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Proper diabetes care requires being constantly vigilant in treating diabetes complications. One especially troubling complication that can affect both type 1s and type 2s is diabetic peripheral neuropathy. This complication, which affects the nerves in the extremities, may make the feet numb and unable to feel pain. When first hearing this, many say, "that's terrific - not feeling pain is better than hurting." Unfortunately, feeling pain is a necessary evil to prevent serious injuries.
What Causes Charcot Foot?
Walking without feeling pain means a person may not know when and how to protect an injured area. Someone without peripheral neuropathy would protect an injured foot by limping, resting or by seeing a doctor. The person with neuropathy feels no pain and just keeps walking.
Some bones may even break without the important warning signals given by the sensation of pain. Continuing to walk on a numb, injured foot can crack, splinter and erode bones in the feet. The affected foot can take on a deformed appearance as joints shift, changing position and shape. Sometimes the deformity is so severe that instead of having a normal concave surface (an arch) on the bottom the foot, it may actually become convex - taking on a rocker bottom appearance. Sometimes you can even feel the projections of displaced bone under the skin surface.
This is referred to as a Charcot foot. These acute changes in a Charcot foot may cause the foot to swell and to become red and warm to the touch. To the uninitiated, this may look like an infection. Sometimes even doctors will have a hard time distinguishing between osteomyelitis (an infection of the bone) and an acute Charcot foot. Sophisticated testing (with special bone scans or MRIs) may be necessary for an accurate diagnosis. This is vital since the treatment of the two problems differ so greatly. Bone infections require antibiotics, sometimes for months, but Charcot changes in bones do not.
Treatment of a Charcot foot begins with immobilization. During the acute stage, the foot is fragile, susceptible to further damage and must be protected. This is often done by casting, splinting and the use of crutches or even a wheelchair. The other foot, which because of neuropathy may also not feel pain, must be protected as well. Favoring the bad foot can lead to the breakdown of tissues in the other extremity. The immobilization and protection lasts for months while the foot heals.
If Charcot changes are diagnosed early and the foot is immobilized, the aforementioned deformities may be prevented. Once the foot changes shape and heals in the abnormal position, however, surgery may be needed to remodel the bones. I have seen many patients with ulcers on the bottom of their feet due to pressure from new bony projections.
Sometimes molded shoes, or shoe inserts (orthoses), can remove enough pressure from these bones to adequately protect them. At other times, surgery to remodel the bone(s) is necessary to help heal these ulcers or to stop new ones from forming. If the ulcers become infected or if the underlying bone becomes infected, the problem is much more complex.
Solutions & Prevention
What can you do to prevent these devastating changes?
First of all, tight control of your diabetes may delay or prevent the onset of the neuropathy that is the underlying cause of Charcot joints. If you already have neuropathy, speak with your podiatrist (you should have one) about preventative diabetic foot care. Examine your feet daily. If you notice any changes in shape, color or temperature, call your podiatrist for advice.
Do you wear the right shoes? Do you need special supports called orthoses? These are all issues that need to be discussed before problems occur.
If you have Medicare, don't forget to ask your doctor about the Medicare Therapeutic Shoe Program. People with diabetes that meet certain criteria (e.g., neuropathy and calluses, deformity, poor circulation, history of ulcers, previous amputation) are eligible for one pair of shoes per year and special innersoles for those shoes that Medicare will help pay for. The shoes and innersoles are designed to decrease the incidence of foot related problems in people with diabetes who are at risk.
There are many things that can be done to prevent and treat Charcot foot. Your awareness that the problem can occur should alert you to protect your feet, to look at your feet regularly and to call your podiatrist or diabetes specialist at the first sign of trouble.
0 comments - Jul 1, 1998
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