March 6, 2011Diabetes-related foot problems like osteomyelitis and Charcot neuro-osteoarthropathy are associated with a high morbidity and high healthcare costs.
In this overview we will focus on two questions:Is this an active Charcot foot or is it osteomyelitis?Is this a Charcot foot with superimposed infection? Osteomyelitis in a diabetic with neuropathy is infection of the bone that usually results from contiguous spread of a skin ulcer. Consequently, the most common location for osteomyelitis is not in the midfoot, but at the pressure points of the forefoot (metatarsal heads, IP joints) and in the hindfoot at the plantar aspect of the posterior calcaneus. To determine whether osteomyelitis is present, place a marker on the ulcer or sinus tract and track it down to the bone and evaluate the MR- signal intensity of the marrow (1). Unlike osteomyelitis, Charcot neuro-osteoarthropathy is primarily an articular disease, which is most commonly located in the midfoot. In the early stage radiography will not demonstrate bone abnormalities, but MRI will show subchondral bone marrow edema. Signal intensities on MRI will not discriminate between active Charcot Joint and osteomyelitis. Chronic stage of Charcot:The chronic stage of Charcot no longer shows a warm and red foot, but the edema usually persists.
Joint deformity, subluxation and dislocation of the metatarsals lead to a rocker-bottom type deformity in which the cuboid becomes a weight-bearing structure. The deformity of the foot with abnormal pressure distribution on the plantar surface coupled with reduced or loss of sensation, makes the foot vulnerable and leads to callus and blister formation aswell as foot ulceration. Foot ulceration can subsequently lead to infections, such as cellulitis and osteomyelitis, and this may eventually lead to amputation.
The simplest method to determine whether osteomyelitis is present is to follow the path of an ulcer or sinus tract to the bone and evaluate the signal intensity of the bone marrow (1).
Osteomyelitis in chronic Charcot is usually located in the midfoot, while osteomyelitis in diabetic neuropathy without Charcot is usually in the forefoot and hindfoot. The clinical diagnosis relies on the identification and characterization of an associated foot ulcer, a method that is often unreliable. On plain radiographs, bone infection may not show up on the first 2 weeks and in a later stage the radiographic characteristics of neuro-osteoarthropathy and osteomyelitis overlap.
In both cases there will be demineralization, destruction and periosteal reaction of the bones, particularly when neuro-osteoarthropathy presents at a later stage. Here, images of a patient with a small cutaneous defect and subcutaneous edema at the metatarsals. A secondary sign, an abscess, is shown in the forefoot, with high signal intensity on STIR, low or intermediate signal on intensity T1W, and ring-enhancement of the borders showing high signal intensity on T1+Gd.
Charcot neuro-osteoarthropathy is a degenerative disease with progressive destruction of the bones and joints.
It is seen in patients with neurological disorders with sensory loss of the feet, including tabes dorsalis, leprosy, diabetic neuropathy, and other conditions involving injury to the spinal cord.
In 1868 Jean-Martin Charcot gave the first detailed description of the neuropathic aspect of this condition in a patient with syphilis.
Today, diabetes mellitus is the most common etiology associated with Charcot osteoarthropathy, with the joints of the foot and ankle being most commonly affected. The neurotraumatic theory states that Charcot arthropathy is caused by an unperceived trauma to an insensate foot. The neurovascular theory suggests that the underlying condition leads to the development of autonomic neuropathy, causing the extremity to receive an increased blood flow, which in turn results in a mismatch in bone destruction by increased osteoclastic activity and bone synthesis (1). The image shows a progressive neuro-osteoarthropathy of the tarsometatarsal joints (Lisfranc dislocation) with subchondral cysts, erosions, joint distention and dislocation. The skin temperature should be 2?C or more at the site of maximum deformity of the affected foot compared with a similar site on the contralateral foot.
The differential diagnosis is infection (osteomyelitis, cellulitis, septic arthritis), inflammation (gout, rheumatoid arthritis) and deep vein thrombosis.
The acute stage of Charcot neuro-osteoarthropathy shows rapid and progressive bone and joint destruction within days or weeks. In the acute stage, the radiographs are normal and may not exclude the diagnosis of acute Charcot neuro-osteoarthropathy. Within 4 months there is progressive decrease of calcaneal inclination with equinus deformity at the ankle.
