What is the treatment for Charcot foot?

Treatment of Charcot Foot

Immediately initiate a non-removable knee-high device (total contact cast as first choice) to immobilize and offload the foot as soon as Charcot neuro-osteoarthropathy is suspected, even before confirmatory imaging is complete. 1, 2

Acute Phase Treatment Algorithm

Immediate Offloading (Start Promptly)

• Total Contact Cast (TCC) is the gold standard first-line treatment for active Charcot foot with intact skin 1, 2
• Non-removable knee-high walker is the second choice if TCC cannot be applied or is not tolerated 1, 2
• Removable knee-high device worn at all times is the third choice, only when non-removable devices are contraindicated or not tolerated 1, 2
• Begin offloading immediately when Charcot is suspected, even while diagnostic workup is ongoing 1, 2

Critical Pitfall to Avoid

Never use below-ankle devices (surgical shoes, postoperative sandals, custom molded shoes, or slipper casts) as they provide inadequate immobilization of diseased bones and joints 1, 2

Adjunctive Measures

• Use assistive devices (crutches, walkers, wheelchairs) to reduce weight-bearing on the affected limb 1, 2
• Consider vitamin D and calcium supplementation during fracture healing phase, dosed according to national guidelines for those at risk of deficiency 1

Pharmacological Therapy: What NOT to Use

Do not use bisphosphonates (alendronate, pamidronate, zoledronate), calcitonin, PTH, methylprednisolone, or denosumab as treatment for active Charcot foot 1

• While bisphosphonates may reduce skin temperature and bone turnover markers, they have not demonstrated clinically meaningful benefits on disease progression, ulceration prevention, or quality of life 1, 3, 4

Monitoring for Disease Remission

Combined Assessment Approach

• Serial temperature measurements comparing affected versus unaffected limb using infrared thermometry 1, 2
• Clinical examination for reduction in edema (though edema alone is insufficient to determine remission) 1, 2
• Imaging studies (radiographs and/or MRI) to confirm bone healing 1, 2
• All three parameters must be considered together to conclude remission 1, 2

Frequency of Follow-up

Appointment frequency should be based on fluctuation in edema volume, comorbidities, treatment risks, access to home care assistance, and patient progress 1

Surgical Considerations

Consider surgical intervention when: 1

• Instability of foot and ankle joints persists
• Deformity creates high risk of ulceration even within the offloading device
• Pain cannot be sufficiently controlled in TCC or non-removable device

Post-Remission Management

Lifelong Protective Strategy

• Custom footwear and orthoses that accommodate and support the foot shape to prevent reactivation 1, 2
• Below-knee customized devices for additional protection when deformity or joint instability is present to optimize plantar pressure distribution 1, 2
• Lifelong program of patient education, protective footwear, and routine foot care 5

Critical Clinical Pearls

Diagnostic Vigilance

• Always consider Charcot in any diabetic patient with neuropathy presenting with a hot, swollen, red foot—even if infection or ulceration is present 1
• The presence of ulceration and active infection does not exclude underlying active Charcot 1
• Initial plain radiographs may be normal; if clinical suspicion remains high, proceed immediately to MRI 1

Common Mistakes Leading to Poor Outcomes

• Delayed diagnosis and treatment leads to progressive deformity and potential amputation 2, 5
• Using removable devices when non-removable options are feasible results in poor adherence and treatment failure 2
• Premature discontinuation of immobilization before true remission is confirmed 1, 2
• Inadequate transition footwear after acute phase increases reactivation risk 1, 2

Long-term Monitoring Considerations

Non-removable device immobilization carries risks including muscle weakness, atrophy, falls, and psychological impacts that require monitoring throughout treatment 6