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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Offload the hot neuropathic foot before radiographic proof
Unilateral warmth, oedema, erythema or shape change in a person with neuropathy may be active Charcot disease despite little pain, normal inflammatory markers and normal early radiographs; ulcer, sepsis, deep infection, gangrene or ischaemia can coexist.
Action: Make the patient non-weight-bearing immediately, immobilise in a safe knee-high device, inspect for ulcer and infection, assess perfusion, glucose and sepsis, and arrange multidisciplinary foot-care assessment within one working day or immediate acute admission for limb- or life-threatening disease.
Synopsis
Treat the hot swollen neuropathic foot as active Charcot neuroarthropathy until excluded, distinguish it from infection without false reassurance, institute immediate knee-high immobilisation and offloading, and prevent collapse, ulceration and amputation through multidisciplinary care.
Suspect active Charcot neuroarthropathy when a person with neuropathy develops unilateral foot warmth, swelling, redness or shape change, often after minor or unremembered trauma and with surprisingly little pain.
First-line action precedes imaging: make the patient non-weight-bearing, immobilise in a knee-high device and refer to the multidisciplinary foot-care service within one working day.
Assess infection and perfusion at the same encounter; Charcot disease, ulcer infection, osteomyelitis and peripheral arterial disease can coexist rather than being mutually exclusive.
Key red flags
A newly hot red swollen foot with diabetes or other neuropathy requires immediate immobilisation and non-weight-bearing even if pain is mild and the first radiograph is normal.
Investigation priorities
01
First-line bilateral foot and systemic assessmentFirst stepFirst line
Identify active inflammation, neuropathy, ulcer infection, sepsis and perfusion threat before imaging.
02
First-line weight-bearing foot and ankle radiographs when safeFirst line
Detect fracture, subluxation, fragmentation, collapse, gas and bony destruction and provide an alignment baseline.
Management branches
ImmediateOffload before confirmation
A neuropathic foot becomes unilaterally hot, swollen, red or newly deformed.
Stop weight-bearing, provide safe transport and immobilise in a knee-high device that protects current alignment and skin.
Inspect for ulcer and spreading infection and assess systemic physiology, glucose, sensation, pulses and the other foot.
Key medicines
Flucloxacillin for selected mild diabetic-foot infectionWhen clinical infection is mild and oral treatment is appropriate, give flucloxacillin 500 mg to 1 g orally four times daily for 7 days, then review response and microbiology; the 1 g four-times-daily dose is off label.
VTE prophylaxis during immobilisation when risk outweighs bleedingUse the local prophylactic low-molecular-weight heparin or fondaparinux regimen after weight, renal function, pregnancy, platelet and bleeding review, following NICE NG89 and considering stopping when lower-limb immobilisation continues beyond 42 days.
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.