5 Facts about Charcot Neuroarthropathy you need to know

1) With an unknown definitive mechanism of incidence, this disease process has many proposed hypothetical mechanisms currently in clinical practice. Some believe that increased inflammation and microfracturing of the bone secondary to sensory loss are key components, others believe glucose levels and specific traumatic events are responsible for this process which are compounded by inability to offload and protect the injured limb leading to progressive breakdown of the bone. We all agree that these elements are part of the problem, but do not necessarily occur in all cases. Especially in non diabetics with the disease of Charcot neuroarthropathy.

2) We know that many cases start with increased warmth, redness, and swelling. Unfortunately not ALL cases give us this "textbook" presentation.

3) We also know that characteristic radiographic changes may occur.  And when they do, differing mindsets and clinical approachs are valid and are practiced routinely in my practice. If an ulceration is present, or progressive radiographic changes are found, surgery is likely required for limb salvage.

4) We generally understand that patients with low or no protective sensory threshold on their feet tend to have a higher incidence of this process.  Also patients that have poor glucose control and are obese tend to have this same increase in incidence. Edema and general leg swelling in diabetic patients with Hemoglobin A1c levels higher than 8.0 tend to have increased risk of Charcot development in their feet. Usually all of these patients have good blood flow with regards to arterial circulation, but may have venous or lymphatic flow compromise.



5) Not all patients with Charcot neuroarthropathy are diabetic. I have treated many patients whom are not diagnosed with diabetes, and did not present with red swollen foot, who developed Charcot neuroarthopathy with radiographic bone degradation and resultant foot deformity. These patients do tend to have profound sensory polyneuropathy of unknown etiology (idiopathic) and are still at risk given the above listed requirements. I have had to reconstruct several patient's feet without diabetes as an underlying diagnosis, and it seems that they tend to have less overall complications but are still prone to the neuroarthropathy nonetheless.



The take away from this blog is that many of the "facts" about this disease process have some "grey area" information. You should seek the expert opinion with good experience in this disease process prior to any surgical intervention or decision for lower leg or foot amputation. The doctors at FFLC are well equipped to accommodate and treat this condition and are well versed in all avenues regarding limb salvage.

Milan Defender Zapata Sidelined Due to Foot Injury

Serie A club Milan defender Cristian Zapata suffers from a fractured foot during the final minutes against Sassuolo.

“AC Milan communicates that in the final minutes of Milan-Sassuolo, Cristian Zapata, following a challenge with another player, suffered a bone fracture at the base of the second metatarsal in his right foot.”

Metatarsal fractures are common injuries of the foot, typical caused by direct crushing injury or by twisting injury where the forefoot is fixed and hindfoot or leg rotating (more common, associated with sports injury). The 5^rd metatarsal bone is most commonly fractured metatarsal bone, while the 3^rd rarely gets fractured in isolation. A British journalist named the 2^nd metatarsal bone the “Beckham bone” due to a fracture David Beckham got after he was tackled by Aldo Duscher, this received a lot of publicity during that time.

Generally these injuries may be treated nonsurgically with a walking boot, or cast. Irregardless of treatment, it is likely this injury will sideline this footballer for a minimum of 8 weeks.  

New Year's Resolutions - Walking and Osteoporosis

Start walking today, as this is a very good way to increase bone density. Osteoporosis is the most common skeletal disorder.  It is characterized by an absolute reduction in bone density and mass.  Bones become weak and are at increased risk of breaking.  Because 28 of the bones in the body are located in the foot and they are under the pressure of the entire body weight, fractures commonly manifest here.  Sunlight does not directly provide vitamin D; it stimulates the body to make vitamin D from a precursor found in the skin.  The active form of vitamin D promotes the uptake of calcium from the intestines so it can be used to calcify bone as well as stimulating the parathyroid hormone to reabsorb calcium before it is filtered out by the kidneys as waste.  Without enough vitamin D, not only are individuals at risk for osteoporosis, but they can also develop a similar condition called osteomalacia.  In osteomalacia, bone cannot be mineralized and symptoms include muscle weakness, bone pain and bone deformities.    The childhood form of osteomalacia that is more commonly known is called rickets.  In rickets, children affected will typically be six to 12 months of age and will have symptoms of muscle tetany or extreme muscle contraction, delayed development, smaller overall stature and soft tissue swelling, or edema around the growth plates located at the ends of bones.  Bowing of the tibia bone inward in the legs is a common consequence of vitamin D deficiency in rickets. 