There is destruction of the tarsometatarsal joint with the typical rocker-bottom deformity.
The bone marrow edema typically is not restricted to one or two bones, but is seen in the entire midfoot. Bone marrow edema and its enhancement are typically centered in the subchondral bone, suggesting articular disease. The subcutaneous tissues are relatively normal and there is no ulcer or other signs of infection.
Crepitus, palpable loose bodies and large osteophytes are the result of extensive bone and cartilage destruction. At the stage of chronic inactive Charcot osteoarthropathy, bone healing and change of active periosteal reaction will proceed into inactive periosteal reaction and sclerotic borders. Debris may be present and effusions may decompress along fascial planes, carrying bony debris far from the joint. Subsequently progressive Charcot neuro-osteoarthropathy is seen with dislocation of the Lisfranc joint. To determine whether osteomyelitis in a Charcot foot at MR imaging is present, follow the path of an ulcer or sinus tract to the bone and evaluate the signal intensity of the bone marrow.
If there is bone marrow edema in the absence of a cutaneous defect, active Charcot may be present.
On the left a typical rocker-bottom deformity of the foot due to collapse of the longitudinal arch. STIR and T1W images in Charcot neuro-osteoarthropathy with a plantar ulcer (asterix) and osteomyelitis of the cuboid. In a patient with Charcot neuro-osteoarthropathy and a rocker-bottom foot, the cuboid bone is an important location of osteomyelitis. If the T1-weighted image at that location shows low signal intensity in combination with a cutaneous defect, osteomyelitis is extremely likely.
On the left STIR and T1-weighted images of a patient with active Charcot neuro-osteoarthropathy with a plantar ulcer along the bony protuberance of the cuboid. There is abnormal signal intensity in the cuboid bone next to the ulcer, indicative of osteomyelitis. Enhancement of the cuboid bone and adjacent soft tissues on postcontrast images, together with the plantar ulcer, makes osteomyelitis very likely. On the left a patient with Charcot neuro-osteoarthropathy with a subcutaneous fistula tract (arrow). When we follow the fistula tract to the bony protuberances of the cuboid, there is no marrow edema at the midfoot.

The "ghost sign" refers to poor definition of the margins of a bone on T1-weighted images, which become clear after contrast administration. The areas of osteomyelitis are more pronounced on the contrast-enhanced T1-weighted image as compared to the native T1-weighted image. The bone marrow edema, which is of low signal intensity on the T1-weighted image without contrast enhances and becomes as bright as normal bone marrow. Because of the curvature of the foot, fat suppression is more uniform with the use of STIR than with T2- weighted imaging with chemical fat saturation. As an alternative to spectral fat saturation technique, Dixon chemical shift imaging is described (8).
Sagittal views are for evaluation of midfoot involvement, the plantar surface and the posterior calcaneus. A view parallel to the toes is adequate for imaging the metatarsophalangeal and interphalangeal joints. Contrast is used to better depict devitalized regions, abscesses, sinus tracts and joint or tendon involvement.
Uniform fat suppression in hands and feet through the use of two-point Dixon chemical shift MR imaging.
Intermittent Pneumatic Compression (IPC): How do they work and what are the contraindications? As outlined in a  previous entry, lipedema is a chronically progressive, symmetrical accumulation of fat in the subcutaneous tissue occurring almost exclusively in women.
Lipedema is not caused by a disorder of the lymphatic system; however, it is commonly misdiagnosed as bilateral primary lymphedema.
Several marked differences between lipedema and primary lymphedema can be distinguished; these differences are highlighted in the table below. While lipedema always affects both legs symmetrically (bilateral appearance), primary lymphedema usually affects one leg only. In contrast, the feet in lymphedema are involved in the swelling, and a diagnostic indicator known as the Stemmer sign is positive. The Stemmer sign is a diagnostic test that involves pinching the skin on the upper surface of the toe (usually second toe) or fingers.
There is also an extremely rare condition called Dercum’s Disease which presents with extremely painful fatty nodules and can include swelling.
