Sudeck's disease stage 1, or diabetic Charcot's foot stage 0? Case report and assessment of the diagnostic value of MRI
© Poll et al; licensee BioMed Central Ltd. 2010
Received: 19 June 2010
Accepted: 5 October 2010
Published: 5 October 2010
The 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).
The 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.
Differentiation 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.
The diagnosis of Sudeck's syndrome stage 1 (synonyma: acute Sudeck's disease, warm phase of algodystrophia, complex regional pain syndrome I, CRPS I [1, 2]) is based on clinical features, including inflammatory painful swelling and erythema of a limb, preceded by a skeletal trauma in most cases. The case of a woman with type-1 diabetes mellitus is reported, who developed CRPS I following a calcaneal fracture, and in whom this condition was mistaken for diabetic Charcot's foot stage 0 on the basis of MR imaging. This case prompted us to review the effectiveness of conventional MRI in patients with either CRPS I, or Charcot's foot stage 0, respectively.
Review of conventional MR imaging
Materials and methods
Clinical records of patients with established CRPS I (according to the Budapest criteria ) of a foot, under care of the Department of Traumatology, Orthopedic and Reconstructive Surgery at the Berufsgenossenschaftliche Klinik (a tertiary reference centre for vocational injuries in the region of Northrhine-Westphalia) between 2005 and 2010 were reviewed. Likewise, files of patients with established diabetic Charcot's foot stage 0, under care of the diabetes foot clinic at the Heinrich-Heine-University of Düsseldorf/Germany between 1997 and 2007 , were reviewed in retrospect. Only cases were included, in whom conventional MRI studies and follow-up data were available.
Conventional MR examinations (with contrast media, except for 7 cases) were performed on a 1.5 Tesla superconducting magnet. Each foot was scanned in sagittal view using T1-weighted turbo-spin-echo (TSE) sequences (TR: 580, TE: 15) with a slice thickness of 3-4 mm. Paracoronal T1-weighted TSE-sequences were acquired parallel to the midfoot through tibia, calcaneus und talus. Sagittal T2-fat-suppressed-STIR-sequences (TR: 3200, TE: 27, TI 160 msec) were also acquired. Bone marrow edema was defined and charcterized by intermediate to low signal on T1-weighted imaging (T1w).
Patients were treated at the discretion of the physicians in charge. Offloading and immobilisation of the foot by using a total contact cast  or wheelchair was applied in cases with Charcot's foot. Various drugs (analgesics, calcitonin, pregabalin, bisphosphonates, vitamin D3, calcium), orthopaedic footwear, crutches and/or physiotherapy were applied in cases with CRPS I.
Data are presented descriptively as means with 95% confidence intervals, unless stated otherwise; Student's t-test was applied. Significance was assumed at a p < 0.05.
Patient characteristics and MRI features
Charcot's foot stage 0, no deformity
- males/females, n
- Age, years
47 (95% CI 40-55)
62 (95%CI 59-65)*
- BMI > 29 kg/m², n
- Diabetes mellitus, n
- Polyneuropathy, n
Bones with BME per foot, n
3.7(95% CI 1.8-5-5)
4.3(95% CI 3.0-5.6)
Feet with diffuse patchy BME, n
Feet with migrating and/or fluctuating BME, n
Feet with soft tissue edema, n
The findings on the conventional MR images are also summarized in Table 1. Charcot's feet responded to treatment by clinical and MRI regression immediately and were healed after 20(95%CI 15-24) weeks. By contrast, CRPS I syndrome fluctuated in symptoms and activity and required significantly longer to heal [43(95% CI 30-76)weeks]; two cases had not healed at the time of writing this report.
The case of our patient demonstrates the diagnostic dilemma that exists in patients with diabetes mellitus and a red, hot, swollen foot with a normal X-ray: clinical symptoms (except for pain quality) as well as MRI findings seem to be suggestive of both, CRPS I, or Charcot's foot stage 0.
CRPS I at the foot is very painful in diabetic and non-diabetic subjects alike: pain is spontaneous, severe, combined with allodynia and hyperalgesia-provided pain sensitivity is normal. By contrast, in diabetic Charcot's foot stage 0 there may be some stress-related pain that subsides upon offloading, but at rest there is little or no spontaneous pain or allodynia- because pain sensitivity is reduced or absent (due to diabetic neuropathy). However, in patients with diabetic neuropathy, CRPS I at the foot may be abnormally painless- and may, therefore, be mixed up with the more common Charcot's foot stage 0.
MRI features of CRPS I (Sudeck's syndrome stage 1) at the foot were demonstrated for the first time by Schimmerl et al. . They showed that in CRPS I bone marrow displays diffuse or spotted hyperintensities ("bone marrow edema") on STIR images, and contrast media enhanced thickening of periarticular and/or subcutaneous and skin tissue. These features, which were confirmed repeatedly [7–10, 17] are still not fully understood; increased permeability of small intramedullary and soft tissue vessels due to an unknown stimulus could be causally involved.
MRI features of Charcot's foot stage 0 (in insensitive feet of patients with diabetic neuropathy) were demonstrated previously: subchondral ("traumatic") bone marrow edema, occasionally triggering neuro-osteoarthropathy (Charcot's foot stage I-III) [11–13, 18]. In this condition, bone marrow edema is believed to indicate bone or joint contusion, osteitis, or stress-induced trabecular microfracture [14–16, 18, 19], respectively.
The MRI findings in the present study are not straightforward. In CRPS I, bone marrow edema (and soft tissue edema) seemed to be distributed in a more patchy and diffuse fashion (as compared to the more focal distribution in Charcot's foot stage 0), and to be more fluctuating in response to treatment (in 3 out of our 6 patients, see Figure 2 and 4). It has been reported previously that in CRPS I, bone marrow edema may fluctuate and migrate to neighbouring bones during the natural regression of the acute (warm) phase [7–9]. In Charcot's foot stage 0, however, the bone marrow edema regresses steadily (without fluctuation and migration) in response to strict offloading and immobilisation, like any other traumatic bone marrow edema does [11–14, 20], see Figures 6 and 8. Correspondingly, the inflammatory activity-edema, hyperthermia- in a Charcot's foot stage 0 may respond within 3 months of offloading and immobilisation by total contact cast , whereas inflammation may fail to respond similarly to the particular therapy in a foot with CRPS I .
In conclusion, although conventional MRI displays distinct skeletal pathology in cases of CRPS I of the foot, and Charcot foot stage 0, respectively, it seems to lack specificity for either condition. Hence, conventional MRI signs have to be interpreted carefully within the clinical context. Further study is warranted to determine the potential of more sophisticated MR imaging techniques like dynamic gadolinium enhanced MRI  or diffusion weighted MRI in these conditions.
Written consent was obtained from the patient P.H. for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief.
List of abbreviations used
bone marrow edema
chronic regional pain syndrome
magnetic resonance imaging
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