Charcot foot (Charcot neuroarthropathy) is a progressive complication primarily affecting individuals with long-standing diabetes and peripheral neuropathy. The condition involves the rapid weakening and destruction of bones and joints in the foot or ankle. Because nerve damage causes a loss of sensation, minor injuries or fractures go unnoticed, leading to continued walking on an unstable foot. While reversing the structural damage is generally not possible, timely intervention can stop the destructive progression and restore stability. Management focuses on controlling the active disease process and preventing further collapse.
Understanding Charcot Foot Stages
The success of stopping the destructive process depends heavily on the stage of the condition at diagnosis. Charcot foot is typically described using a temporal staging system, such as the Eichenholtz classification.
Acute Phase (Stage 1 or Fragmentation)
This phase is marked by significant inflammation, presenting as a foot that is red, swollen, and warmer than the opposite foot. During this stage, bones actively break down and fragment, causing the most severe structural damage. Early detection in this phase allows for the most effective intervention to halt active destruction.
Subacute Phase (Stage 2 or Coalescence)
Inflammation begins to subside, and the body attempts to repair the damage by consolidating the fragmented bone pieces.
Chronic Phase (Stage 3 or Reconstruction)
Inflammation has completely resolved, and the foot structure is stabilized. The foot is typically left with a fixed deformity.
Halting Progression in the Acute Phase (Non-Surgical Intervention)
Halting bone destruction in the acute, inflammatory phase is the closest outcome to “reversal.” This is achieved through aggressive offloading and immobilization of the affected foot to stabilize it until inflammation subsides and weakened bones consolidate.
The standard of care for acute stabilization is the Total Contact Cast (TCC). This non-removable, custom-molded cast redistributes high pressure points over a larger surface area, including the lower leg. The TCC provides mechanical stability, preventing movement between fragmented bones necessary for healing.
TCC treatment often lasts three to eight months, with the cast changed every one to two weeks to monitor the foot. The acute phase is resolved when the foot’s temperature difference compared to the healthy foot falls below two degrees Celsius, signaling the destructive process has stopped. Patients are then transitioned to a protective brace or custom footwear.
Addressing Irreversible Damage (Surgical Reconstruction)
If the acute phase is missed or conservative treatment fails, the Charcot process progresses to a fixed, chronic deformity. A common outcome is the “rocker-bottom” foot, where the arch collapses inward, creating a bony prominence susceptible to chronic ulceration. When damage is permanent, surgical reconstruction is necessary to restore stability and function.
The primary goals of surgery are to realign the foot, remove sharp bony prominences (exostectomy), and fuse affected joints (arthrodesis). Surgeons use specialized internal or external fixation hardware to hold the realigned bones in place while they heal. The procedure aims to create a stable, plantigrade foot—one that rests flat on the ground—which can be safely accommodated in protective footwear.
Surgery is performed only after the acute, inflammatory phase has passed, as operating on an inflamed foot carries a higher risk of complications. Recovery is extensive, often requiring months of complete non-weight-bearing followed by gradual rehabilitation. The success of the surgery is measured by achieving a stable foot that prevents ulcers and allows for safe ambulation.
Long-Term Monitoring and Preventing Recurrence
Lifelong protective measures are mandatory after the foot has successfully stabilized, whether through non-surgical immobilization or surgical reconstruction. The foot remains vulnerable to a new Charcot event or the development of pressure ulcers. Patients must wear custom-molded footwear and specialized orthotic inserts to ensure proper pressure distribution.
Regular foot inspections should be performed daily to check for signs of pressure, redness, or skin breakdown. Strict management of diabetic neuropathy is also required, meaning consistent control of blood glucose levels is paramount to mitigate the risk of further nerve and bone damage. Patients who maintain protective footwear and excellent glycemic control have a high rate of limb preservation.