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Charcot Arthropathy Workup

  • Author: Mrugeshkumar Shah, MD, MPH, MS; Chief Editor: Jason H Calhoun, MD, FACS  more...
Updated: Dec 18, 2014

Laboratory Studies

Essential tests

The white blood cell (WBC) count with differential often is ordered to help distinguish between Charcot arthropathy and osteomyelitis. The WBC count is elevated when infection is present, and often, a left shift is revealed with infection. However, WBC count is a nonspecific marker for inflammation, and the results may be elevated in patients with Charcot arthropathy.

The erythrocyte sedimentation rate (ESR) is used to help distinguish between Charcot arthropathy and osteomyelitis and is often elevated in infection; however, it is a nonspecific marker for inflammation.

The basic metabolic profile (Chem 7) is ordered to identify the underlying etiology. Elevated levels of creatine and of blood, urea, nitrogen (BUN) could suggest renal disease, whereas an elevated glucose level could suggest diabetes.

Other tests

Additional tests may be ordered, depending on the patient's history, physical examination results, and risk factors.

Glycosylated hemoglobin (HbA1c) indicates the level of hyperglycemic control in diabetes. Elevated HbA1c indicates poor hyperglycemic control. Hyperglycemia can cause nonenzymatic collagen glycosylation, which can lead to laxity in ligaments and unstable joints.

Levels of alkaline phosphatase, calcium, phosphorus, and parathyroid hormone (PTH) can help the physician to identify bone diseases, such as Paget disease. Hypercalcemia may be indicative of cancer or metastases.

Vitamn B12/folate deficiency could suggest an etiology of peripheral neuropathy. This deficiency also could suggest chronic alcoholism.

Findings of liver function tests/coagulation studies may suggest chronic alcoholism.

Rapid plasma reagin (RPR)/fluorescent treponemal antibody – absorption (FTA-ABS) tests aid in the diagnosis of syphilis.


Imaging Studies

Plain radiographs (see the image below) are used for the following purposes:

  • To help stage disease (see Relevant Anatomy)
  • To help determine if active disease is present or if the joint is stable (monitor serial radiographs)
  • To help identify osteopenia, periarticular fragmentation of bone, subluxations, dislocations, fractures, and generalized destruction
    Neuropathic arthropathy (Charcot joint). Neuropath Neuropathic arthropathy (Charcot joint). Neuropathic arthropathy of the shoulder in a patient with syringomyelia. Note the destruction of the articular surface, dislocation, and debris, which are pathognomonic for a neuropathic joint.

Bone scanning (not always ordered) helps differentiate between Charcot arthropathy and osteomyelitis. An indium-111 WBC scan often is used because it is more specific than the technetium-99m scan.

Magnetic resonance imaging (MRI)[10] allows anatomic imaging of the area and may help distinguish between osteomyelitis and Charcot arthropathy.

Doppler ultrasonography is used to rule out deep vein thrombosis.


Diagnostic Procedures

Lumbar puncture is used if the RPR test is positive. An FTA-ABS test is ordered if tertiary syphilis/tabes dorsalis is suggested.

Bone probing is done with a blunt, sterile surgical probe. It is necessary to probe down to the bone to rule out osteomyelitis.

Portable infrared dermal thermometry is used for skin temperature assessment. It can be used to monitor active inflammation. A 3-5° difference is generally seen in the acute stage.

Joint aspiration is used to help rule out a septic joint.

Synovial biopsy can be helpful. Small fragments of bone and cartilage debris are embedded in the synovium because of joint destruction. Some state that this is pathognomonic, whereas others state that it is highly suggestive of Charcot arthropathy.

Contributor Information and Disclosures

Mrugeshkumar Shah, MD, MPH, MS Staff Physician, Physical Medicine and Rehabilitation, Massachusetts General Hospital/Spaulding Rehabilitation Hospital

Mrugeshkumar Shah, MD, MPH, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.


Walter Panis, MD Clinical Instructor, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School

Walter Panis, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neurorehabilitation, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

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Neuropathic arthropathy (Charcot joint). Neuropathic arthropathy of the shoulder in a patient with syringomyelia. Note the destruction of the articular surface, dislocation, and debris, which are pathognomonic for a neuropathic joint.
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