Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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A hot swollen neuropathic flat foot is Charcot until excluded
Rapid unilateral warmth, oedema and shape change in a person with neuropathy, particularly diabetes, may be active Charcot arthropathy even with little pain and normal early radiographs; ulceration, infection or ischaemia adds limb-threatening urgency.
Action: Stop weight-bearing, immobilise in a safe device, inspect skin, assess perfusion, sensation, glucose and infection, and arrange multidisciplinary diabetic-foot assessment within one working day or immediate acute admission for sepsis, deep infection, gangrene or critical ischaemia.
Synopsis
Recognise progressive collapsing foot deformity from posterior tibial tendon and ligament failure, separate flexible from rigid disease and neuropathic collapse, assess skin and circulation, and deliver orthotic, rehabilitation and reconstructive care before fixed disability develops.
Adult acquired flatfoot is now described as progressive collapsing foot deformity because tendon, spring ligament, hindfoot, forefoot and sometimes ankle fail together.
Key findings are medial ankle pain, hindfoot valgus, forefoot abduction and too-many-toes appearance, with weak or painful single-leg heel rise and failure of the heel to invert.
Determine flexibility: a deformity that corrects with heel rise or manual positioning can use joint-preserving options, whereas fixed subtalar or midfoot disease often requires fusion-based planning.
Key red flags
A unilateral hot red swollen foot with neuropathy requires immediate offloading and active Charcot assessment rather than continued walking for presumed tendon pain.
Investigation priorities
01
First-line standing flexibility and heel-rise examinationFirst stepFirst line
Confirm progressive deformity, posterior tibial dysfunction and whether hindfoot and forefoot remain correctable.
02
First-line weight-bearing foot and ankle radiographsFirst line
Quantify arch collapse, talar uncoverage, hindfoot alignment, arthritis and ankle tilt under load.
Management branches
First-lineStage flexibility and tissue safety
A new or progressive adult flatfoot is present without immediate sepsis or ischaemic threat.
Examine standing alignment, single heel rise, manual flexibility, calf tightness, joints, skin, sensation and pulses.
Obtain weight-bearing foot, hindfoot and ankle radiographs when symptoms or progression justify structural assessment.
Key medicines
Topical diclofenac gelApply 2–4 g of diclofenac 1.16% gel to intact painful medial-foot or ankle skin per dose, no more than three or four times daily for a short trial within the product maximum.
Oral naproxen with gastroprotection when appropriateWhen justified, take oral naproxen 250–500 mg with food twice per day and stop after the shortest useful course; where gastroprotection is needed, prescribe omeprazole 20 mg once daily during exposure.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.