In diagnosing Charcot’s foot and minimizing subsequent risk of amputation, Caputo, et. al., addressed six important points that every physician treating diabetic patients should know.7
1. Be aware that Charcot’s foot can mimic cellulitis or deep venous thrombosis. While you should certainly consider cellulitis in a patient who is diabetic and presents with a warm, edematous and erythematous foot, misdiagnosing Charcot’s arthropathy in the acute phase of the disease can be disastrous for the patient. Failure to initiate proper treatment not only exacerbates the problem but also can lead to inappropriate treatment with antibiotics, a futile attempt of incision and drainage and needless complications.
If there is any doubt about the presence of infection, you can initiate antimicrobial therapy but you must offload the extremity if the diagnosis of Charcot’s foot remains likely. In our practice, we have a high clinical suspicion of acute Charcot’s foot for all patients who present with diabetes and unilateral swelling of the lower extremity.
2. Do not allow the existence of little or no pain to mislead you or the patient. A finding of minimal pain or no pain can lead patients and physicians to ignore this debilitating disease.
3. Keep in mind that radiographic findings are often normal in the early developmental phase of the disease. X-ray findings often present later during the process of Charcot’s foot, making the diagnosis difficult. If you suspect acute Charcot’s arthropathy during the initial clinical presentation, institute a proper treatment regimen and take serial radiographs.
4. Strict immobilization and protection of the foot, preferably in a total contact cast, is the standard of care to managing the acute Charcot process.
5. A careful program of detailed patient education, protective footwear and a multidisciplinary team approach is required to prevent future complications. Reactivation of the Charcot process can occur and a foot with significant deformity remains at risk for ulceration, infection and osteomyelitis. Meticulous management for these patients, from a podiatric standpoint, is an integral aspect of a lifelong program of foot protection and prevention of skin breakdown.
6. Reconstructive surgery is often reserved for patients who are refractive to conservative measures despite compliance and aggressive treatment.