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Acute Neuropathic Arthropathy Of Ankle Joint: Report Of A Rare Case

Gopinathan Patinharayil*, Anwar Marthya, Jayachandran Nambiarveetil, Chathoth Meethal Kumaran*

Department of Orthopaedics , Medical College, Calicut, Kerala, India

Address for Correspondence:
Department of Orthopaedics ,Medical College,Calicut,Kerala,India 
Phone: +91 9447059014



Acute Neuropathic Arthropathy of the Ankle resulting from acute trauma, even though rare, is reported in diabetic patients.  If detected late, it can cause permanent deformity and disability.  It can also cause flap damage and can lead to amputation.  The aim of this article is to report a patient with history of diabetis mellitus with acute neuropathic arthropathy of left ankle joint which evolved over a short period of 6 weeks, following acute trauma.  A 38 years old diabetic male presented with history of trivial fall and sustained a minimally displaced fracture of left medial malleolus extending to the tibial plofound.  Since the episode was painless because of diabetic peripheral neuropathy, patient came walking on the second day with swelling of left ankle joint.  Below knee POP cast was given as a primary treatment.  But since the ankle was totally painless, patient walked with the cast and removed the POP on seventh day on his own.  He returned after 6 weeks with gross swelling and deformity of left ankle joint.  But it was totally painless.  Radiograph at 6 weeks showed non union of fracture medial malleolus with gross disorganization of the ankle joint along with bony fragmentations.  The patient was treated with ankle foot orthosis.  Follow up radiograph showed non union of medial malleolus, but consolidation of other fragments.  This article stresses to be aware of this particular condition; and even though rare, it should be suspected in diabetic patients with acute injuries.  Late diagnosis will result in disability and deformity.  Awareness about the existence of this condition will avoid chances of missed diagnosis.
Keywords: acute neuropathic arthropathy; ankle joint; diabetis mellitus; neuropathy; acute injury.

J.Orthopaedics 2007;4(2)e23


Acute neuropathic arthropathy is a rare complication of acute trauma to ankle and foot.  It is reported in diabetic patients1. Many surgeons fail to diagnose it in the initial stage, untill full grown neuropathic arthropathy sets in.  Delay in diagnosis will result in gross deformity and disability2.  The real incidence of acute neuropathic arthropathy has not been estimated because of the diagnostic difficulties3.  The recommended treatment of acute neuropathic arthropathy is non weight bearing immobilization for at least 3 months 4, 2, . Diabetic patients do have higher incidence of incordination in the lower limbs due to neuropathy and are likely to have frequent falls5. Due to greater weight  transmission, acute neuropathic arthropathy of foot and ankle is likely to take longer time to heal 1.  Body weight, body mass index and duration of diabetis are likely to affect the outcome of acute neuropathic arthropathy1.  The current article describes a 38 years old diabetic patient with acute neuropathic arthropathy of left ankle which followed a trivial fall.  Follow up radiograph at 6 weeks showed well established acute neuropathic arthropathy.  This article intends to discuss the pathophysiology of acute neuropathic arthropathy.  It is important to note that 25000 cases of neuropathic arthropathy are undiagnosed every year 6.  It is also important to be aware of this condition so that such missed diagnosis can be avoided. 

Case Report:

A 38 years old male patient with a history of diabetes mellitus for the last 5 years, presented following a trivial fall, which was followed by swelling of left ankle but without pain.  Patient initially thought it as a sprain, and did not request for medical help.  He presented after two days to the Orthopaedic OPD and the X –rays at that time showed minimally displaced fracture of the medial malleolus extending to tibial plafound (Figure 1).  It was totally painless.  He was immobilized with below knee POP cast and was directed not to bear weight.  Since it was totally painless, he did not follow the instructions and started weight bearing on the next day.  And on seventh day, the patient removed the POP on his own and walked full weight bearing.  As there was no pain, he did not request for the medical help for 6 weeks.  At 6 weeks he presented to the OPD again because of persistent swelling and deformity of the left ankle joint.  X- rays at that time showed full blown neuropathic arthropathy with non union of medial malleolus and fragmentation (Figure 2).  He was treated with Ankle-Foot-Orthosis.  At the time of writing this report the fracture did not unite, but other fragments consolidated and the swelling decreased in severity.  There was no skin breakdown.  He had loss of all modalities of sensation including proprioception in the foot distal to the ankle.  Random blood sugar at the time of first presentation was 240 mg% and subsequently it was well under control with Insulin.  He was on oral hypoglyceamic drugs for 5 years.  The opposite limb had features of peripheral neuropathy.  But there was no evidence of neuropathic arthropathy.  His body weight was 80 Kg.

