Category Archives: diabetic neuropathy

Charcot foot management using MASS posture foot orthotics: A case study

by Edward S. Glaser DPM1; David Fleming BS2*; Barbara Glaser2

The Foot and Ankle Online Journal 10 (3): 4

Background: A 62-year old male being treated for Charcot arthropathy of his right foot at the VA Medical Center in Orlando, FL.  The patient was using a knee walker with a below knee cast at onset of treatment.
Methods:  Custom rocker sole walking boot with built in EVA MASS posture orthotic and MASS orthotic Therapy
Results:  Quality of life improvements.  As the Charcot foot remodeled it coalesced into a foot with an increased medial longitudinal arch allowing for return closer to normal gait and footwear.  No ulcerogenesis was noted with aggressive orthotic therapy.  Protective sensation partially returned to feet bilaterally.
Conclusions:  An increase in patient quality of life without introducing ulcers.   More research needs to be done to determine if this treatment protocol contributes to protective sensation returning to patients with DPN.

Keywords: Charcot foot, diabetic neuropathy, orthoses, MASS Posture

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0004

1 – Founder and CEO of Sole Supports, Inc.
2 – Sole Supports, Inc.
* – Corresponding author: dfleming@solesupports.com


The patient is a 62-year old, well nourished, caucasian male with a 12-year history of Type II Diabetes Mellitus. He has experienced neuropathy for 9 years and for the last 7 years he has been profoundly numb bilaterally distal to the ankle. Following a 10-month period of misdiagnosis, he was diagnosed with Charcot foot on November 18, 2015, at the Orlando VAMC. Podiatric treatment for four months prior consisted of ambulating in a BK cast with a knee walker. Casts were reapplied every 3-4 weeks. During the four months of immobilization, the patient noted considerable atrophy of the right gastroc-soleus muscle and loss of his medial longitudinal arch. The patient’s right foot had become a semi-rigid rocker sole foot (Figure 1).

Figure 1 Rocker sole foot.

When the patient was first seen, insensitivity was confirmed with a Semmes Weinstein 5.07 monofilament test bilaterally. No ulcers were visibly present. The patient’s right foot had significant swelling and the patient had gone from a size 12.5 USA (M) shoe to a size 14 USA (M) shoe prior to casting according to the patient.

To prevent amputation of his foot, a prospective protocol was created as the patient progressed.  If at any time the patient developed an ulcer, the project would have been terminated and traditional care would have resumed.

Methods

A Semmes Weinstein 5.07 monofilament was used to determine the patient’s protective sensation.  The locations for monofilament testing were as follows: the plantar aspect of metatarsal heads and distal phalanges 1,3,5. The plantar aspect of the heel, medial arch, and lateral arch. The dorsal aspect of the skin at the base of metatarsal 3, and plantar aspect of the heel, bilaterally [1].

Figure 2 Paper Test shown with MASS Orthotic.

The Paper Test (Figure 2) consisted of the patient weight bearing on the affected foot with a piece of paper placed under both the forefoot and the rearfoot.  The practitioner then attempted to remove the piece of paper by pulling it anteriorly/posteriorly.  If the paper tore then that was a positive result, if the paper slid out it was a negative result.  A positive result meant that part of the foot was providing adequate force to the ground, resulting in the paper being torn.  A negative result meant that part of the foot was not providing adequate force to the ground and slid out un torn.  The paper test was used to determine when it was appropriate to move him from the custom MASS posture rocker sole shoe boot to the MASS orthotic  inside of a diabetic shoe.

Figure 3  Custom walking boot with EVA Shell MASS Posture Orthotic.

Following removal of the  plaster cast, a custom rocker-sole post-op boot with an EVA shell MASS posture orthotic built in (Figure 3) on 1/28/16.  That boot caused irritation and so the design was refined and a new rocker-sole boot with an EVA shell MASS Posture orthotic fitted in the boot (Figure 4) was created and dispensed to patient on 3/4/2016.  The boot (Figure 4) was removed and replaced with a modified golf shoe boot with an EVA shell MASS Posture orthotic fitted into the boot (Figure 5), which was dispensed to the patient on 3/25/2015.  Each change of successive custom boot was modeled from a new, more aggressively captured medial longitudinal arch.  The golf shoe boot (Figure 5) was removed and replaced with an ultrahigh molecular weight polyethylene shell. MASS orthotic (O1) for use with his diabetic shoes.  O1 was dispensed and fitted on 5/6/2016 with use of a full foot lift for his left foot to compensate for the edema on his right foot.   After the edema decreased another MASS orthotic with a polyethylene shell (O2) was dispensed and fitted, for his normal tennis shoes, on 8/25/2016, along with reducing the full foot lift on his left foot.

