Charcot–Marie–Tooth disease (CMT; , ), also known as hereditary motor and sensory neuropathy (HMSN), is an inherited neurological disorder that affects the peripheral nerves responsible for transmitting signals between the brain, spinal cord, and the rest of the body.
It is the most common inherited neuropathy that causes sensory and motor symptoms of numbness, tingling, weakness and muscle atrophy, pain, and progressive foot deformities over time. In some cases, CMT also affects nerves controlling automatic bodily functions like sweating and balance. Symptoms typically start in the feet and legs before spreading to the hands and arms. While some individuals experience minimal symptoms, others may face significant physical limitations. There is no cure for CMT; however, treatments such as physical therapy, orthopedic devices, surgery, and medications can help manage symptoms and improve quality of life.
CMT is caused by mutations in over 100 different genes, which disrupt the function of nerve cells' axons (responsible for transmitting signals) and their myelin sheaths (which insulate and accelerate signal transmission). When these components are damaged, nerve signal transmission slows down or becomes impaired, leading to problems with muscle control and sensory feedback. The condition was discovered in 1886 by doctors Jean-Martin Charcot and Pierre Marie of France and the English neurologist Howard Henry Tooth.
This disease is the most commonly inherited peripheral neuropathy, affecting approximately one in 2,500 people.
Signs and symptoms The symptoms of CMT often appear in childhood and adolescence, but in some cases, they may not develop until adulthood. The severity and progression of symptoms can vary widely between individuals even among members of the same family. Some people do not experience symptoms until their early 30s or 40s. The most common early sign of CMT is difficulty walking, often due to weakness in the muscles of the lower legs and feet. This muscle weakness can lead to foot drop, where patients have trouble lifting the front part of the foot, causing them to trip or adopt a high-stepping gait. Over time, individuals may develop distinctive foot deformities, such as high arches (known as pes cavus) and curled toes (hammertoes), due to muscle imbalance.
As the disease progresses, the weakness often spreads to the hands and forearms, making tasks that require fine motor skills—like buttoning a shirt or writing—more difficult. In addition to motor symptoms, many people with CMT also experience a gradual loss of sensation in the feet, legs, hands, and arms. This sensory loss may affect the ability to feel pain, temperature, or touch, and can lead to problems with balance, especially in low-light conditions.
Symptoms and progression of the disease can vary. Involuntary grinding of teeth and squinting are prevalent and often go unnoticed by the person affected. Breathing can be affected in some, as can hearing, vision, and neck and shoulder muscles. Scoliosis is common, causing hunching and loss of height. Hip sockets can be malformed. Gastrointestinal problems can be part of CMT, as can difficulty chewing, swallowing, and speaking (due to atrophy of vocal cords). A tremor can develop as muscles waste. Pregnancy has been known to exacerbate CMT, as well as severe emotional stress. Patients with CMT must avoid periods of prolonged immobility, such as when recovering from a secondary injury, as prolonged periods of limited mobility can drastically accelerate symptoms of CMT.
Pain is a common symptom experienced by individuals with Charcot–Marie–Tooth disease, often resulting from postural abnormalities, skeletal deformities, muscle fatigue, and cramping. This pain can typically be managed through a combination of physical therapy, orthopedic interventions, and the use of corrective or assistive devices. In cases where these approaches do not provide sufficient relief, analgesic medications may be necessary to alleviate discomfort and improve quality of life.
Although the disease is typically slowly progressive and not life-threatening, the degree of disability can vary. Some people may live relatively normal lives with mild symptoms, while others may require orthopedic supports, physical therapy, or even surgery to manage complications.
The variation in symptoms and severity is influenced by the specific genetic mutation causing the condition. While some genes are linked to earlier onset and more severe forms of CMT, others result in milder forms with slower progression. Furthermore, even when the same gene is involved, the symptoms can differ between individuals.
Neuropathic pain is a recognized symptom of Charcot–Marie–Tooth disease, although its presence and severity can vary greatly among individuals, and not all patients experience pain. For some, it can be moderate to severe and significantly interfere with daily activities and overall quality of life. When it presents, the pain experienced in CMT is often similar in character to that observed in other forms of peripheral neuropathy, including postherpetic neuralgia and complex regional pain syndrome. Addressing this symptom typically requires an individualized treatment plan, which may include pharmacological interventions, physical therapy, and other supportive strategies to manage and alleviate discomfort.
Charcot–Marie–Tooth disease type 1A (CMT1A) can also include mild enlargement or hypertrophy of leg muscles, particularly the calves, alongside typical symptoms of distal muscle weakness and atrophy. However, this muscle enlargement typically represents pseudohypertrophy due to fatty tissue infiltration rather than actual muscle growth.
This hypertrophic type of CMT is not caused by the muscles enlarging directly, but by pseudohypertrophy of the legs as fatty tissue enters the leg muscles.
