Charcot Arthropathy

When someone is first diagnosed with this disease their first response is “charcot, like a shark”. Charcot Arthropathy, is pronounced “shark-O” and has a French/German derivative.

What exactly is Charcot and who does it affect?

Charcot is a degenerative process of joints in the foot and ankle and can present in many different ways. It is a slow progressive process and usually presents itself with bones in the foot appearing to have fractures and dislocations. Charcot is a disease process where the joints of the foot and ankle have bony destruction. Charcot is caused by neuropathy, or a lack of sensation, which is primarily caused by Diabetes Mellitus. Other causes can be caused by Alcoholism, syphilis and other causes of neuropathy.

Charcot begins slowly but as the disease progresses it can appear similar to an infection. The joints of the foot that can are affected appear to be red, hot, swollen, deformed and perhaps have an ulceration. There are 4 different stages of Charcot. The first being Stage 0, this is a pre Charcot stage with minimal symptoms. Stage 1 is an acute stage, when a patient will present with the above mentioned symptoms including a red, hot, swollen foot. Stage 2 is the step down from Stage 1 and there is less redness, swelling during this stage. Stage 3 is a dormant stage and happens in between attacks/ Stage 1.

How is this diagnosed?

Diagnosis can be difficult because Stage 1 can represent other pathologies such as infection, gout or septic arthritis. Having neuropathy with Diabetes puts a patient with symptoms at high suspicion for Charcot. Diagnosis can be difficult because when someone presents to their physician with these symptoms the disease has usually been going on for a while. Diagnosis is usually by clinical exam but x-rays, MRIs and CT scans can be taken to aid in the diagnosis.

How is it treated?

Treatment is broken down into surgical or non-surgical options. During the Acute Phase/Stage 1 non-surgical options are the way to proceed. This includes a total contact cast, which is a non-weight bearing cast and doesn’t allow the foot to touch the ground. By using an offloading device it allows the joints to heal.  This phase of the disease can take many months and even up to a year to heal. Surgical treatment is recommended for Stage 3, which includes foot and ankle fusions and reconstruction. Not all patients are candidates for surgical treatment, since there are a lot of complications and a long recovery time from these surgeries.

What are the long term complications from this disease?

Even with early treatment and compliance this disease has flare ups. Flare ups cannot be predicted and as the disease goes on there can be increase bony destruction. As the disease progresses there can be a collapse of the foot with prominent bones that appear to be “sticking out of the bottom of the foot”.  This type of foot is known as a rocker bottom foot. At this stage certain shoes and orthotics can be custom made to help with support of this foot.

In conclusion, Diabetic neuropathy with Charcot can have devastating consequences for a patient. If you are a diabetic it is recommended to see a Podiatrist every few weeks to do a diabetic foot exam. Seeing a Podiatrist regularly can prevent some of these complications.

For more information, please visit our website at www.foonj.com

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Arthritis Take 3

In this blog I will discuss a less commonly known type of arthritis. Psoriatic arthritis (PA), which affects 15-30% percent of people with psoriasis, can affect the foot and ankle. The skin disorder known as psoriasis is more common than the arthritis associated with it.

What are the symptoms?

PA is more common between the ages of 30-50 and it affects men and women equally. Like some of the other arthritic diseases we discussed in the past few blogs, people with PA can present with an array of symptoms. Systemically, patients can present to the physician being fatigue and lethargic.  Common symptoms are red, hot, painful and swollen joints. PA tends to affect the feet and ankles more than most other joints in the body. Patients can presents with large red toes, also known as sausage toes. Pain in the Achilles tendon and/or plantar fascia is a common symptom in this disease. Other common symptoms would be discoloration and separation of the toenails. In addition to have these symptoms a patient would have to be diagnosed with the psoriatic skin disorder in order to be diagnosed with PA. There is a genetic component to the disease, but there is little that is known about the exact cause.

Below are two pictures depicting the “sausage toe” and the separation and splitting of the toenail.

How do I get diagnosed with PA?

Just like some of the other rheumatologic disease, a Rheumatologist should be consulted to confirm or deny the diagnosis. There are no specific tests to diagnose a patient with RA, but other diseases can be ruled out.  A telltale sign to differentiate this disease from RA would be it affects the distal knuckles in the toes and fingers.  X-rays, MRI, CT scan or Ultrasounds can be performed to assess which joints are affected and the severity of the disease.  