The one upside of these diseases is that there are some preventative measures that can be taken to avoid their occurrence.  To keep your foot bones and the rest of the bones in your body healthy, be sure you have enough vitamin D as a part of your healthy diet.  Bone mass peaks at age 35, so it is especially important to maintain an adequate amount of vitamin D and calcium in your diet and through exposure to sunlight later in life.  Females are prone to developing osteoporosis following menopause and therefore should also take extra care to keep their bones strong.  By contacting your podiatrist at the first signs of foot injury or bony pain in your feet and ankles, both any fractures that have occurred as well as loss of bone density can often be identified in one set of x-rays.    The sooner that loss of bone density is identified, the sooner steps can be taken to supplement vitamins and minerals necessary to keep you healthy and on your feet!

Holiday Foot Care Reminders

With the holidays fast approaching, many individuals may feel the mounting pressure of finding the perfect gift by spending hours at the mall.  The pressure placed on feet dashing from store to store can add up, and in individuals with diabetes can become dangerous.   Even though the holiday of St. Nicholas passed this past week, in which children leave their shoes out to be filled with treats, individuals with diabetes may still want to leave their old shoes out for good and opt for a better, pressure relieving pair.  

High pressure in a healthy foot signals pain, and subsequent alleviation of the inciting pressure by the person moving their foot or changing their shoe to stop the pain from occurring.  In diabetic individuals with peripheral neuropathy, pain and areas of high pressure cannot be felt due to loss of sensation.  This loss of sensation causes of loss of protection to the foot and wounds may develop in areas of abnormally high pressure.  Any deformity that predisposes the foot to rub in a shoe creates an area that is more likely to ulcerate.  Surgery to remove deformities including bunions, hammer toes and bony bumps in the ball of the foot are one of the ways that your podiatrist may remove an area of increased pressure that is likely to develop or has previously developed an ulcer.  Surgery to lengthen the tendon that attaches the calf muscles to the heel bone is also used to lessen pressure on the ball of the foot.  When this tendon is too tight, the heel is lifted and the front of the foot is levered down towards the ground, creating an area of high pressure. 

Along with surgery, regular callus and corn removal by your podiatrist is also very helpful in removing pressure.  Shoes, casting and custom orthotics are all used to better disperse pressure on the foot.  These treatment means are also useful to prevent ulcers from developing or recurring.  By custom molding shoes to the foot, deformities are accommodated for and areas of high pressure are relieved.  Custom orthotics for diabetic patients with neuropathy are made with several layers of material so that any friction that would normally be imparted to the foot is instead absorbed by the orthotic.  Talk to your podiatrist about taking pressure off this holiday season and keeping your feet healthy!

Brian Timm, DPM, FACFAS

National Diabetes Awareness Month

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For most people, November is the time of year to begin preparing for the holiday season, but November is also National Diabetes Month.  In the United States alone, 25.8 million children and adults have diabetes.  This makes up about 8.3% of the population, and is projected to reach 21% by the year 2050.  There are millions of Americans with undiagnosed diabetes.

Many more who will eat candied apples, canned cranberries, apple and pumpkin pie, and all the turkey and stuffing they can handle; and may likely be precipitating their diabetes and obesity even further without even being aware that they have the signs/symptoms of diabetes in the first place. 

Early warning signs of the disease:

• Increased thirst
• Increased hunger (especially after eating)
• Dry mouth
• Frequent urination or urine infections
• Unexplained weight loss (even though you are eating and feel hungry)
• Fatigue (weak, tired feeling)
• Blurred vision
• Headaches

Diabetes can affect the entire body, including the foot and ankle.  Neuropathy is one of the most common complaints of diabetic patients.  Neuropathy results in damage to nerves, specifically the peripheral nerves, or nerves outside of the brain and spinal cord. Peripheral Neuropathy causes a burning or tingling sensation usually on the feet and legs, or on the arms.  This damage to the nerves is caused by excess blood glucose, or high blood sugar.  Over time excess glucose injures the walls of blood vessels that supply the nerves.  As neuropathy worsens, the ability to feel the lower extremity becomes diminished, which makes diabetics more prone to injuries that go unnoticed.  Neuropathy is the leading cause of diabetic foot ulcers.  Diabetic foot ulcers are caused from a combination of neuropathy, trauma, and deformity.  Deformities such as hammertoes, equinus (limited upward bending of the ankle), or bunions in diabetic patients are more problematic than in non-diabetic patients because of the other complications that come with diabetes.  If diabetic foot ulcers are left untreated they may end up getting infected, and even result in amputation.  Diabetic patients often have decreased circulation in the extremities due to hardening of the arteries or vessels, and this may slow healing time, which is why it’s vital for diabetic patients to take extra precautions when it comes to caring for their feet. 

