Question
A 50 year old man with type 2 diabetes is sent to you by his GP with a warm, swollen foot. Antibiotics have not helped. His radiograph is shown.
- What are the main points in the assessment of this patient?
- How would you distinguish this from infection?
- What are the stages and how would you manage him?
Answer
Assessment
- Likely Charcot neuroarthropathy of the midfoot
- Neuropathy with loss of protective sensation on 10 g monofilament testing
- Vascular assessment with pulses, ankle brachial and toe pressures
- Skin for ulceration, which raises the risk of osteomyelitis
- Temperature difference over 2 degrees compared with the other foot
- Glycaemic control and renal function
- Radiographs show fragmentation, subluxation and loss of the arch, with rocker bottom deformity later
Charcot versus infection
- Charcot foot without an ulcer is rarely infected
- Elevation for 10 to 15 minutes reduces redness in Charcot but not in cellulitis
- MRI shows diffuse subchondral oedema in Charcot and sinus tracts, abscess or marrow replacement near an ulcer in osteomyelitis
- Bone biopsy if doubt remains
Stages and management
- Eichenholtz stages are fragmentation, coalescence and consolidation, with stage 0 as the prodromal inflamed foot with normal radiographs
- Brodsky anatomical types are tarsometatarsal (most common), Chopart and subtalar, ankle and calcaneal tuberosity
- Total contact casting and non weight bearing until temperature difference settles, often 3 to 6 months
- Then a Charcot restraint orthosis walker and custom footwear
- Surgery for unbraceable deformity, recurrent ulceration or instability, with exostectomy or realignment arthrodesis using superconstructs
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.