Sudeck's disease stage 1, or diabetic Charcot's foot stage 0? Case report and assessment of the diagnostic value of MRI

Abstract

BackgroundThe diagnosis of Sudeck's syndrome stage 1 (nowadays termed complex regional pain syndrome I, abbreviated CRPS I) is based on clinical features, namely swelling and pain in a limb. Plain X-ray may be normal. In the absence of pain sensitivity, e.g. in diabetic neuropathy, CRPS I of the foot can be mistaken for Charcot's foot stage 0 (so-called neuro-osteoarthropathy).Case presentationThe case of a type-1 diabetic woman is reported, in whom CRPS I following a calcaneal fracture was mistaken for Charcot's osteoarthropathy (because of bone marrow edema displayed by conventional MR imaging). In addition, a review is presented on 6 consecutive cases with CRPS I of the foot, and on 20 cases with Charcot's foot stage 0, with particular emphasis on MR imaging findings. The number of bones per foot affected with marrow edema was similar in either condition, with a tendency towards a more patchy, diffuse distribution of bone marrow edema in CRPS I. Bone marrow edema apparently regressed more promptly in response to treatment in Charcot's foot stage 0.ConclusionDifferentiation of CRPS I from Charcot's foot stage 0 remains a diagnostic dilemma in patients with pain insensitivity. Conventional MRI may be helpful, when repeated for monitoring the treatment response.

Follow up of MRI bone marrow edema in the treated diabetic Charcot foot – a review of patient charts

“…(b) Contrary to earlier claims [38], EESC in the present study did not regress without fluctuation and migration in some cases. Temporary non-regression (or progression) of EESC was observed in the present study in about 1/3 of all FUS.…”

Bone marrow lesions: A systematic diagnostic approach

“…[ 26 ] Depending upon the stage of disease, soft tissue edema(acute/subacute stage) and soft tissue atrophy (chronic stage) may be associated. [ 26 27 ] However, two important pitfalls should be kept in mind. In children and adolescents, patchy/reticular appearance of the marrow may be normally observed with patchy red marrow conversion.…”

Charcot Neuroarthropathy of the Foot and Ankle

“…Zampa et al measured contrast medium (gadolinium) uptake on dynamic MRIs in 40 patients with acute CN and found this to be a reliable means of monitoring the treatment outcome in the acute stage 41 . However, differentiating early Sudeck disease from the acute stage of CN is still a grey area 42 . In diabetic neuropathic feet, Thorning et al found areas of increased bone marrow edema in the midfoot and hindfoot, remote from the area shown to be affected by T2 weighted MRI 43 .…”