Figure 1: Xray on first presentation showing minimally displaced fracture of the medial malleolus extending to Tibial plafond Figure 2: X ray at 6 weeks after the initial injury showing established neuropathic arthropathy of the ankle joint

Discussion :

Neuropathic Arthropathy was first described by Jordan in 1936 6.  It was originally described in tabes dorsalis by Jean Mary Charcot.  With the effective control of syphilis, now the majority of neuropathic arthropathic joints are due to diabetis mellitus.  Colhisty and Thomson 4 reported 18 adult patients with juvenile onset diabetis mellitus and neuropathic fractures of ankle.  They advocated strict immobilization as a mode of treatment.  Arrmstrong et al 7 reported that longer periods of immobilization is needed for a better outcome.  It is possible that a patients after a fall presenting with swelling and a normal X- ray, the surgeon diagnoses the injury as minor, as it is usually painless and sends the patient home, without immobilization or restriction of weight bearing1.  This could aggravate the condition.  It is also possible that the patient may present late, since the condition is totally painless.  It will be too late when the patient presents for medical help1 as in this case. 

So it is important that this condition should be diagnosed early.  Surgical outcome of acute neuropathic arthropathy is usually is very poor 8, 2. In this case patient had marginal improvement with ankle-foot-orthosis.  He had symptomatic relief, even though the fracture of medial malleolus did not unite.  Early immobilization is an effective treatment and helps in limiting the destructive phase of acute neuropathic arthropathy1.  Each year 40000 new cases of neuropathic arthropathy are diagnosed11.  Majority of them are usually chronic.  Less than 10% of neuropathic arthropathy affects the ankle joint 9  

Usual presentation of neuropathic arthropathy is in the sixth and seventh decade of life with a long history of diabetes mellitus (15 years) 10.  This patient presented in his fourth decade of life with a history of diabetes mellitus for the last 5 years.  The usual features of diabetic peripheral neuropathy are loss of all modalities of sensation including proprioception 11.  Neuropathy is a pre-requisite for neuropathic arthropathy.  Majority are diabetic patients on either oral hypoglyceamic drugs or insulin 12.  Edema, erythema, crepitus and increase in foot temperature are the usual signs of neuropathic arthropathy 6.  

The radiographic appearance of neuropathic arthropathy is classified as hypertrophic, atrophic and atrophic evolving on hypertrophic 13.  The pathophysiology of acute neuropathic arthropathy is unknown.  There are certain theories, which describe the pathophysiology of neuropathic arthropathy.13  

Nuerovascular theory:  There is loss of sympathetic tone to the blood vessels which results in hyperemia of bone and ligaments.  The hyperemia leads to bone resorption and ligament weakning resulting in fractures and dislocations during normal weight bearing.  The patient will have no pain; hence the fracture is not immobilized.  This results in hypertrophic non union.  

Nuerotraumatic theory: It states that repeated microtrauma due to the peripheral neuropathy, results in exaggerated healing as the fracture is not protected, 13.  Microangiopathy and increased atherosclerosis could also contribute to the pathogenesis of neuropathic arthropathy 11.  

Even though diabetis mellitus is a commonest cause of neuropathic arthropathy, other causes 13 should be kept in mind to avoid missed diagnosis. They include Syphilis, Multiple sclerosis, Hansens disease, Syringomyelia, Alcoholism, Myelopathy, Steroid injection and congenital insensitivity to pain. 

There are 3 stages in the development of neuropathic arthropathy  13.  In stage one, there is swelling, erythema, warmth and hyperemia.  In stage II, also known as coalescence stage, there will be fractures, subluxations or dislocations.  Stage III is the healing stage. There will be no inflammation, but with residual deformity.  It is always important to rule out osteomyelitis in neuropathic arthropathy 10.  Osteomyelities is quiet distinct clinically and radiologically.  

