What is the treatment for Charcot's foot?

Treatment of Charcot Foot

Immediately initiate knee-high immobilization with a non-removable offloading device as soon as Charcot neuro-osteoarthropathy is suspected, even before diagnostic imaging is complete, to prevent devastating progression of deformity. 1

Immediate Management Algorithm

Step 1: Suspect and Act Immediately

• Begin immobilization the moment you suspect active Charcot—do not wait for imaging confirmation 1
• Clinical presentation includes a red, hot, swollen foot in a patient with diabetes and peripheral neuropathy 1
• Critical pitfall: Active infection or ulceration does NOT exclude Charcot—both conditions can coexist 1
• Even if initial plain X-rays appear normal, proceed with immobilization while awaiting further diagnostic workup 1

Step 2: Choose the Appropriate Offloading Device

First-line choice: Total Contact Cast (TCC) 1, 2

• Provides superior immobilization of the ankle joint compared to prefabricated devices 1, 2
• Customized to accommodate deformity and edema 1
• Must be renewed at each visit unless made removable (which compromises immobilization) 1
• Requires specialized expertise to apply properly 1

Second-line choice: Knee-high walker rendered non-removable 1, 2

• Use when TCC expertise is unavailable or cost/equity considerations are paramount 1
• Must be made non-removable to ensure compliance and adequate immobilization 1, 2
• Comparable efficacy to TCC when properly applied 2

Third-line choice: Removable knee-high device 2

• Only for patients who absolutely cannot tolerate non-removable devices 2
• Main disadvantage is poor adherence, which can lead to treatment failure 2

Never use below-ankle devices—they provide inadequate immobilization and insufficient offloading 2

Step 3: Reduce Weight-Bearing Further

• Prescribe assistive devices (crutches, walker, or wheelchair) to minimize weight-bearing on the affected limb 2
• This additional measure reduces mechanical stress beyond what the cast alone provides 2

Diagnostic Imaging Protocol

Initial imaging:

• Obtain weight-bearing plain X-rays (AP, medial oblique, and lateral views of foot; AP, mortise, and lateral views of ankle) 1
• If patient cannot bear weight, non-weight-bearing films are acceptable but may miss dynamic malalignments 1
• Bilateral X-rays are ideal for comparison 1

If X-rays are normal but clinical suspicion remains high:

• Perform MRI to diagnose or exclude active Charcot 1
• MRI shows bone marrow edema in early-stage (stage 0) Charcot before fractures develop 1
• Important caveat: MRI bone marrow edema can also indicate osteomyelitis—expert radiologist interpretation is essential 1
• If MRI is unavailable or contraindicated, consider nuclear imaging, CT, or SPECT-CT 1

Duration of Treatment

• Continue non-removable offloading for 4-6 weeks after clinical signs of active Charcot have resolved and the disease enters remission 1
• Expect total treatment duration of many months (mean 18.5 weeks in one cohort, with some patients requiring 28+ weeks) 3
• Monitor for remission using combined approach: skin temperature normalization (comparing affected to unaffected limb), resolution of edema, and imaging confirmation of bone healing 2

Monitoring for Complications

Watch for adverse effects of prolonged immobilization: 1

• Development of new foot ulcers (reported in 14% of patients) 2
• Skin lesions from cast removal 1
• Muscle atrophy and weakness 1
• Falls risk 1
• Contralateral hip/knee pain from limb-length discrepancy—consider shoe raise for opposite limb 1
• Psychological distress from prolonged immobility and social isolation 1

Post-Acute Phase Management

Once remission is achieved: 2

• Transition to customized footwear with accommodative insoles to prevent reactivation 2
• Consider below-knee customized devices if significant deformity or joint instability persists 2
• Lifelong protective footwear and routine foot care are mandatory 4
• Regular podiatry follow-up to prevent ulceration 1

Critical Clinical Pearls

• Do not delay treatment: Early immobilization in stage 0 (before fractures develop) prevents deformity, whereas delayed treatment in stage 1 (after fractures) commonly results in severe deformity 1
• The presence of pain in an otherwise insensate foot is common (76% of cases) and should heighten suspicion 3
• Bilateral Charcot occurs in 9% of cases and requires significantly longer casting duration 3
• Surgery (exostectomy or fusion) may be needed in 25% of cases, which extends immobilization time 3