Acute Charcot Neuroarthropathy (Charcot Foot)
This patient requires immediate non-weight-bearing immobilization and urgent referral to a multidisciplinary diabetic foot care team, as the clinical presentation is highly consistent with acute Charcot neuroarthropathy—a limb-threatening condition that demands prompt intervention to prevent permanent deformity and future ulceration. 1
Clinical Diagnosis
The constellation of findings strongly indicates acute Charcot foot:
- Sudden onset unilateral foot edema with warmth, erythema, and swelling in a patient with long-standing diabetic neuropathy (4 years) 1
- Absence of pain despite significant inflammation—pathognomonic for neuropathic process 1
- Bounding pulses with warm skin—indicating intact arterial perfusion, ruling out ischemia 1, 2
- Taut, indurated skin with foot broadening—suggesting underlying bony destruction and architectural collapse 1
- Normal inflammatory markers (CBC, ESR)—Charcot foot can present without systemic inflammation 1
- No ulceration or trauma—excludes diabetic foot infection as primary diagnosis 1, 2
Immediate Evaluation Required
Imaging Studies
- Plain radiographs of the affected foot (weight-bearing if possible, non-weight-bearing if not) to assess for fractures, subluxations, or bony destruction 2
- MRI of the foot should be considered if radiographs are equivocal, as early Charcot changes may not be visible on plain films and MRI helps differentiate from osteomyelitis 2
Vascular Assessment
- Ankle-brachial index (ABI) measurement is indicated despite palpable pulses, as clinical examination alone is unreliable in diabetes 1
- If ABI >1.40 (suggesting medial arterial calcification, common in diabetes), obtain toe-brachial index (TBI) or duplex ultrasound 1, 2
- The presence of bounding pulses and warm skin makes significant peripheral arterial disease unlikely, but documentation is essential 1, 2
Neurological Documentation
- Confirm loss of protective sensation (LOPS) using 10-g monofilament testing at multiple plantar sites 1, 2
- Perform at least one additional test: vibration perception (128-Hz tuning fork), pinprick, or ankle reflexes 1, 2
Immediate Management
Non-Weight-Bearing Immobilization
- Immediate total contact casting or removable cast walker with strict non-weight-bearing status 1
- This is the cornerstone of acute Charcot management to prevent progressive deformity 1
Urgent Referral
- Refer immediately to a multidisciplinary diabetic foot care team including endocrinology, orthopedic surgery/podiatry, and vascular specialists 1
- Early recognition and referral to specialists is mandatory to improve limb salvage 1
Glycemic Optimization
- Optimize glycemic control as this may improve foot outcomes, though evidence is moderate 1
- Target HbA1c should be individualized but improved control may slow progression 1
Critical Pitfalls to Avoid
Do not mistake acute Charcot foot for cellulitis or deep vein thrombosis—the absence of pain in the setting of neuropathy and the characteristic warm, swollen foot with intact pulses distinguishes Charcot from infection or venous disease 1
Do not allow continued weight-bearing—even brief periods of ambulation can cause catastrophic progression of bony destruction and permanent deformity 1
Do not delay referral pending imaging results—clinical suspicion alone warrants immediate immobilization and specialist consultation 1
Risk Stratification
This patient falls into Category 3 (High Risk) per the International Working Group on the Diabetic Foot classification, requiring examination every 1-3 months once the acute phase resolves 1
Risk factors present include:
Long-Term Surveillance
- Annual comprehensive foot examination at minimum, with more frequent monitoring given high-risk status 1
- Patient education on daily foot inspection and importance of appropriate footwear 1
- Custom-molded shoes will likely be needed after acute phase resolution to accommodate deformity and prevent ulceration 1