1. evaluation of The Neuropathic foot
DR. MARIE S. NELSON, DPM, FACFAS

2. Peripheral Neuropathy
National Institute of Neurological Disorders and Stroke- 20 million people in the US with peripheral neuropathy
Inherited
Acquired
idiopathic

3. Why is the neuropathic foot important?
Loss of limb
Risk factor for amputation in diabetic patients. 3,4,5,8
Early identification, education, prevention of amputation

4. Etiologies Diabetes Alcoholism Nutritional deficiencies
Neurological ds
Infectious Diseases
Spinal disorders
Hereditary
Autoimmune
Toxins
Medication/Chemotherapy

5. Signs and symptoms SENSORY Numbness Tingling Burning Shooting
Hyperesthesia
Allodynia

6. Signs and symptoms MOTOR Weakness Cramps Atrophy Fasciculations
Decreased reflexes

7. Signs and symptoms11 AUTONOMIC Loss of sympathetic tone
Arteriovenous shunting
Anhidrosis: Decrease or Loss of function of Sweat glands

8. Diagnosis of the neuropathic foot
History and Physical/Lower Extremity Neurological Exam
Vibratory Sensation
Proprioception
Deep Tendon Reflexes
Semmes-Weinstein Monofilament Test 2,6
EMG/NCS
Labs

9. Semmes-Weinstein monofilament test
Psychologists: Florence Semmes and Sidney Weinstein (1960). 6
STUDIES:
Nather et al, Diabetic Foot and Ankle: Cost, portability, administration of test and acceptance by patients.2
Feng et al, Journal of Vascular Surgery: Low cost, non-invasiveness and easy/quick to perform. 6

10. TREATMENT Patient Education Early diagnosis Vitamins Topicals
Antidepressant/ anticonvulsant
Neurology consult
Pain Management
Multidisciplinary approach

11. NEUROTROPHIC ULCERS11
Caused by Neuropathy, Biomechanical pressure, vascular supply
Atrophy of intrinsic muscles
Weakness of anterior leg muscles
Boike et al, Cleveland Clinic 2010

12. Neurotrophic ulcers
Decrease in sensation Inability to sense trauma or daily stress
Chronic repetitive stress-----skin breakdown------ Ulceration

13. Characteristics of neurotrophic ulcers11
Plantar surface of the foot under pressure points
Common location: Plantar big toe or first metatarsal head
Fibrotic or hyperkeratotic rim
Hyperkeratosis may cover the ulcer

14. Charcot’s arthropathy / neuropathic arthropathy
French neurologist Jean-Martin Charcot ( ) first described in Tabes Dorsalis 1868
Diabetic neuropathy is most common cause
Combination of inflammatory process and repetitive microtrauma

15. CHARCOT’S ARTHrOPATHY
MECHANISM
Neurotrauma
Neurovascular

16. Charcot’s arthropathy
Patients may report a history of minor trauma or other predisposing factors such as ulceration, infection, surgery 12

17. Charcot Pre-disposing factors
Neuropathy
Adequate circulation
May follow successful revascularization. 9

18. Classification of Charcot’s arthropathy
Active/Inflammed/Acute
Inactive/Stable/Chronic
Eichenholtz Classification
Sanders and Frykberg Classification
Brodsky and Rouse Classification

19. Eichenholtz STAGE 0- Edema, NO radiographic changes ****
STAGE 1- Fragmentation
STAGE 2- Coalescense
STAGE 3- Reconstruction/Remodeling

20. Diagnosis of charcot History and Physical
Inflammation: Red, Hot, Swollen foot
Little pain/ No pain
Hallmark: Midfoot Collapse or Rocker-Bottom deformity

21. Diagnosis of Charcot
X-rays
MRI
Combination of Studies

22. Treatment of charcot
OFF LOADING/*** TOTAL CONTACT CAST/CAM WALKER/ CROWE WALKER
SURGERY

23. references The Neuropathic Foot. A. Jernberger
Assessment of Sensory Neuropathy in Patients with Diabetic Foot Problems. Aziz Nather, Wong Kenng Lin, Zammer Aziz, Christine Hj Ong, Bernard Mc Feng, Clarabelle B Lin
Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. David Armstrong, Lawrence Lavery.
Pathways to Diabetic Limb Amputations: Basis for Prevention. Roger E Pecoraro, Gayle E. Reiber, Ernest M. Burges.
Risk Factors for Amputation in Patients with Diabetes Mellitus. Gayle Reiber, Roger Pecoraro, Thomas D. Koepsell.
UtThe Semmes Weinstein Monofilament Examination as a Screening Tool for Diabetic Peripheral Neuropathy. Yuzhe feng, Felix Schlosser, Dauer E Sumpio
ilization of Nerve Conduction Studies for the Diagnosis of Polyneuropathy in Patients with Diabetes: A retrospective Analysis of Large Patient Series. Xuan kong, Eugene A. Lesser, Frisso A. Pitts, Shai N. Gazain.
Evaluating The Prevelance and Incidence of Foot Pathology in Mexican Americans and Non-Hispanic Whites from a Diabetes Disease Management Cohort. Lawrence Lavery, David Armstrong, Robert Wunderlich, Jeffrey Tredwell, Andre Boulton.
The Charcot Foot in Diabetes. Lee C. Rogers, Robert G. Frykberg, David G. Armstrong, Andrew J.M. Boulton.
The Natural History of Acute Charcot’s Arthropathy in a Diabetic Foot Specialty Clinic. Armstrong D G, Todd W F, Lavery L A, Harkless L B, Bushman T R
Prevention and Treatment of Leg and Foot Ulcers in Diabetes Mellitus. Allan Boike, Michael Maier, Daniel Logan.
Charcot Foot in Diabetes and an Update on Imaging Ergen et all