The traditional method of treatment of neuropathic arthropathy is conservative, even though surgical fusion and amputation are described 14.  Bisposphanates may help in reducing bone loss 13.  Sincare 1 achieved 100% healing with total contact casting and partial weight bearing.  After healing rocker bottom heel is given to prevent future damage1.  This case was treated with ankle-foot-ortosis.  The other devices which can be used are  Charcot restrained orthotic walker, Patellar Tendon bearing caliper, or extra depth shoes.  Combined magnetic field therapy may be beneficial in neuropathic arthropathy.  Electrostimulation is reported to be useful in the treatment of neuropathic arthropathy  15  

The traditional methods are the gold standards in the treatment of neuropathic arthropathy.  But complimentary techniques may help in better healing. 


This article describes a case of acute neuropathic arthropathy, which evolved over a short period of 6 weeks.  Patient had history of diabetes mellitus.  It is very important not to miss the diagnosis in the acute stage so that the delay in starting the treatment can be avoided.  This article signifies the need to be aware of acute neuropathic arthropathy even though the X-ray may look normal.  An early diagnosis will help in a long way to prevent deformity and disability. 

Reference :

  1. Sincare R D. Acute Charcot arthropathy in Patients with Diabetes Mellitus:Healing Times by foot location.J diabetic complications 1998;12:77-82.

  2. Johnson JTH. Neuropathic fractures and joint injuries: Pathogenesis and rationale of prevention and treatment. J Bone Joint Surg1967; 49A:1–30,

  3. Armstrong DG, Lavery LA. Acute Charcot arthropathy of the foot and ankle. Phys Ther 1998;78:74-80.

  4. D.R. Clohisy and R.C. Thompson. Fractures associated with neuropathic arthropathy in adults who have juvenile-onset diabetes. J Bone Joint Surg 1988;70-A: 1192–1200

  5. P.R. Cavanagh, J.A. Derr, J.S. Ulbrecht, R.E. Maser and T.J. Orchard. Problems with gait and posture in neuropathic patients with insulin-dependent diabetes mellitus. Diabetic Med 1992;9: 469–474.

  6. Grady JF. O’connoor KJ, Axe TM,Zager EJ, Dennis LM, Brenner LA.Use of electro stimulation in the treatment of diabetic neuro arthropathy. Jam PodiatrMed Assoc 2000;90:287-94.

  7.  D.G. Armstrong, W.F. Todd, L.A. Lavery, L.B. Harkless and T.R. Bushman, The natural history of acute Charcot’s arthropathy in a diabetic foot specialty clinic. Diabetic Med 1997:14;357–363.

  8. Sinha S, Munichoodappa CS, Kozak GP. Neuro-arthrop-athy (Charcot joints) in diabetes mellitus: Clinical study Manageof 101 cases. Medicine 1972;51:191–210.

  9. Gupta R .A short history of Neuropathic Arthropathy.Clin Orthop1993;296:43-49.

  10. Pinzur MS  Charcots foot . Foot and Ankle Clin 2000;5:897-912

  11. Shaw JE. The Pathogensis of Diabetic Foot Problems: an overview. Diabetes1997: 46(suppl 2):S 58-61.

  12. Smith DG, Barnes BC, Sands AK, Boyko EJ, Ahroni JH. Prevalence of radiographic foot abnormalities in patients with Diabetes. Foot ankle. int 1997;18:342-6.

  13. Melanie D, Osterhouse DC, Norman W, Kettner DC. Neuropathic Osteo arthropathy in Diabetic foot. J Manipul and Physiol Ther 26;6:416-22.

  14. Harrelson JM. Management of of diabetic foot . Orthp clin North Am 1989;20:605-19.

  15. Evans RD, Foltz D, Foltz K. Electrical stimulation with bone and wound healing. Clin Podiatr Med Surg 2001;18:79-95.


This is a peer reviewed paper 

Please cite as :Gopinathan Patinharayil: Acute Neuropathic Arthropathy Of Ankle Joint: Report Of A Rare Case

J.Orthopaedics 2007;4(2)e23





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