foot Ankle Int. Mar 2013;34(3):359-64. doi:10.1177/1071100712464957
Rosenbaum AJ, DiPreta JA. Classifications in brief: Eichenholtz classification of Charcot arthropathy. Clin Orthop Relat Res. Mar 2015;473(3):1168-71. doi:10.1007/s11999-014-4059-y
Rogers LC, Frykberg RG. The Charcot Foot. Medical Clinics of North America. 2013/09/01/ 2013;97(5):847-856. doi:https://doi.org/10.1016/j.mcna.2013.04.003
Ahluwalia R, Bilal A, Petrova N, et al. The Role of Bone Scintigraphy with SPECT/CT in the Characterization and Early Diagnosis of Stage 0 Charcot Neuroarthropathy. J Clin Med. Dec 21 2020;9(12)doi:10.3390/jcm9124123
Lauri C, Glaudemans A, Campagna G, et al. Comparison of White Blood Cell Scintigraphy, FDG PET/CT and MRI in Suspected Diabetic Foot Infection: Results of a Large Retrospective Multicenter Study. J Clin Med. May 30 2020;9(6)doi:10.3390/jcm9061645
Abyar E, McKissack H, Johnson MD. Chapter 19 – The surgical management of the Charcot foot: physical examination of the foot prior to surgery, indications and criteria for amputation, and surgical techniques. In: Pierre-Jerome C, ed. The Essentials of Charcot Neuroarthropathy. Elsevier; 2022:441-448.
Apelqvist J, Bakker K, van Houtum WH, Schaper NC. Practical guidelines on the management and prevention of the diabetic foot. https://doi.org/10.1002/dmrr.848. Diabetes/Metabolism Research and Reviews. 2008/05/01 2008;24(S1):S181-S187. doi:https://doi.org/10.1002/dmrr.848
Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot Foot in Diabetes. Journal of the American Podiatric Medical Association. 01 Sep. 2011 2011;101(5):437-446. doi:10.7547/1010437
Rogers LC, Bevilacqua NJ. The diagnosis of Charcot foot. Clin Podiatr Med Surg. Jan 2008;25(1):43-51, vi. doi:10.1016/j.cpm.2007.10.006
Labovitz JM, Shapiro JM, Satterfield VK, Smith NT. Excess Cost and Healthcare Resources Associated With Delayed Diagnosis of Charcot Foot. The Journal of Foot and Ankle Surgery. 2018/09/01/ 2018;57(5):952-956. doi:https://doi.org/10.1053/j.jfas.2018.03.036
van Baal J, Hubbard R, Game F, Jeffcoate W. Mortality Associated With Acute Charcot Foot and Neuropathic Foot Ulceration. Diabetes Care. 2010;33(5):1086-1089. doi:10.2337/dc09-1428

Surgical Management of the Charcot Ankle2024-01-17

Charcot neuroarthropathy of the ankle is an especially challenging condition that often leads to instability and destruction of the joint with significant morbidity requiring an amputation in many instances^1-3. According to Brodsky et al., the ankle is affected in 9% of patients with Charcot neuroarthropathy, whereas the hindfoot is involved in 30-35%³. The overall goal of Charcot ankle reconstruction is to achieve a painless, plantigrade and stable foot, and thus avoid ulceration with subsequent infection^1,2. However, this procedure is also associated with a high complication rate^1,2.

Postoperative Management in Charcot Foot Reconstruction2024-01-10

The successful treatment of Charcot foot does not end with a completed surgery; success also requires a diligent postoperative care regime. This devastating condition mainly affects patients with diabetes and peripheral neuropathy, resulting in bone destruction and joint deformation¹. During the initial, inflammatory stage, the recommended treatment consists of off-loading with total contact casts or custom orthotics to prevent further damage, although surgical management is indicated in cases of severe instability or soft tissue compromise². After the acute stage, the focus of treatment is on deformity correction and foot reconstruction to prevent further damage and improve the patients’ quality of life².

Foot and Ankle Charcot Reconstruction with External Fixation2023-12-20

Surgical reconstruction of foot and ankle Charcot with external fixation is especially useful in the presence of poor bone quality, ulceration, compromised soft tissue, active infection, or osteomyelitis – cases in which the use of internal fixation is limited or contraindicated¹.

