Synopsis
Recognise active Charcot neuro-osteoarthropathy early, distinguish it from infection and acute ischaemia, and protect the foot before irreversible collapse occurs.
- A warm, swollen, red foot with intact skin in a person with diabetes and neuropathy is active Charcot until proved otherwise, even when pain and radiographic changes are absent.
- Make the foot non-weight-bearing immediately and refer within one working day for multidisciplinary triage; continued walking can convert inflammation into irreversible collapse.
- Immediate acute referral overrides the routine Charcot pathway when sepsis, ulcer with ischaemia, gangrene or deep infection concern is present.
Key red flags
Fever, purulence, ulcer tracking to bone, spreading erythema, systemic illness or marked inflammatory deterioration raises concern for infection with or without Charcot.
A cold mottled foot, absent Doppler signals, rest pain, gangrene or abrupt perfusion change suggests ischaemia rather than uncomplicated active Charcot.
Crepitus, bullae, disproportionate pain or haemodynamic instability may indicate necrotising infection and requires immediate acute surgical care.
New deformity, instability, plantar prominence or skin compromise shows structural progression and impending ulceration even when the patient reports little pain.
An ulcer over abnormal bone, purulence, a tract, fever or systemic illness increases osteomyelitis concern. Charcot and infection can coexist, so do not force a false either-or choice.
Investigation priorities
Document inflammatory asymmetry, skin integrity, neuropathy, deformity and competing infection or vascular findings.
Management branches
A person with diabetes and neuropathy develops unexplained unilateral foot warmth, redness or swelling with or without deformity.
- Make the affected foot non-weight-bearing immediately, provide safe mobility support and refer within one working day to the multidisciplinary foot care service.
- Inspect for ulcer and infection, assess perfusion and neuropathy, and arrange weight-bearing foot and ankle radiographs when safe; escalate immediately for acute threats.
Active Charcot is suspected or confirmed and frequent wound access or another contraindication does not preclude non-removable treatment.