Treatment of Charcot Foot
Immediately initiate a non-removable knee-high offloading device (total contact cast as first choice) as soon as Charcot foot is suspected, even before confirmatory imaging is complete, to prevent progressive deformity and disability. 1, 2
Immediate Management: Offloading and Immobilization
First-Line Treatment Hierarchy
Total Contact Cast (TCC) is the gold standard first-choice treatment, providing optimal immobilization of the foot and ankle joints while redistributing plantar pressures 1, 2
Non-removable knee-high walker serves as the second-line option when TCC is not available or feasible, and must be rendered truly non-removable (not just instructed to keep on) 1, 2
Removable knee-high device is the third-line option, reserved only for patients who cannot tolerate non-removable devices due to contraindications or severe intolerance, with the critical caveat that patient non-adherence significantly compromises outcomes 1, 2
Critical Timing
Begin offloading immediately when clinical signs of inflammation (red, hot, swollen foot) are present in a diabetic patient with neuropathy, even while awaiting diagnostic imaging 1, 2
Early immobilization and reduced weight-bearing minimize the development of permanent deformity 1
What NOT to Use
- Avoid all below-ankle devices (surgical shoes, postoperative sandals, custom molded shoes, slipper casts) as they provide inadequate immobilization of diseased bones and joints with limited offloading capacity 1, 2
Adjunctive Measures
Weight-Bearing Reduction
- Use assistive devices (crutches, walkers, wheelchairs) to further reduce weight-bearing on the affected limb during the acute phase 1, 2
Pharmacological Interventions: What NOT to Use
Do NOT use bisphosphonates (alendronate, pamidronate, zoledronate), calcitonin, PTH, or methylprednisolone for treatment of active Charcot foot, despite earlier research suggesting potential benefits 1
Do NOT use denosumab for active Charcot neuroarthropathy 1
Consider vitamin D and calcium supplementation only during the fracture healing phase, in doses according to national guidelines for those at risk of deficiency or insufficient intake 1
This strong recommendation against bisphosphonates represents a notable divergence from older research 3, 4 that suggested potential benefits in reducing skin temperature and disease activity. The 2024 IWGDF guidelines explicitly recommend against their use based on moderate-quality evidence, prioritizing patient safety over theoretical benefits 1.
Surgical Intervention
Consider surgery when there is instability of foot and ankle joints, deformity with high risk of ulcer development in the offloading device, or pain that cannot be adequately stabilized in a TCC or non-removable knee-high device 1
Surgical options include arthrodesis procedures (tibio-calcaneal, triple, talo-navicular, subtalar) and midfoot fusion, though complications including infection, nonunion, and need for revision are common 5
Monitoring for Disease Remission
Combined Assessment Approach
Use temperature measurement, clinical edema assessment, and imaging together to determine when active Charcot is in remission; no single parameter is sufficient alone 1, 2
Do not rely on soft tissue edema alone to determine remission status 1, 2
Frequency of follow-up appointments should depend on fluctuation in edema volume, comorbidities, treatment risks, access to home assistance, and patient progress 1
Prevention of Reactivation After Remission
Prescribe customized footwear and/or orthoses that accommodate and support the altered foot shape to prevent reactivation once the acute phase has resolved 1, 2
Use below-knee customized devices for additional protection when deformity or joint instability persists after the acute phase 1, 2
Diagnostic Considerations
Imaging Protocol
Obtain plain X-rays (anteroposterior, medial oblique, and lateral projections) as the initial imaging study, ideally weight-bearing and bilateral 1
Perform MRI when plain X-rays appear normal but clinical suspicion remains high, as MRI can detect early bone marrow edema and soft tissue changes before radiographic abnormalities appear 1
Consider nuclear imaging, CT, or SPECT-CT if MRI is unavailable or contraindicated 1
Common Diagnostic Pitfall
Do not exclude Charcot foot simply because infection or ulceration is present; active Charcot can coexist with diabetic foot infection, and the inflammatory signs may be mistakenly attributed solely to infection 1
The presence of a hot, swollen foot in a diabetic patient with neuropathy should always raise suspicion for Charcot, regardless of other concurrent pathology 1
Key Clinical Pitfalls to Avoid
Delayed treatment leads to progressive, irreversible deformity and increased risk of ulceration and amputation 2, 5
Inadequate immobilization with below-ankle devices fails to control the disease process 1, 2
Poor adherence with removable devices undermines treatment effectiveness 2
Skin complications (new ulcers, blisters) can occur with improperly applied casts, requiring careful monitoring 2