Although diabetes is a life altering disease keeping a tight control on blood glucose levels can minimize complications.  Other ways to protect the feet in individuals with diabetes are by wearing special shoes made for diabetics, examining the feet daily, washing the feet and making sure to dry them completely, avoiding smoking, wearing clean, dry socks that are changed daily, and never walking barefoot.  Management of diabetes is the key to preventing complications, and for those that do not have diabetes the key to prevention is exercise, maintaining a healthy weight, and eating a well balanced diet.

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

External fixation here in Naples Florida

External fixation may look very high-tech, and maybe even scary.  However, external fixation has been used in one way or another since almost 2400 years ago.  External fixation techniques were described by Hippocrates, and were used in treating tibia fractures.  External fixation is a minimally invasive technique to reduce displaced fractures and has become a very important part of deformity correction and nonunion and pseudo arthrosis repair as well.

Jean François Malgaigne was one of the many pioneers that made advancements with external fixation devices.  In 1846, Malgaigne used a device that consisted of a clamp and four metal prongs to reduce and stabilize a fracture of the patella, or kneecap.  Following this external fixation device many other similar inventions were used to treat fractures in various locations.  In 1938, Raoul Hoffman made advancements that made external fixation even more useful, and allowed surgeons to place pins into a fracture for stabilization with guidance, while being minimally invasive.  In 1951, Dr. Gavriil A. Ilizarov developed the external fixation device that is still in use today.  Ilizarov’s fixation device consists of a metal frame that encircles the limb, and is attached to underlying bone by pins.  Threaded rods and hinges allow movement of the bone to the correct alignment.  Ilizarov’s external fixator is great because adjustments can be made without opening the fracture site, and the device provides stability. Also it can be converted to internal fixation once the soft tissues have become less swollen. 

Modern day external fixation not only provides stability to a fracture, but can also be used for soft tissue deformities, as well as other bony deformities.  External fixation is preferred when slow correction is required, and even more useful in high risk patients with vascular disease and even open fractures with high risk of infection.  The chance of getting a blood clot is lessened because with external fixation patients can be partial weight bearing, or weight bearing as tolerated following the procedure due to the stability that the fixation provides.  External fixators have been used for other bony deformities, such as Charcot, ankle arthritis, and clubfoot.  External fixation can also be used to lengthen amputated foot and toe stumps.  External fixation has definitely helped many people, but there are still some cons.  Pain and infections are two issues associated with external fixation, and rates vary depending on the extent of the procedure, and the location of the device.  External fixation devices are used by specially trained physicians and all three of the doctors at FFLC are capable of utilizing these various techniques for patients that require such interventions.  

Brian Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle surgery

Swimming and your feet

Everyone is starting to return to Florida for the seasonal upgrade in weather.  Fire up the pool warmer, and get ready to swim.

 Swimming is known for being an activity that is less damaging to the joints of the knee, foot and ankle, and can even offer a means of exercise for athletes of other sports with certain foot injuries!

Just about the worst thing a runner can hear is that they are injured and going to have to take time off from running.  Luckily, swimming can help soften this blow by offering an alternative way to get some cardiovascular activity.  Stress fractures are small fracture that occurs from excessive force on normal bone and can force runners to talk a break from running for several weeks.  For the runner with a stress fracture, swimming is often a great alternative that will not bear weight on the injury.  Swimming can also help an athlete ease back into their favorite sport after other serious injuries.  For example, after a peroneal tendon tear, swimming can help to make the transition from being immobilized in a cast or a CAM walker boot to normal running or other weight bearing sports go more gently by allowing the muscles to slowly adapt.  

Swimmers should also be careful to take care to avoid injuries that can occur from intense pool training.  Ankle pain is a common complaint from the repetitive motion the ankles are forced through while swimming.  The Achilles tendon, which is responsible for flexing the foot, may also become irritated from the repetition and develop Achilles tendonitis.  While the Achilles is doing much of the work, the extensor tendons on the top of the foot can also become irritated by being tightly pulled.  By taking care to stretch the feet and ankles properly and always listen to your body when working out, these injuries can be minimized.  Swimmers also need to take extra care to avoid developing warts, Athlete’s foot, and fungal nails from bacteria and fungus that may live in locker rooms and poolside surfaces where other bare feet have deposited them.  If these conditions do develop, see us at Family Foot and Leg Center for an urgent evaluation, as to help prevent spread to others. 

Dr Timm, DPM, FACFAS

Board Certified by the American Board of Foot and Ankle Surgery in Foot and Reconstructive Rearfoot and Ankle Surgery.