How do I get treated for PA?
Just like the other rheumatic diseases, anti-inflammatory medications and the disease modifying antirheumatic agents are the common ways to treat it. Locally, corticosteroid injections into the affect joints can be performed as well. Exercise is important so that joints do not get stiff and cause long term disability.

This concludes the series of arthritis and the lower extremity. In conclusion, there is a lot of overlap with the symptoms and diagnosis of arthritis in the lower extremity. You should not ignore symptoms and should see a physician as soon as possible.

For more information, please see our website at www.footnj.com

Arthritis Take 2

Last week I discussed osteoarthritis and how it can affect the foot and ankle, but that is only hitting the surface when it comes to rheumatologic diseases and the foot. Rheumatoid arthritis, psoriatic arthritis, and other connective tissue diseases are just a few that can affect that foot and ankle. In this blog we will discuss these diseases, how they affect the feet, how they are diagnosed and most importantly how they are treated.

Rheumatoid Arthritis

Rheumatoid arthritis, also known as RA, is an autoimmune disease that affects synovial joints. It is a painful disease and without treatment it can cause severe disability. 85% of people with RA have symptoms in their ankle and foot joints. Joints with RA appear to be swollen, painful, warm and may become fused over time.  Below is a picture of RA in the hands, which causes severe swelling in the joints.

RA is different from osteoarthritis in that classic RA there appears to be stiff joints in the morning, whereas with osteoarthritis there are stiff joints throughout the entire day. With Osteoarthritis it gets worse over time and then becomes stable, RA becomes worse over time to a point where one cannot function or do daily life tasks.

Diagnosis is made with a multitude of test and via clinical exam. An x-ray of the feet during the mid to late stages of the disease may show subluxed/dislocation joints. In addition, there is decreased space within the joint and an increase in swelling around the joint. A blood test to test for Rheumatoid Factor can be performed, but a positive test doesn’t always mean there is RA and vica versa. During the course of diagnosis it is crucial to see a Rheumatologist, who can help rule out other autoimmune and rheumatologic diseases.

Treatment involves prolonging the disability that comes with the disease. Anti-inflammatory medications as well as disease-modifying antirheumatic drugs (DMAIRs) drugs are the mainstay of treatment. A Rheumatologist will prescribe and monitor these medications. Exercise is also important to help to decrease the symptoms and the disability of the disease.

RA in the foot causes lateral subluxation of the toes, this means that the toes tend to drift to the outside of the foot. Below is a picture where this can be seen.

This foot deformity can be prevented as the physician begins to see the toes are drifting. Once the deformity has occurred the best way to treat this is via surgery. The surgery will re align the joints that are causing the foot to deform. A foot like this can cause a great amount of pain, callus build up and can be very difficult for someone to find shoes.

In conclusion, rheumatoid arthritis is a systemic autoimmune disease that can affect all systems of the body and all aspects of one’s life. Early diagnosis is crucial to prevent long term problems. Concomitant care by your physician and by a rheumatologic specialist is critical for proper early treatment.

For more information on RA, visit http://www.arthritis.org/conditions-treatments/disease-center/rheumatoid-arthritis/

Next week I will conclude these series with Psoriatic arthritis and the feet.

For more information please visit our website, www.footnj.com

Arthritis and your feet

Many people visit their physicians with compliant of foot pain that they contribute to arthritis. Many people think that as they age arthritis is “normal” and that it is okay to be suffering with this pain. The truth is there are many different types of arthritis that affect the foot and ankle, and people don’t have to suffer with pain sine there are many different treatment options.

Osteoarthritis

The most common type of arthritis to affect the foot and ankles is osteoarthritis. Osteoarthritis affects over 27 million Americans and as the population ages the numbers will continue to rise. Osteoarthritis is a degenerative process where the cartilage in the joints becomes eroded. This may lead to pain, stiffness, swollen joints, hearing cracks in the joints while walking, feeling like joints “are about to give out” and decreased in daily activities of life. This type of arthritis is related to an increase in age, trauma, genetics, and other medical conditions. Diagnosis is made by clinical exam and/or by x-rays, MRI, and CT.