I have Lymphedema and my left leg is extremely sensitive…if I barely bump it the pain is excruciating.
Has anyone with Lympoedema and lipedema ever received disability benefits either from work or the state that they live in. Alicia, If it is acceptable, I would like to discuss the disability benefits for Lymphedema.
Compression to the lower extremities is used to increase healing of venous stasis ulcers by improving the blood supply and reducing edema and distension. Controversy exists regarding the most effective sub-bandage pressure (ranging from 20 mm Hg to 45 mm Hg) for timely healing. Compression wraps are bandages that help control swelling when used with correct assessment, application, and fit by the patient or caregiver, along with compliance and mobility of the patient. The CompreFit is an all new, non-elastic lower extremity garment that provides 30-40 mmHg gradient compression. The CompreFit is designed for daytime use for individuals with the following indications: lymphedema, post-surgical swelling, chronic venous insufficiency, and is effective in the treatment of venous stasis ulcers.
The CompreFit costs less than other national brands offering similar compression and last longer than bandages. The Juxta-Fit CircAid wrap is unlike any of the other available compression wraps in that they provide clinically proven, inelastic, adjustable and thereby sustainable compression in the treatment of venous stasis ulcers.
Firmness and comfort with the necessary level of compression can be easily achieved with the variable adjustment of the CircAid wrap.
The Juxta-Fit CircAid Wrap is available in configurations that rise from the foot to just above-the-knee, or from the groin to just below the knee.
Minimized slipping due to the material’s limited stretch dynamic that adjusts to the limb. The CircAid Wrap Juxta-Lock™ (alternating) Band System allows for a quick and easy application and minimal adjustments that help maintain compression levels and comfortable fit. Adjusting the bands of the garment to a firm and comfortable compression achieves therapeutic levels of gradient compression and can be worn 24 hours a day with the bands being slightly loosened for nighttime wear. Easy alternative for those who lack strength or dexterity to use traditional compression stockings or bandages.
The standard legging is available in two standard lengths, 28cm and 33cm and in sizes ranging from Small to XXL with full calf options. Farrow Wrap™ compression wraps for legs provide unique compression for all patients, especially those who are not able to wear compression stockings. Farrow Wrap™ uses bands, so there is no dragging of material up and down a leg, which decreases the likelihood of tearing skin. The Farrow Wraps resists rolling or sliding down the leg and so they will work on patients with hourglass-shaped legs providing reliable compression.
Farrow Wrap Liners come in The Silver, Regular and Farrow Hybrid liners are all made with X-Static Silver and create an anti-microbial barrier, reducing the risk of infection and odor.
As the name suggests, Swollen Ankles is a medical syndrome characterized by inflammation in the lower legs, especially the ankles. If the swelling occurs due to strains or sprains in the ankle, sufferers may experience pain in the inflamed region.
Drugs, such as calcium channel blocker, that are used for curing high blood pressure can lead to side effects that include inflamed ankles. Oral Contraceptive medicines give rise to side effects like ankle swelling due to the presence of high estrogen in them. This condition, marked by swollen veins, is held as one of the prime reasons behind this disease. The diagnosis of the disorder depends on the condition that the physician suspects in the patient.
Wearing loose fitting socks and stockings ensure smooth flow of bloods and fluids in the legs. Having 3-4 tablespoon of lecithin seeds daily for about 3 months is very effective to treat this syndrome. If obesity is the reason for swollen ankles exercise can bring down the weight and cure the condition. If you are suffering from swollen ankles and not sure if you are really having this condition, you can check out these Swollen Ankle photos.
The sensory neuropathy renders the patient unaware of the osseous destruction that occurs with continuous ambulation.
Primarily the lower extremities are affected, but lipedema may occur in combination with the upper extremities as well.

If both legs are involved in primary lymphedema the swelling appears asymmetric (see image on bottom of this article). If a fold of skin can be pinched and lifted up at the base of the second toe or middle finger, the Stemmer sign is negative.
Use the “Index” list on the left side of this page and select the article you are interested in. Compression wraps are available in elastic or non-elastic and in single to multilayer systems requiring varying types of application and exerting different levels of compression. Because of differences in compression leg wraps, selection of the most effective and efficient compression wraps for legs can be difficult.