Figure 4 Refined Custom walking boot with EVA Shell MASS Posture Orthotic.

Figure 5 Modified golf shoe boot with EVA Shell MASS Posture Orthotic.

Results

Our patient initially presented completely insensate with diabetic neuropathy on 1/28/2016.  On 3/25/2016 the patient had regained 6/10 sensation on the right foot and 8/10 on left with the monofilament test.  On 5/6/2016 the patient had a 8/10 sensation on right foot and 10/10 on left.  It should be noted that the patient has been fully compliant keeping his diabetes in control.

Although the patient’s Charcot foot has now fully fused, the foot appears to have remodeled and partially regained the medial longitudinal arch (Figure 6).  The authors believe that this is due, at least in part, to the patient weight bearing in a MASS Posture.  No ulcers developed with the forces applied to the foot.  This is due, at least in part, to the even distribution of body weight across the plantar surface of the foot.  

Figure 6 Clinical view of foot after treatment.

The patient is leading a normal life that includes golf and walking approximating an ideal gait cycle on both hard flat surfaces (hardwood) and uneven flexible surfaces (grass).  

Discussion

For peripheral neuropathy, it is common conventional wisdom that only the levels of Hgb A1C correlate to the presence of neuropathy.  This particular case, along with previous findings of Michael Graham, suggest that there is a secondary biomechanical etiology that may contribute to Diabetic Peripheral Neuropathy (DPN).  Michael Graham showed that reversing neuropathy could be obtained by reducing tension on the neurovascular bundle and the intracompartmental pressures of the posterior tibial nerve utilizing an extra osseous talotarsal implant [2].  This helps explain why some diabetics with equally poor Hgb A1C’s develop DPN but others do not. The biomechanical factor is postulated to involve the mechanical elongation of the perineurium surrounding the posterior tibial nerve.  As the foot drops in posture, the neurovascular bundle is pulled plantarly increasing tension due to elongation [3].  This may cause the perineurium to compress the nerve while increasing fluid pressure within the sheath, contributing to its loss of function.

Conclusion

The authors postulate that using MASS Posture orthotics in combination with controlling diabetes may prevent or, in some cases reverse, diabetic neuropathy by reposturing the foot and thereby decreasing nerve tension and entrapment while evenly distributing the force from the body across the entire plantar surface of the foot.  Additionally, the authors postulate that it is possible during active Charcot to remodel the medial longitudinal arch closer to an idealized foot posture.  Further research is required with an established protocol prior to treatment with a larger sample size to provide more data to verify results.

References

  1. Smieja, M., Hunt, D. L., Edelman, D., Etchells, E., Cornuz, J., Simel, D. L. and For The International Cooperative Group for Clinical Examination Research (1999), Clinical Examination for the Detection of Protective Sensation in the Feet of Diabetic Patients. Journal of General Internal Medicine, 14: 418–424. 
  2. Graham ME, Jawrani NT, Goel VK. The Effect of HyProCure® Sinus Tarsi Stent on Tarsal Tunnel Compartment Pressures in Hyperpronating Feet. The Journal of Foot and Ankle Surgery. 2011;50(1):44-49. 
  3. Graham ME, Jawrani NT, Goel VK. Evaluating Plantar Fascia Strain in Hyperpronating Cadaveric Feet Following an Extra-osseous Talotarsal Stabilization Procedure. The Journal of Foot and Ankle Surgery. 2011;50(6):682-686. 

Bilateral Charcot neuroarthropathy, a challenge for diagnosis and treatment

by Nathalie Denecker1*, Dimitri Aerden2, Michel De Maeseneer3pdflrg

The Foot and Ankle Online Journal 9 (1): 6

Charcot neuroarthropathy is a devastating foot disorder whose differential diagnosis with infectious, bone or articular disease is difficult. We report a rare case of a woman with diabetes who developed bilateral Charcot neuroarthropathy after erysipelas of her left leg and subsequent trauma, which complicated diagnosis as well as efficient off-loading.