Charcot Foot Reconstruction Using Internal Fixation2023-12-12

Appropriate timing for surgical intervention is a matter of controversy among specialists¹. While in the past Charcot foot surgical reconstruction was mainly reserved to salvage the limb, today surgeons also perform operative corrections to ensure patients can use commercially available footwear instead of cumbersome orthoses¹. Regardless, the main goal of Charcot foot surgery, independent of the fixation method, is to create a stable and plantigrade foot. This article will discuss different approaches for Charcot foot surgery with internal fixation, focusing on midfoot reconstruction.

Expert Tips on How to Medically Diagnose Charcot Arthropathy2023-11-30

The diagnosis of Charcot neuroarthropathy of the foot and ankle can be challenging due to a lack of information in the patient's history, clinical assessment, imaging, and laboratory findings¹. It is assumed that one in four cases of acute foot and ankle Charcot are undiagnosed or misdiagnosed¹. However, correct diagnosis and effective treatment are crucial to avoid ulceration, worsening deformity, infection, or amputation¹.

Medical Resources for Charcot Foot & Ankle Specialists2023-11-14

There is an overwhelming wealth of scientific literature available on Charcot foot. In this article, we gather and summarize some of the most interesting sources, including Charcot neuroarthropathy of the foot and ankle reviews, diabetic foot reviews, and diabetic foot care articles.

The Experts’ Definition of Diabetic Charcot Foot2023-11-14

Charcot foot is a progressive, devastating pathology defined by bone and joint changes that occur as a result of loss of sensation. Also called Charcot joint or neuropathic arthropathy, this condition is almost always associated with the vascular and neurological changes caused by poorly controlled diabetes¹.

Charcot Surgical Reconstruction2023-11-14

Charcot foot, also called Charcot neuropathy, is a condition caused by a combination of peripheral neuropathy and vascular disorders that results in progressive joint damage and eventually foot instability¹. If left untreated, the consequences for patients are devastating, with reduced quality of life, inability to weight-bear, and an increased risk of amputation².

Surgical Approaches for Charcot Foot2023-11-14

Charcot neuroarthropathy is a rare, but devastating complication of diabetes¹. Progressive destruction of the bones and joints of the foot cause deformities and thus alter foot biomechanics¹. If not recognized nor treated properly, the disease can result in ulcer formation, infection, and progression of the disease with joint instability and bone destruction^2,3. In the worst case, limb amputation is required^4,5.

Tips for Timely Diagnosis of Charcot Foot and Ankle2022-01-17

It is known that around 9 per cent of patients with diabetic neuropathy and foot ulcers develop a Charcot foot and ankle. This pathology often goes unrecognized, particularly during the acute phase, until severe complications occur, such as an abnormal pressure distribution on the plantar fascia with bones weakened enough to fracture, followed by a marked foot and ankle deformation and, in the worst cases, by amputation. Thus, today, one of the most crucial questions is how to timely diagnose this condition.

Magnetic Resonance for Charcot Foot and Ankle Diagnosis2021-12-21

Charcot Foot and Ankle is a significant problem caused by peripheral neuropathy, with an estimated incidence of 0.3 to 7.5% in the diabetic population. This condition, which is also known as Charcot arthropathy, Charcot joint, or neuropathic arthropathy, affects the soft tissues, joints, and bones in the foot and ankle. If left untreated, it may lead to progressive foot deformity, ulceration, or osteomyelitis. In the most advanced stages, it may be necessary to resort to limb amputation.

Tips for the Prevention of Charcot Foot and Ankle2021-12-17

Charcot Foot and Ankle is a severe condition that, if left untreated, may lead to deformity, permanent disability, amputation or ultimately to the patient’s death. People with diabetic neuropathy are at high risk of developing Charcot Foot and Ankle, because of the decreased sensation and diminished ability to feel temperature, pain or trauma.

Computerized Tomography for Charcot Foot and Ankle Diagnosis2021-12-14

Charcot Foot and Ankle, also known as Charcot arthropathy or Charcot joint, is a condition caused by peripheral neuropathy, leading to the progressive degeneration and destruction of the soft tissue, joint, and bone. In modern society, the most common cause for this neuropathic neuropathy is diabetes mellitus, with long-term diabetic patients having an increased risk of developing the condition.