Causes and genetics
Charcot–Marie–Tooth (CMT) disease is an inherited neurological disorder primarily caused by genetic mutations that disrupt critical proteins within peripheral nerves. These mutations predominantly affect proteins essential for the structure and function of the myelin sheath, including peripheral myelin protein 22 (PMP22), myelin protein zero (P0/MPZ), connexin32 (Cx32/GJB1), and periaxin (PRX), leading to demyelination. Additionally, mutations in proteins involved in axonal integrity, such as neurofilament light chain (NF-L), dynamin 2 (DNM2), ganglioside-induced differentiation-associated protein 1 (GDAP1), and mitofusin 2 (MFN2), can cause axonal forms of CMT. Due to the close interaction between Schwann cells (which produce myelin) and axons, mutations affecting Schwann cells often result in secondary axonal degeneration, further complicating disease progression. Ultimately, the pathogenesis of CMT involves the disruption of essential cellular processes, including protein synthesis, sorting, intracellular transport, protein degradation, and mitochondrial function, highlighting the complex molecular mechanisms underlying this disorder. + Chromosome 17 and 1 Causes of Charcot–Marie–Tooth (CMT) Disease:ChromosomeGene involvedExplanation17PMP22The most common cause (70–80% of cases) of CMT is a duplication on the short arm of chromosome 17, involving the gene PMP22. This duplication leads to an excess of PMP22 protein, disrupting the normal structure and function of the myelin sheath1MFN2Mutations affecting the gene MFN2, located on chromosome 1, impair the function of mitochondrial proteins. Mutated MFN2 causes mitochondria to form clusters or aggregates, restricting their movement along axons toward synapses, and thus impairing synaptic function. In some forms like X-linked CMT (CMTX), mutations in the GJB1 gene lead to dysfunction in gap junctions within Schwann cells, further impairing nerve signal transmission.
Classification
Charcot–Marie–Tooth (CMT) disease is a genetically heterogeneous disorder, meaning that it can be caused by mutations in many different genes.
To date, dozens of genes have been linked to various forms of CMT, reflecting the complexity of its molecular basis. As a result, CMT is classified into several major types, such as CMT1, CMT2, CMT4, CMTX, and intermediate forms, based on the pattern of inheritance and whether the primary defect affects the myelin sheath or the axon. CMT1 involves demyelination and is most caused by duplication of the PMP22 gene, while CMT2 is primarily axonal and frequently linked to mutations in genes such as MFN2 or NEFL. X-linked and autosomal recessive forms, like CMTX and CMT4, are also recognized and often associated with more severe or early-onset symptoms.
Each type is further divided into subtypes, defined by the specific gene that is mutated. This genetic classification helps guide diagnosis, prognosis, and, potentially, the development of targeted therapies.
GARS1-related axonal neuropathy (CMT2) Charcot–Marie–Tooth type 2 (CMT2) is commonly classified as an axonal neuropathy due to the degeneration of nerve axons observed in affected individuals. Unlike CMT type 1, which results from damage to the myelin sheath, CMT type 2 is characterized by direct injury to the axon itself. This axonal damage can disrupt nerve signal transmission between the brain and muscles, resulting in symptoms such as muscle weakness, atrophy, reduced sensation, and foot deformities. The onset of symptoms in CMT2 typically occurs between the ages of 5 and 25.
CMT2D is one of more than 31 recognized subtypes of Charcot–Marie–Tooth disease type 2 (CMT2) and is diagnosed when both motor and sensory deficits are present—such as loss of sensation caused by degeneration of sensory axons. In cases where only motor symptoms are observed without sensory involvement, the condition is classified as distal hereditary motor neuropathy type V (dHMN-V). The reason behind the variability in sensory involvement among patients with GARS1-related neuropathy remains unclear.
Symptoms of CMT2D typically include muscle weakness, loss of sensation, reduced reflexes, and muscle atrophy, which are similar to those seen in both CMT1 and other CMT2 variants. The severity and combination of symptoms vary widely among patients, particularly regarding the extent of sensory involvement.
CMT2D is a result of autosomal dominant mutations in the human GARS1 gene located at 7p14.3 and is thought to be caused by aberrant gain-of-function missense mutations.
The GARS1 gene encodes the enzyme glycyl-tRNA synthetase (GlyRS), which belongs to the class II group of aminoacyl-tRNA synthetases. This enzyme is essential in the process of protein synthesis, facilitating the bonding of the amino acid glycine to its corresponding transfer RNA (tRNA). Through this process, GlyRS ensures the accurate incorporation of glycine during translation, making it essential for proper protein production.
Many different mutations have been found in CMT2D patients, and how mutations in GARS1 cause CMT2D remains unclear. However, mutant glycyl-tRNA synthetase (GlyRS) is thought to interfere with transmembrane receptors, causing motor disease, and that mutations in the gene could disrupt the ability of GlyRS to interact with its cognate RNA, disrupting protein production. The GARS1 mutations present in CMT2D cause a deficient amount of glycyl-tRNA in cells, preventing the elongation phase of protein synthesis. Elongation is a key step in protein production, so when a deficiency of glycyl-tRNA exists, protein synthesis is unable to continue at glycine sites. GARS1 mutations also stall initiation of translation due to a stress response that is induced by glycine addition failure. By stalling elongation and initiation of translation, CMT2D mutations in GARS1 cause translational repression, meaning that overall translation is inhibited.