Silent bone stress injuries in the feet of diabetic patients with polyneuropat

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Arch Orthop Trauma Surg. 2007 Jan 11

" Silent " bone stress injuries in the feet of diabetic patients with

polyneuropathy: a report on 12 cases.

Chantelau E, Richter A, Ghassem-Zadeh N, Poll LW.

Diabetes Foot Clinic, Department of Endocrinology, Diabetes and

Rheumatology, Heinrich-Heine-University of Dussseldorf, Dusseldorf,

Germany.

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

uneventually 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).