Easier to put on than elastic stockings with similar compression, the CompreFit promotes a high rate of compliance. The CompreFit also saves hundreds of hours per year when compared to wrapping and rerolling bandages. You can wear these superior compression wraps for legs all day and all night with minimal adjustment for increased comfort in the evening.
The ability to change the circumference diameter by as much as 20 percent allows the custom-made compression wraps to be tailored to each individual leg with superior yet comfortable fit. Linear stretch technology hugs the leg's contours, reduces slipping, and makes foam inserts virtually unnecessary. Because the Farrow Wrap™ uses bands, it can also accommodate additional swelling without elevating the limb or visiting the doctor. Chances are that you may be having Swollen Ankle, a common condition that is seen in many men and women every year. This is formed if the person having inflamed ankles suffers from edema, a condition marked by fluid retention in the body tissues and cells and serous cavities. Mild Swollen Ankles in pregnancy is normal as body fluids increase during maternity for the upkeep of both mother and child.
People suffering from traumatic ankle injury or rheumatoid arthritis are at great risk from this syndrome. If the physician suspects a swelling in the ankle because of an injury, he or she may advise getting an X-ray done. The cure for Swollen Ankles normally includes treating the condition that actually caused it.
If you are suffering from ankle swelling, it is better to avoid or limit intake of foods that have high salt content. If you feel wearing tight stockings have been the cause of your swollen ankles and legs, a lighter option might definitely help you. As aforesaid, swelling in the ankles may be a symptom of complicated health conditions like heart disease, liver disease or kidney failure. Lipedema is characterized by symmetric enlargement of the limbs, combined with tenderness and easy bruising. The feet are not involved in lipedema; the symmetrical distribution of fat is located between the hips and the ankles. The Stemmer sign is positive and indicative of lymphedema when a skin fold cannot be lifted, but can only be grasped as a lump of tissue.
Lymphedema is pitting and the tissue feels firmer that the one in lipedema, especially with fibrotic tissue typically being present starting in stage 2.
You can also use the “Select Category” window on the right of this page and select the topic you are interested in. Elimination of edema is so basic and important to venous ulcer healing that the most effective level of compression should be used. The purpose of this integrated review was to determine healing rates of venous ulcers with various compression wraps. Made from polyester and Velcro™ the CompreFit is lightweight, durable, and very comfortable.
The consistent, gradient compression, combined with natural pumping action of the leg muscles during normal movement, provide a highly effective mode for edema reduction. With these compression wraps for legs, patented technology provides a form-fitting experience that makes the use of inserts a thing of the past. The Juxta-Fit has supremely variable band widths that can accommodate the shape of any limb and necessary compression level. If the patient cannot, but has a family member or a friend that can reach their feet, they can easily get Farrow Wraps on and off. The Farrow Wrap™ should last at least 6 months with the proper care, and may last longer. Hence, timely medical treatment of this disease is highly necessary so that you can get back to health very soon.
The cause for the onset of lymphedema are malformations of the lymphatic system, while he underlying cause for the development of lipedema remains unknown; it is thought to be associated with hormonal disorders.
Once selected, a new page will load with a number of articles related to the topic you chose. I had breast cancer surgery 7 years ago and 27 lymph nodes were removed and was followed by radiation.
The interlocking and overlapping strap design makes it easy to achieve consistent, gradient compression. The Upper, Knee and even the Whole Legging sections are custom-made so that they can be fitted and combined for the creation of six different CircAid wrap garment options. These medicines widen the small blood vessels resulting in leakage of fluids from vessels to the tissues. A diuretic helps the kidneys flush out the extra fluid that are contained within the ankle tissues. Circumstances that can lead to lipedema developing into lymphedema are explained in a previous post.
These types of compression wraps mimic calf muscle pump action and help to improve venous return.
I’m telling you, it’s time for the Medical World to wake up and realize that Hormones do a LOT more for us than what we know, or have studied!!
That feminine look is going away, I’m getting chin hair, you know the whole bunch of changes. I need to find a natural replacement that will at least help restore something, though I fear it may already be too late.

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