Radionuclide for Charcot Foot and Ankle Diagnosis2021-12-09

Early Charcot Foot Diagnosis is essential to a proper management, but this can be challenging. There are some factors that should increase clinical suspicion for acute Charcot arthropathy, namely if the patient presents with:

Radiography for Charcot Foot and Ankle Diagnosis2021-12-07

Charcot Foot and Ankle, also known as Charcot arthropathy, neuropathic arthropathy or Charcot joint, is a progressive condition that affects the bones, joints and soft tissue of the foot and ankle. It is caused by peripheral neuropathy. Today, diabetes is the most common cause for developing Charcot Foot and Ankle.

Charcot Foot and Ankle Diagnosis: The Multidisciplinary Approach2021-12-02

Patients with Charcot neuroarthropathy, a condition that affects the bones, joints, and soft tissues of the foot and ankle, greatly benefit from a timely diagnosis and appropriate treatment. However, Charcot Foot and Ankle diagnosis can be quite challenging, especially in an early stage, where acute symptoms can be similar to other conditions.

Charcot Foot and Ankle: Patient Questions and Doctor Answers2021-11-30

Linked to peripheral neuropathy, Charcot Foot and Ankle is one of the serious foot complications affecting people with diabetes. Foot injuries that go unnoticed due to the reduced pain sensation accumulate, and, over time, there is bone deformation, ulceration, and infection. In a worst-case scenario, amputation may be necessary.

Charcot Foot and Ankle Causes: Where the Pathology Starts2021-11-25

Charcot Foot and Ankle, also known as Charcot arthropathy, is a progressive, inflammatory condition that affects the bones, joints, and soft tissues in the feet of people with peripheral neuropathy. If left untreated, Charcot of the foot and ankle leads to severe deformity, ulceration, and – worst-case scenario – to limb amputation.

The Stages of Charcot Foot and Ankle Disease and The Importance of a Quick Diagnosis2021-11-23

When dealing with Charcot Foot Disease, a swift diagnosis is crucial to improve patient outcomes and avoid complications such as foot deformity, ulceration, and in a worst-case scenario, limb amputation. However, not all physicians are able to recognize the initial signs of a Charcot Foot and Ankle in their diabetic patients.

Emergency in Diabetic Foot and Ankle2021-11-16

Diabetic foot is one of the most important sources of morbidity in patients with diabetes, affecting 6.4% of patients worldwide. It is the most common cause of lower extremity amputation.

Charcot Foot and Ankle: Definition and Classification2021-11-12

Charcot Neuroarthropathy, also called Charcot Foot and Ankle, is a progressive and inflammatory condition that weakens the soft tissues, bones, and joints of the foot and ankle. This complex and challenging type of neuropathic arthropathy is commonly linked to diabetes. If left untreated, it can lead to devastating consequences, such as deformity, ulceration, and infection. In the worst-case scenario, it may result in limb amputation.

The Surgical Approach to the Charcot Foot and Ankle Treatment2021-05-24

Charcot Foot and Ankle is a complex, challenging and sometimes devastating inflammatory foot disease which causes loss of sensation, weakening of the bones and collapse of the weight bearing joints. Most often due to diabetes and underlying neuropathic arthropathy, it needs a multidisciplinary team approach in order to treat it properly and prevent amputation.

What Is Arthrodesis (Joint Fusion)?2021-05-06

Arthrodesis may be defined as the surgical immobilization of a joint by fusion of the bones. It is commonly referred to as joint fusion, also known as artificial ankylosis or syndesis. It can be performed in several parts of the body, and it is indicated in the presence of painful joints, often due to arthritis or osteoarthritis, with highly compromised mobility.

REQUEST MORE INFORMATION

Please read our Privacy Policy before submitting this form

I have read and understood the Privacy Policy above and, therefore, I hereby consent to the processing of my personal data by Orthofix S.r.l.:

A) to allow Orthofix to carry out marketing initiatives described in point 3 (d) of the Privacy Policy, including for sending you marketing and promotional communications regarding Orthofix-branded products or services, or new initiatives and events. *

I consent

I do not consent

B) for transmitting your personal data to third parties (namely to other Orthofix Group’s legal entities and to distributors engaged by them and Orthofix directly), in order to enable them to provide you with their own marketing and promotional communication. *