What Is a Charcot Restraint Orthotic Walker (CROW)?

The Charcot Restraint Orthotic Walker, or CROW, is a rigid boot designed to accommodate and support a foot with Charcot neuroarthropathy (CN).

CROW consists of a fully enclosed ankle/foot orthotic with a rocker-bottom sole. It is a common treatment used to minimize further deformity and prevent ulcer development after acute CN has calmed down.

CN occurs when bones and joints in the foot fracture, break up or pop out of place with minimal or no known direct injury. In the United States, this deformity most commonly occurs in people with diabetes. The foot first enters an acute stage of swelling, warmth and redness, that can be mistaken for an infection. Broken bones and dislocations can occur, causing severe deformities of the foot and ankle. Some patients develop pain or ulcers when the affected foot becomes deformed. CN can affect the other foot or happen again in the same foot. The foot does not regain its normal shape. 

Diagnosis

Patients with acute CN can begin using the CROW after swelling gone down, however that can take months. Patients with mild to moderate CN deformities will benefit most from the CROW. Patients with severe CN deformities or extreme foot/ankle instability may need surgery instead of using the CROW.

Treatment

The CROW is custom-made for each patient’s foot. The outer shell consists of two plastic or fiberglass clamshell pieces that are strapped together with Velcro. It is sturdy and can be walked on, and prevents other bones from cracking or breaking. The bottom of the boot has a rounded rocker-bottom shape. The boot contains a custom, removable foam insole that is adjusted to distribute weight equally and support the ankle joint.

The CROW provides even support to the entire foot, especially to areas that are overstressed due to the CN. CN deformities often cause the foot to bend out of shape. The resulting stress on the foot can cause ulcers, which can develop into severe infections if left untreated. By distributing pressure equally throughout the leg and foot, the CROW removes excessive forces and gives the foot time to heal. It is easier to use than a cast, can be removed for wound care and washing, and is more durable.

Recovery

Fortunately, the CROW is adaptable to daily life. Because of the clamshell design, the patient can easily remove the boot in order to keep the foot clean and sleep better. In addition, its fitted shape and good support allow people to return to walking, standing and driving more normally.

The most important outcome is that patients are able to continue to bear weight while minimizing pressure and giving the foot a chance to heal. Healing may require many months. However, CN may return and/or affect the other foot, so regular and lifelong monitoring of the condition is necessary.

Risks and Complications

Despite the sturdiness of the boot and the distribution of forces, the bones of the foot could still break down further. Due to lowered ability to detect pressures that are too high in the neuropathic foot, the foot could develop open sores, even though the boot is designed to prevent this. As always with Charcot deformity, some joints may heal incorrectly or not at all. Unfortunately, other factors such as poor glucose control, malnutrition, obesity, and chronic swelling can prevent healing despite use of a CROW.

FAQs

What options do I have when my foot is still swollen?
Patients often wear special casts until their feet stop swelling enough for them to use a CROW. The cast serves to stabilize the foot and prevent unstable motion, similar to the CROW. However, unlike the CROW, these casts cannot be removed at home

I am a diabetic. How can I best ensure that I don't get Charcot Neuroarthropathy?
Unfortunately, any individual who develops neuropathy can develop CN. The best advice is simple to give, but often difficult to follow: good long-term glucose control maintaining as close to a normal HgA1c, as well as maintaining an appropriate weight will markedly reduce the risk of developing CN.  

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