Charcot foot

What happens

In a foot with little or no feeling, walking on an injury doesn’t hurt the way it should. The bones, often already weakened, can fracture and the joints can dislocate, and continued walking makes the collapse worse. The arch can fall until the foot takes on a rocker-bottom shape, creating pressure points where ulcers form.^[1]

International guidelines separate the active stage, when the bones are inflamed and fragile, from the later inactive stage, when the foot has healed in whatever shape it ended up.^[2]

Who is at risk

Anyone with significant neuropathy (loss of protective feeling in the feet) can develop Charcot foot. Diabetes is by far the most common cause of that nerve damage, which is why Charcot is usually discussed as a complication of diabetes.^[1,2] The risk is higher with long-standing neuropathy, and people with neuropathy and a tight Achilles tendon appear more prone to it.^[1] Because the foot can’t feel the damage, people keep walking on it, which makes it worse.

Recognizing it early

Suspect Charcot if you have neuropathy and one foot becomes:

• warmer than the other,
• red and swollen,
• sore or aching, or oddly painless for how it looks,
• changing shape.^[1,3]

A temperature difference between the feet is a useful early clue. Get seen quickly: early treatment gives the greatest chance of keeping the foot’s shape.

How we evaluate it

We compare the two feet (including skin temperature), examine for deformity and ulcers, and check circulation. X-rays at the practice are the first imaging test; MRI or other imaging may be needed when X-rays are normal early on, or to tell Charcot from infection.^[1,2]

Treatment

• Offloading and immobilization in a total contact cast or a non-removable boot during the active stage, often for months, with regular temperature checks and X-rays to judge when the inflammation has settled.^[2]
• Transition to protective footwear: custom shoes, inserts or a Charcot restraint orthotic walker, once the foot is stable.^[1]
• Lifelong foot protection: regular foot checks and ulcer prevention.^[5] See diabetic foot care.
• Surgery when the foot is unstable, can’t be braced, or keeps developing ulcers. Reconstruction can preserve a foot that can walk in a shoe, but it is a major operation with a significant complication rate.^[1,4]

Common questions

How long does treatment take?

The bones usually take several months to heal, and sometimes considerably longer, in a cast or boot, with the foot rechecked regularly until it is cool and the X-rays are stable.^[1,2] After that comes a gradual move into protective footwear, and protection for life.

Can I walk on it while it heals?

Only as your cast or boot allows. Keeping weight off the inflamed bones is what stops the foot from collapsing further, which is why guidelines favor a knee-high device that can’t be taken off during the active stage, and why you may be asked not to put weight on the foot at all until it is safe.^[2,1] We go over exactly what you can do, and how to get around safely.

Is it an infection?

Charcot and infection can look alike, and both can make a foot warm, red and swollen. An open wound makes infection more likely. X-rays, sometimes MRI, and blood tests help tell them apart, and we treat promptly whichever it is.^[2] See wound care.

What about my other foot?

Someone who has had Charcot in one foot is more likely to develop it in the other, so we examine and protect both feet at every visit and teach you what to look for.^[1]

When to seek care