Abstract
Background
Bone stress injuries are rarely being diagnosed in patients with sensory neuropathy, most likely because they may be silent in terms of pain. Load-related pain is considered a key feature of any bone stress injury, a symptom, which may be partially or completely absent in subjects with sensory neuropathy (loss of protective sensation). We evaluated the clinical course of bone stress injuries in insensitive feet in diabetic patients with polyneuropathy.
Methods
We investigated 12 consecutive diabetic patients with bone stress injuries of the foot (bone marrow edema, bone bruise and microtrabecular fractures, on magnetic resonance imaging MRI), which were undetectable on plain X-ray. All patients suffered from diabetic polyneuropathy, none of them had an active foot ulcer.
Results
The patients presented with a swollen foot, which was only mildly painful and did not prevent them from walking. Complaints were related to the swelling, which increased during load-bearing. In seven cases, a traumatic event preceding the onset of symptoms could be ascertained. MRI disclosed stress injuries in 2.5 (1–8) [median (range)] bones per foot. In 11 patients, treatment was started immediately by off-loading with total contact cast for 17 (8–52) weeks, followed by gradual increase in weight bearing. One patient unfortunately received off-loading treatment only after deforming fractures had developed. All bone injuries healed uneventuelly in eight patients, and with residual mild osteoarthrosis in three patients without gross deformities. However, the untreated patient developed severe Charcot foot deformity.
Conclusions
In diabetic patients with polyneuropathy, symptoms of bone stress injuries of the foot are atypical, in that there is load-related swelling rather than load-related pain. Immediate diagnosis, and treatment with off-loading, leads to a restitutio ad integrum like in non-neuropathic patients. Delayed cessation of overuse, however, may cause irreversible joint and bone damage (Charcot foot).
Similar content being viewed by others
References
Bachmann LM, Kolb E, Koller MT, et al (2003) Accucary of the Ottawa ankle rules to exclude fractures of the ankle and mid-foot: a systematic review. BMJ 326:417–419
Brand PW (1991) The insensitive foot (including leprosy). In: Jahss MH (ed) Disorders of the foot and ankle. Medical and Surgical management, 2nd edn. WB Saunders, Philadelphia, pp 2170–2186
Brand PW (1983) The diabetic foot. In: Ellenberg M, Rifkin H (eds) Diabetes mellitus. Theory and practice, 3rd edn. Medical Examination Publishing, New York, pp 829–850
Busch K, Chantelau E (2003) Effectiveness of a new brand of stock ‘diabetic’ shoes to protect against diabetic foot ulcer relapse. A prospective cohort study. Diabetic Med 20:665–669
Chantelau E (2005) The perils of procrastination: effects of early versus delayed detection and treatment of incipent Charcot fracture. Diabetic Med 22:1707–1712
Chantelau E, Richter A, Schmidt-Grigoriadis P, Scherbaum WA (2006) The diabetic Charcot foot: MRI discloses bone stress injury as trigger mechanism of neuroarthropathy. Exp Clin Endocrinol Diabetes 114:118–123
Chantelau E, Onvlee GJ (2006) Charcot foot in diabetes- farewell to the neurotrophic theory. Horm Metab Res 38:361–367
Clohisi DR, Thompson RC (1988) Fractures associated with neuropathic arthropathy in adults who have juvenile-onset diabetes. J Bone Joint Surg 70A:1192–1200
Edmonds ME, Roberts VC, Watkins PJ (1982) Blood flow in the diabetic neuropathic foot. Diabetologia 22:9–15
Edmonds ME, Petrova NL, Edmonds A, Elias DA (2006) Early identification of bone marrow oedema in the Charcot foot on MRI allows rapid intervention to prevent deformity. Abstract. Diabetic Med 23(Suppl 2):70
Eustace S, Keogh C, Blake M, et al (2002) MR imaging of bone oedema: mechanisms and interpretation. Clin Radiol 56:4–12
Fredericson M, Bergman AG, Matheson GO (1997) Stress fractures in athletes (In German). Orthopäde 26:961–971