What type of treatment options are there for me?

Osteoarthritis in the foot and ankle is usually treated with conservative measures first. Decreasing one’s weight and increasing one’s activity may reduce the symptoms of osteoarthritis. Exercise, which is not destructive on the joints, is good to help with the pain, such as swimming. Anti-inflammatory medications help with pain reduction but are not always a long term solution. There are different types of anti-inflammatory medications depending on the severity of the osteoarthritis. Some of the anti-inflammatory medications have gastrointestinal side effects. In addition, there are topical anti-inflammatory medications, which have no systemic gastrointestinal effects. Injections of steroids into the affected joints, will help with short term pain reduction, but will not help with cartilage loss.

If all of these measures fail, surgery is the next step in treatment. Depending on where the osteoarthritis is located and what the exact symptoms are, will determine what type of surgery is required. If the ankle is affected, arthroscopic surgery is performed as first line therapy. If that does not help an ankle fusion or replacement may be required. There are many other foot joint, such as the subtler joint, that can be affected by arthritis. If this is the case fusion of that joint is necessary. Prior to surgery your physician will order an MRI or CT to determine the extent of the arthritis and the cartilage loss. The recovery from these surgeries is a few months in a cast with no weight to the leg. Due to the extent of the surgery and the recovery, this option is a last resort for the really debilitating cases of arthritis.

Osteoarthritis is the most common type of arthritis to affect the foot and ankle, in next week’s blog other forms of arthritis, such as rheumatic and psoriatic, will be discussed.

For more information, please visit our website at www,footnj.com

Foot Wounds: How to avoid them and how to treat them

There are many different types  of wounds that may appear on the foot and/or leg. The most common ones seen by podiatrists is a diabetic wound, which are caused by neuropathy (which is damage to the nerves, [see earlier blog on diabetes]). Many of these patients do not feel their feet, and therefore, present to a physician with an infected wound. Other types of common leg wounds are pressure wounds, the most common location being the back of the heel. These types of wounds would be found on bed bound patients. Another common type of leg wound is an arterial wound which is caused by Peripheral Arterial Disease (see earlier blog for more on PAD).  Another leg wound is a venous wound, when the veins in the legs don’t work properly and a wound develops on the inside of the lower leg. Despite what type of wound one has proper wound care, in addition to close supervision  by a trained physician in the field of wound care is critical to healing wounds.

Why are wounds so hard to heal?

Many times wounds are not treated until they are large in size. Many people with wounds many attempt, with good intentions, to treat the wounds by themselves. Usually wounds need to be treated with a multi team approach, including podiatrists, vascular surgeons, plastic surgeons etc. Many wounds tend to take a long time to heal due to other underlying medical conditions. For example, a diabetic wound can take a while to heal due to poor control of blood sugar, peripheral neuropathy and possible lack of circulation. Once all these issues are addressed the wound may have become chronic. In addition, wounds that are caused by arterial or venous disease need close supervision and many times surgery by a vascular surgeon. Without enough blood flow a wound will not heal. Many wounds that are caused by the venous disease take a long time to heal due to severe leg swelling, known as lymphedema. If the swelling is not controlled the wound will not heal.

Where do I seek treatment for a wound?

The best place to seek treatment wound be a wound center. Many hospitals around the country have a wound healing center, which employ the necessary multi specialties to help with wound healing. Internists, Infectious Disease Specialists, Podiatrists, Vascular and Plastic Surgeons are the type of physicians that wound work at a wound center. Many wound centers contain Hyperbaric Oxygen chambers, which are machines with high levels of oxygen, which help accelerate wound healing. In addition, there are many specialty, advanced wound care products, dressings and grafts, that can only be found at wound centers.

How Can I prevent a wound?

Patients that are high risk for wounds include diabetics with neuropathy, people with PAD, people with severe varicose veins with swollen legs, people with sickle cell etc. These patients should carefully inspect their feet daily to make sure there are no small cuts or openings. On the first site of an open lesion they should contact their physician. In addition, if a patient has an area on their foot that many be more prominent and perhaps be a pressure point, proper orthotics and offloading shoes can be dispensed by a podiatrist.

For more information, please visit our website at www,footnj.com