Changes in loading distribution in patients with Charcot foot during long-term follow-up

Background. The inactive stage of the diabetic Charcot arthropathy foot (CA) is characterised by fixed foot deformities and an absence of inflammation. However, it remains unclear if the shape of the foot and its biomechanics change during long-term follow-up.

Aim. To evaluate changes in loading distribution of the affected foot, in patients with inactive CA, during long-term follow-up.

Materials and methods. Twenty seven patients with unilateral inactive CA (19 females, 8 males) were studied. Computer pedography (emed AT, novel gmbh) was performed and baseline and the last studies were analysed. Maximal peak pressures (PP) were obtained for the first and the last studies and the percentage of the PP change was calculated for the total follow-up period and for periods: <24 months, 24–48 months, >48 months.

Results. PP increased: under the hallux 50%; 1st metatarsal–30.7%; 2nd toe–20%; 2nd toe–6%; midfoot–9%. PP decreased under 3–5 toes up to 67%. Significant changes at the first period were found under 3–5 toes only (−62%). The increase in loading under the other parts of the foot appeared at 24 months; however, these changes became significant between 24 and 48 months and peaked after 48 months of follow-up. The maximal increase of PP was noticed under the hallux, the 2nd toe, metatarsals 1–3 and the midfoot.

Conclusions. We revealed the gradual redistribution of PP, under the different parts of the foot, in patients with inactive CA. This redistribution reflects changes in the shape of the affected foot. The loading increased under the hallux, the 2nd toe and the corresponding metatarsals, 3rd metatarsal and midfoot, and decreased under the 3–5 toes. These changes increased during the follow-up, becoming more pronounced after 4 or more years. Our data may be useful for constructing custom-made footwear for patients with CA.

diabetes mellitus, diabetic osteoarthropathy, Charcot foot, gait physiology, computer pedography

1. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129. doi: 10.2337/dc11-0844

2. Milne TE, Rogers JR, Kinnear EM, 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. doi: 10.1186/1757-1146-6-30

3. Hastings MK, Johnson JE, Strube MJ, et al. Progression of foot deformity in Charcot neuropathic osteoarthropathy. J Bone Joint Surg Am. 2013;95(13):1206-1213. doi: 10.2106/JBJS.L.00250

4. Bregovskiy V, Tsvetkova T, Demina A. Biomechanical changes in patients with diabetes during follow up. In: Proceedings of the 11th Scientific Meeting of the Diabetic Foot Study Group; 2013 Sep 20-22; Sitges, Spain.

5. Armstrong DG, Peters EJG, Athanasiou KA, Lavery LA. Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg. 1998;37(4):303-307. doi: 10.1016/s1067-2516(98)80066-5

6. Armstrong DG, Lavery LA. Elevated Peak Plantar Pressures in Patients Who Have Charcot Arthropathy. J Bone Joint Surg. 1998;80(3):365-369. doi: 10.2106/00004623-199803000-00009

7. Zampa V, Bargellini I, Rizzo L, et al. Role of dynamic MRI in the follow-up of acute Charcot foot in patients with diabetes mellitus. Skeletal Radiol. 2011;40(8):991-999. doi: 10.1007/s00256-010-1092-0

8. Armstrong DG, Lavery LA. Acute Charcot's Arthropathy of the Foot and Ankle. Phys Ther. 1998;78(1):74-80. doi: 10.1093/ptj/78.1.74

9. Демина А.Г., Бреговский В.Б., Карпова И.А. Критерии продолжительности иммобилизации пораженной конечности при диабетической нейроостеоартропатии Шарко // Сахарный диабет. – 2014. – Т. 17. – №4. – С. 60-65. [Demina AG, Bregovskiy VB, Karpova IA. Criteria of immobilization duration of the affected foot in diabetic Charcot neuro-osteoarthropathy. Diabetes Mellitus. 2014;17(4):60-65. (In Russ.)] doi: 10.14341/dm2014460-65

10. Bus SA, Maas M, Cavanagh PR, et al. Plantar Fat-Pad Displacement in Neuropathic Diabetic Patients With Toe Deformity: A magnetic resonance imaging study. Diabetes Care. 2004;27(10):2376-2381. doi: 10.2337/diacare.27.10.2376

11. Bus SA, Maas M, Michels RP, Levi M. Role of intrinsic muscle atrophy in the etiology of claw toe deformity in diabetic neuropathy may not be as straightforward as widely believed. Diabetes Care. 2009;32(6):1063-1067. doi: 10.2337/dc08-2174