Gill G, Benbow S, Tesfaye S, et al (1997) Painless stress fractures in diabetic neuropathic feet. Postgrad Med J 73:241–242
Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, Rao BR, Silverman ED (1983) Distribution and natural history of stress fractures in US Marine recruits. Radiology 146:339–346
Greider TD (1983) Orthopedic aspects of congenital insensitivity to pain. Clin Orthop Relat Res 172:177–185
Kiuru MJ, Pihlajamäki HK, Ahovuo JA (2004) Bone stress injuries. Acta Radiol 45:317–326
Kiuru MJ, Pihlajamäki HK, Hietanen HJ, Ahovuo JA (2002) MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta Radiol 43:207–212
Kiuru MJ, Niva M, Reponen A, Pihljamäki HK (2005) Bone stress injuries in asymptomatic elite recruits. Am J Sports Med 33:272–276
Kumar V, Cotran RS, Robbins SL (1997) Basic Pathology. 6th edn. WB Saunders Philadelphia, USA
Lassus J, Tulikoura I, Konttinen Y, et al (2002) Bone stress injuries of the lower extremity. Acta Orthop Scand 73:359–368
Leland OS, Maki PC (1985) Heart disease and diabetes mellitus. In: Marble A, Krall LP, Bradley RF, Christlieb AR, Soeldner JS (eds) Joslin’s Diabetes mellitus, 12th edn. Lea and Febiger, Philadelphia, pp 553–582
Liniger C, Albeanu A, Bloise D, Assal JP (1990) The tuning fork revisited. Diabetic Med 7:859–864
Luetters CM, Keegan THM, Sidney S, et al (2004) Risk factors for foot fracture among individuals aged 45 years and older. Osteoporosis Int 15:957–963
Maas M, Slim EJ, Akkerman EM, Faber WR (2001) MRI in clinically asymptomatic neuropathic leprosy feet: a baseline study. Int J Lepr 69:219–224
Muthukumar T, Butt SH, Cassar-Pullicino VN (2005) Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT, and MR imaging. Semin Musculoskelet Radiol 9:210–226
Onvlee GJ (1998) The Charcot foot. A critical review and an observational study of a group of 60 patients. Thesis, University of Leiden/The Netherlands
Radke S, Walther M (2003) Transient bone marrow edema syndrome- a rare differential diagnosis of foot pain (In German). Fuss Sprunggelenk 1:289–295
Resnick HE, Stansberry KB, Harris TB, et al (2002) Diabetes, peripheral neuropathy, and old age disability. Muscle Nerve 25:43–50
Schulte D (1897) Die sogenannte Fussgeschwulst. Arch Klin Chir 55:872–892
Szczesny G, Olszewski WL (2002) The pathomechanism of posttraumatic edema of lower limbs: I. The effect of extravasated blood, bone marrow cells, and bacterial colonization on tissues, lymphatics, and lymph nodes. J Trauma 52:315–322
Szczesny G, Olszewski WL (2003) The pathomechanism of posttraumatic edema of lower limbs: II. Changes in the lymphatic system. J Trauma 55:350–354
Veihelmann A, Szczesny G, Refior HJ, Mesmer K (2002) Microcirculatory changes in the soft tissues of the mouse lower limb after mechanical trauma. Abstract. J Bone Joint Surg Br 84B(Suppl 1):21
Thompson RC, Clohisi DR (1993) Deformity following fracture in diabetic neuropathic osteoarthropathy. J Bone Joint Surg 75A:1765–1773
Weishaupt D, Schweitzer ME (2002) MR imaging of the foot and ankle: patterns of bone marrow signal abnormalities. Eur Radiol 12:416–426
Whitesides TE (2001) Pain: friend or foe? J Bone Joint Surg 83A:1424–1425
Williams G, Pickup JC (1999) Handbook of diabetes. 2nd edn. Blackwell Science, Oxford, UK, p 156
Yu GV, Hudson JR (2002) Evaluation and treatment of stage 0 Charcot’s neuroarthropathy of the foot and ankle. J Am Podiatr Med Assoc 94:210–220
Zanetti M, Steiner CL, Seifert B, Hodler J (2002) Clinical outcome of edema-like bone marrow abnormalities of the foot. Radiology 222:184–188
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chantelau, E., Richter, A., Ghassem-Zadeh, N. et al. “Silent” bone stress injuries in the feet of diabetic patients with polyneuropathy: a report on 12 cases. Arch Orthop Trauma Surg 127, 171–177 (2007). https://doi.org/10.1007/s00402-006-0271-x
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-006-0271-x