Key words: bilateral Charcot foot, diabetic foot, diabetic neuropathy, off-loading

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0006

1,2 – UZ Brussel, Diabetic foot clinic, Laarbeeklaan, 101, 1090 Brussel, BELGIE
3 – UZ Brussel, Radiology department Laarbeeklaan, 101, 1090 Brussel, BELGIE
* – Correspondence: Nathalie Denecker nathalie.denecker@uzbrussel.be


Charcot neuroarthropathy (CN) of the foot is a rare but debilitating disorder that affects bones, joints and soft tissues and leads to significant deformity unless diagnosis is established early. We report a case of bilateral synchronous CN that proved particularly challenging because diagnosis was obfuscated 1) by bilateral symptomatology and 2) a preceding erysipelas. In addition, we had no prior experience in off-loading both limbs simultaneously.

Case report

A 58-year old woman with insulin dependent type 2 diabetes and lower limb neuropathy presented to the emergency department with fever and erythema of the left leg. The limb was erythematous and warm with a plantar neuropathic ulcer on the left hallux. Distal pulses were detected bilaterally. Blood sampling showed overt inflammation. The diagnosis of erysipelas was established with the toe ulcer as entry point. A wound smear revealed Pseudomonas aeruginosa for which intravenous antibiotics were administered for 8 days. She returned with increased oedema and pain of her leg two weeks later, although inflammatory blood parameters had normalised.

Ten days later inflammatory symptoms had persisted and spread to the contralateral foot and ankle: both feet now were swollen, red and warm, and some bruises from a recent trauma were detected. X-rays of both feet were normal. A bone scintigraphy with SPECT-CT (Single Photon Emission Computed Tomography) was suggestive for CN of both feet, with tracer uptake in the midfoot (Figure 1a) and small bony fragments on CT (Figure 1b). Hotspots over the 2nd metatarsal heads bilaterally raised the possibility of underlying osteomyelitis.

Bilateral immobilization with total contact casts (TCC) was deemed impracticable. Hence, the left foot was treated with a removable air-cushioned cast (Aircast®) but this required the patient to be hospitalized. Oedema of the tarsus and metatarsal bases shown on magnetic resonance imaging (MRI) confirmed bilateral CN (Figure 2a) but osteomyelitis of the 2nd metatarsal head was rejected by leucocyte scan with SPECT-CT. Transfer to a rehabilitation centre and regular ambulatory appointments to renew the TCC were initiated. Three months later clinical inflammatory signs and oedema of the midfoot on control MRI had decreased, although increased oedema was observed at the talar bone bilaterally (Figure 2b). Off-loading was continued with bilateral Aircast® walkers for another 3 months until orthopaedic shoes became available. Final ambulatory rehabilitation was satisfactory.

1a1b

Figure 1 (a) Bone scintigraphy shows tracer uptake in the midfoot and 2nd metatarsal heads bilaterally. (b) Irregular margins and bone fragments in the midfoot are seen on SPECT-CT.

Discussion

Charcot neuroarthropathy or Charcot foot is a devastating complication of neuropathy which is mostly seen as a rare complication of longstanding diabetes [1-5]. Men and women are equally affected [2,6]. Until recently, the prevailing hypothesis for pathogenesis was neurotraumatic or neurovascular [2,7,8]. Authors have observed however that CN is also associated with an enhanced inflammatory response, presumably triggered by minor trauma, prior infection, ulceration or foot surgery. Pro-inflammatory cytokines (TNF-α, IL-1ß) are released and lead to increased expression of receptor activator of nuclear factor-κB (RANK) ligand, thereby activating NF-κB (Nuclear Factor κB), a potent promotor of osteoclastic activity which promotes osteolysis and fractures [1,2,8,9].

The prevalence of CN is underestimated but affects less than 1% of all patients with diabetes [6,8-10]. Moreover, local inflammation is inhibited by limited arterial inflow, a frequent occurrence in patients prone to macrovascular disease [9]. Ipsilateral recurrence of CN is rare [10]. Over several years, contralateral CN may occur in 20% to 30% [6,7,11]. Off-loading of the index foot has been suggested as the initiating event that may develop CN at the contralateral foot [11].

2a2b

Figure 2 (a) MRI of the right foot initially shows bone marrow oedema of the tarsus and metatarsal bases. (b) Three months later oedema in the original regions has improved but is now more prominent in the talar bone.

Diagnosis of acute Charcot foot is primarily established clinically because no specific laboratory tests are available: a unilateral red, warm, swollen foot that is remarkably painless due to neuropathy. Differential diagnosis should be made with infection (cellulitis, osteomyelitis, arthritis, abscess), acute gout, deep venous thrombosis and trauma (sprain, fracture) [1-4,11,12]. Imaging techniques are helpful but X-rays lack sensitivity during the first weeks. The sensitivity of bone scintigraphy is superior and its low specificity is improved by SPECT-CT. MRI has diagnostic accuracy in the early stages and allows differentiation from osteomyelitis [1-3,11]. According to literature, the diagnosis of CN may be missed in 79% and delayed up to 29 weeks [11]. Unfortunately, early recognition of CN and prompt treatment is mandatory to prevent foot deformation.

