How should I approach the management of a patient with Charcot foot, including offloading strategies?

Management of a patient with Charcot foot involves prompt recognition, diagnosis, and offloading to prevent progression and deformity.

Suspect acute Charcot arthropathy in patients with diabetes who present with redness, warmth, swelling, or deformity of the foot, especially if peripheral neuropathy or renal failure is present, even if pain or deformity is not reported.

Confirm diagnosis by arranging a weight-bearing X-ray of the affected foot and ankle; consider MRI if X-ray is normal but suspicion remains.

Refer the patient within 1 working day to a multidisciplinary foot care service for triage within 1 further working day.

Until definitive treatment starts, offer non-weight-bearing treatment.

For treatment, the multidisciplinary foot care service should provide a non-removable offloading device to offload the foot; if this is not suitable due to clinical or patient factors, a removable offloading device may be considered.

Monitor treatment progress clinically by measuring foot-skin temperature differences and taking serial X-rays until resolution, defined as a sustained temperature difference of less than 2 degrees Celsius between feet and no further X-ray progression.

Bisphosphonates are not recommended for treating acute Charcot arthropathy outside clinical trials.

Patients with foot deformities from previous Charcot arthropathy are at high risk of ulceration and should be managed by the foot protection service.