Lateral x-ray of the right foot of a 73-year-old man with insulin-dependent diabetes.
A 73-year-old man with insulin-dependent diabetes presents with right foot pain that has been ongoing for several months. This is the first time he has sought medical attention because until now the pain has been tolerable. On physical examination, the patient has no erythema or warmth. There is pain to palpation over the midfoot, and a “rocker bottom” deformity is noted.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Submit your diagnosis to see full explanation.
The patient presents with midfoot collapse on radiographs and a “rocker bottom” deformity, which are consistent with Charcot arthropathy. The exact etiology of Charcot arthropathy is unclear, but the condition is thought to be caused by a hypovascular response that reduces bone density and healing ability in the foot.
Repetitive microtrauma that exceeds the rate of healing causes a high incidence of fracture and progressive bony destruction. Without early intervention and with continued weight bearing, severe foot destruction can occur. The most commonly affected site is in the midfoot or the subtalar, talonavicular, or calcaneocuboid joints. However, Charcot arthropathy may also occur in the hindfoot, ankle, heel, or forefoot.1,2
The Eichenholtz classification system is commonly used to describe the stages of Charcot arthropathy. This patient has presented at stage 3, or the chronic phase, when fracture fragments consolidate and remodel.
Treatment of stage 3 Charcot arthropathy involves the use of accommodative footwear with protective orthosis. The foot is considered stable, and weight bearing as tolerated is allowed. Nonsurgical treatment has a success rate of 75%. Progressive pain, severe deformity, infection, and skin ulceration may be indications for surgery. Surgical treatments include exostectomy, or removal of the ulcer-inciting bony prominence, arthrodesis, or amputation.1,2
The stage at presentation and disease progression vary widely among patients. Some patients may present very early with no radiographic changes, whereas others may present with a severely destabilized foot. Disease progression also varies and may continue to occur despite early protection. With prompt recognition and management, however, the potentially devastating consequences of Charcot arthropathy may be prevented.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Reddy S. Charcot Arthropathy. http://www.aofas.org/PRC/conditions/Pages/Conditions/Charcot-Arthropathy.aspx. Accessed May 11, 2016.
- van der Ven A, Chapman CB, Bowker JH. Charcot neuroarthropathy of the foot and ankle. J Am Acad Orthop Surg. 2009;17(9):562-571.