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Foot Small Muscle Atrophy Is Present Before the Detection of Clinical Neuropathy

¹ Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
² Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
³ Joslin-Beth Israel Deaconess Foot Center and Microcirculation Laboratory, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Address correspondence and reprint requests to Robert L. Greenman, PhD, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Rd., Boston, MA 02115. E-mail: rgreenma{at}bidmc.harvard.edu

OBJECTIVE—To characterize structural changes and the metabolic profile of foot muscles and correlate them with diabetic neuropathy measurements using phosphorus-31 (³¹P) rapid acquisition with relaxation enhancement (RARE) magnetic resonance imaging (MRI).

RESEARCH DESIGN AND METHODS—We studied 12 control subjects, 9 nonneuropathic diabetic patients, and 12 neuropathic diabetic patients using ³¹P RARE and proton (¹H) MRI at 3 Tesla. The ratio of the total cross-sectional area of the foot to that of the muscle tissue was calculated from transaxial ¹H and ³¹P images. The average ³¹P concentration across the metatarsal head region was measured from the ³¹P images.

RESULTS—The muscle area–to–total area ratio differed among all three groups (means ± SD): 0.55 ± 0.04 vs. 0.44 ± 0.05 vs. 0.06 ± 0.06 for control, nonneuropathic, and neuropathic subjects, respectively (P < 0.0001). The average ³¹P concentration also differed among all groups: 27.7 ± 3.8 vs. 21.7 ± 4.8 vs. 7.9 ± 8.8 mmol/l for control, nonneuropathic, and neuropathic subjects (P < 0.0001). The muscle area–to–total area ratio strongly correlated with clinical measurements: Neuropathy Disability Score, r = –0.83, P < 0.0001; vibration perception threshold, r = –0.79, P < 0.0001; and Semmes-Weinstein monofilaments, r = –0.87, P < 0.0001.

CONCLUSIONS—Small muscle atrophy is present in diabetes before clinical peripheral neuropathy can be detected using standard clinical techniques. The ³¹P RARE MRI method evaluates the severity of muscle atrophy, even in the early stages when neuropathy is absent. This technique may prove to be a useful diagnostic tool in identifying early-stage diabetic foot problems.

Abbreviations: ABI, ankle brachial index • FOV, field of view • MRI, magnetic resonance imaging • MRS, magnetic resonance spectroscopy • NDS, Neuropathy Disability Score • RARE, rapid acquisition with relaxation enhancement • SWM, Semmes-Weinstein monofilaments • VPT, vibration perception threshold

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