Rapid immobilisation of the affected foot is paramount and accomplished best by TCC, the gold standard for off-loading [1,13]. A removable pneumatic walker achieves comparable off-loading but non-compliance remains a problem [4,10]. Immobilisation is advised until clinical signs have resolved and a temperature difference of <2°C between feet is recorded [1,9,14]. In general, this occurs after 3-12 months, with 6 months being most common [10,11,14]. Bisphosphonates which inhibit bone resorption have been suggested as adjunctive therapy but current data do not support their routine use [5].

Bilateral synchronous CN as reported in the presented case is not only an extremely rare occurrence, but also greatly complicates diagnosis and subsequent immobilisation/off-loading. To our knowledge, only one similar case has previously been reported: a man in which contralateral CN presumably was elicited two weeks after off-loading his index foot with a TCC [12]. In our case, a skin infection probably triggered CN on the index side which unfortunately also delayed diagnosis. On the contralateral side both the overloading of the right foot due to pain on the left side, or trauma may have been the trigger for CN. The number of radiological exams that had to be performed, and their conflicting findings demonstrate how difficult a diagnosis can be. Long-term immobilisation and off-loading of both limbs was extremely debilitating to our patient and justified hospitalisation in a rehabilitation centre.

In summary, diagnosis of acute Charcot foot is challenging, especially when triggered by prior infection or trauma. Bilateral CN, although extremely rare, further complicates the diagnosis as well as efficient off-loading and immobilisation.

References

  1. Rogers LC, Frykberg RG, Armstrong DG, Boulton AJM, Edmonds M, Van Ha et al. The Charcot Foot in Diabetes. Diabetes Care 2011; 34(9): 2123–2129. (PubMed)
  2. Gouveri E, Papanas N. Charcot osteoarthropathy in diabetes: A brief review with an emphasis on clinical practice. World J Diabetes 2011; 2(5): 59–65. (PubMed)
  3. Botek G, Anderson MA, Taylor R. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleve Clin J Med 2010; 77(9): 593-599. (PubMed)
  4. Pinzur MS. Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int 2007; 28(8):952-9. (PubMed)
  5. Richard JL, Almasri M, Schuldiner S. Treatment of acute Charcot foot with bisphosphonates: a systematic review of the literature. Diabetologia 2012; 55: 1258–1264. (PubMed)
  6. Hartemann-Heurtier A, Van GH, Grimaldi A. The Charcot foot. Lancet 2002; 360: 1776-1779. (PubMed)
  7. Jeffcoate W, Lima J, Nobrega L. The Charcot foot. Diabet Med 2000; 17(4): 253-258. (PubMed)
  8. Molines L, Darmon P, Raccah D. Charcot’s foot: Newest findings on its pathophysiology, diagnosis and treatment. Diabetes Metab 2010; 36(4): 251–255. (PubMed)
  9. Jeffcoate WJ. Theories concerning the pathogenesis of the acute charcot foot suggest future therapy. Curr Diab Rep 2005; 5(6): 430-435. (PubMed)
  10. Christensen TM, Gade-Rasmussen B, Pedersen LW, Hommel E, Holstein PE, Svendsen OL. Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker. J Diabetes Complications 2012; 26(5): 430-434. (PubMed)
  11. Milne TE, Rogers JR, Kinnear EM, Martin HV, Lazzarini PA, Quinton TR et al. Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review. J Foot Ankle Res 2013; 6(1): 30. (PubMed)
  12. Fauzi AA, Yang CT. Bilateral diabetic Charcot foot. Aust Fam Physician 2013; 42(1-2):55-56. (PubMed)
  13. Ramanujam CL, Facaros Z. An overview of conservative treatment options for diabetic Charcot foot neuroarthropathy. Diabet Foot Ankle 2011; 2:1-5. (PubMed)
  14. Moura-Neto A, Fernandes TD, Zantut-Wittmann DE, Trevisan RO, Sakaki MH, Santos ALG et al. Charcot foot: skin temperature as a good clinical parameter for predicting disease outcome. Diabetes Res Clin Pract 2012; 96(2): e11–14. (PubMed)