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Charcot Arthropathy

PTA 236 In-Service


Spring 2013
Jennifer Schore
What is Charcot Arthropathy?
 Also known Charcot Foot

 Most commonly seen in individuals with diabetes


mellitus (DM)

 Results from nerve damage and poor circulation


common to DM

 Begins as inflammatory condition, ultimately affecting


bones, joints, soft tissue of foot and ankle, and leading
to foot deformity

AAOS (2011)

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Charcot Foot: severe deformity due to
ankle joint breakdown

AAOS (2011)
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Some statistics about DM
 8.3% of US population has DM (25.8 million, diagnosed and
undiagnosed)

 60-70% of people with DM have mild to severe neuropathy, which


can result in impaired sensation

 ~9% of those with diabetic neuropathy develop Charcot foot

 Most will be in their 50s and 60s and have had DM for 10-20 years

CDC (2011), AAFP (1996), AAOS (2011)

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Charcot Foot Progression
 DM results in decreased circulation, which in turn weakens bones
and makes fracture more likely

 Neuropathy leads to loss of sensation in feet, so patients do not feel


fractures

 As patient continues to walk on broken foot, bone fragments can


develop and pressure of the fragments on skin result in decubitus
ulcers

 More fractures develop and joints dislocate

AAOS (2011)

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Signs and Symptoms
 Profound unilateral swelling
 Locally increased skin temperature
 Erythema
 BUT no pain, or less pain than expected
 No skin openings
 X-rays may appear normal
 Synovial joint biopsy is definitive; bone fragments
will be in joint

Witmer (2004)

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Bone fragments lead to ulcer

(Left) This patient with Charcot of the ankle has developed a deformity that
places abnormal pressure on the outside of the ankle. (Right) This pressure
has led to the development of a chronic sore (ulcer) that can be extremely
difficult to treat (AAOS 2011).

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How is Charcot Foot treated?
 Prevention is the best treatment!

 Nonsurgical: casting to reduce swelling, protect bones,


for 3 months or more with changes every 1-2 weeks
(NWB), followed by custom made shoe

 Surgical: if protective footwear not effective


 Achilles tendon lengthening
 Removal of bony prominence on inferior foot
 Repair/ reconstruction

AAOS (2011)

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Complex Surgical Treatment

(Top) In this x-ray taken from the side, the patient has unstable Charcot of the back
of the foot. The dislocation of the joints is seen where the two bones in the back of
the foot do not line up (arrowhead). (Bottom) A complex realignment and fusion
was performed to prevent the patient from developing a prominence and
ulceration (AAOS 2011).
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What does this mean for us?
 Clinician observation of key symptoms to report to
PT/ physician

 Patient education: diabetes self care

 Gait training with cast and AD (NWB)

 Post-surgical ankle muscle strengthening and


stretching*
*Dutton (2012)

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How to Assess Intervention?
 Difficult to clearly assess interventions just
mentioned b/c patient outcomes affected by health
and health behaviors (not just by intervention)

 To assess DM teaching concerning prevention:


tracking decubitus stages and # new ulcers over
time

 To assess gait training with AD and post-surgical


therex: RoM/ MMT, Functional Gait Assessment
(FGA) (Wrisley et al. 2004), measured over time

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References and Additional Resources
 References
American Academy of Family Physicians (AAFP) (1998). The Charcot Foot in Diabetes: Six Key Points.
http://www.aafp.org/afp/1998/0601/p2705.html, accessed 2/19/2013.

American Academy of Orthopedic Surgeons (AAOS) (2011). OrthoInfo: Diabetic (Charcot) Foot.
http://orthoinfo.aaos.org/topic.cfm?topic=A00655, , accessed 2/19/2013.

Centers for Disease Control and Prevention (CDC) (2011). National diabetes fact sheet: national
estimates and general information on diabetes and prediabetes in the United States.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf, accessed 2/26/2013.

Dutton, M. (2012). Orthopedics for the Physical Therapist Assistant, Sudbury, MA: Jones and Bartlett
Learning.

Witmer, J. (2004). Understanding Charcot Foot. Advance for Physical Therapy and Rehab Medicine. Vol.
15, issue 5, p.44.

Wrisley, D., Marchetti, G., Kuharsky, D. and Whitney, S. (2004). Reliability, Internal Consistency, and
Validity of Data Obtained with the Functional Gait Assessment. Physical Therapy. Vol. 84, no. 10,
pp906-918).

 Additional resources: ADA, AAOS, AAFP

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Conclusion

 Any questions?

 What do you know now?

 How was the presentation?

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