Charcot foot is a progressive, devastating pathology defined by bone and joint changes that occur as a result of loss of sensation. Also called Charcot joint or neuropathic arthropathy, this condition is almost always associated with the vascular and neurological changes caused by poorly controlled diabetes¹.

Although it was first diagnosed more than 130 years ago, diabetic Charcot foot remains a challenge for clinicians due to its rareness². The estimated prevalence of Charcot joint is about 0.1% to 0.9% among patients with diabetes^1,3,4. To put these numbers in context, for a prevalence of 0.56%, a general practitioner with 2,000 patients at his care and 100 patients with diabetes will have 0-1 patients with diabetic Charcot foot, and a new case every 13 years⁵.

Albeit rare, the consequences of neuropathic arthropathy can be catastrophic for patients: if unrecognized, disease progression may lead to ulcer formation, infection, and progression to active Charcot neuropathy, with joint instability and bone destruction^6,7. In extreme cases, diabetic Charcot foot can result in limb amputation^8,9.

Timely diagnosis is therefore essential, requiring an attentive clinician who is able to distinguish a Charcot joint from other pathologies such as erysipelas, cellulitis, acute gout, or peripheral vascular disease⁹. According to Mohammad Sharif, DPM, the combination of clinical signs and X-rays is the most common diagnostic approach to detect early Charcot. We dedicate other articles in this series to the medical diagnosis of Charcot arthropathy. In this text, we focus on the Charcot foot classification and definition.

What is Charcot Foot?

In January 2011, an international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this condition¹⁰.

The specialists defined the pathology as “a condition affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase.” Following the acute inflammatory phase, the interaction of metabolic, neuropathic, and traumatic factors “may lead to varying degrees and patterns of bone destruction, subluxation, dislocation, and deformity”¹⁰.

The authors also describe the hallmark deformity known as “rocker-bottom” foot, where there is a midfoot collapse in advanced stages of Charcot neuropathic arthropathy (Figure 1).

Medical Classification of Diabetic Foot

The natural progression of diabetic Charcot foot typically follows three stages, as described by Eichenholtz in 1966:

Stage I: acute or fragmentation phase
Stage II: subacute or coalescence phase
Stage III: consolidation and reconstructive phase

The first stage presents with evidence of osteopenia on radiographs, presence of periarticular debris or fragments, and joint subluxation or dislocation¹¹. On physical examination, the affected joint will display swelling, erythema, and/or ligamentous laxity¹¹. If the patient is in the second stage, their radiographs will show absorption of debris, early sclerosis, and bony consolidation of the larger fragments present in stage I, while clinical observation will reveal an apparent improvement of the condition, with decreased joint warmth and swelling¹¹. In the last stage described by Eichenholtz, there is progression of the joint to a more stable structure, which presents as a fixed deformity on clinical examination, without any signs or symptoms of inflammation¹¹.

Table 1 provides an overview of the Eichenholtz Charcot stages, with the addition of a stage 0¹² to reflect the observed clinical signs that precede radiographic changes.

Table 1: Modified Eichenholtz classification¹¹

Stage	Radiographic findings	Clinical findings
0 (prodromal)	Normal radiographs	Swelling, erythema, warmth
I (fragmentation)	Osteopenia, fragmentation, joint subluxation, or dislocation	Swelling, erythema, warmth, ligamentous laxity
II (coalescence)	Absorption of debris, sclerosis, fusion of larger fragments	Decreased warmth, decreased swelling, decreased erythema
III (reconstructive)	Consolidation of deformity, joint arthrosis, fibrous ankyloses, rounding and smoothing of bone fragments	Absence of warmth, absence of swelling, absence of erythema, stable joint ± fixed deformity

Other classification systems focus on the anatomical aspects of neuropathic arthropathy, such as those proposed by Sanders and Frykberg¹³ and by Brodsky and Rouse¹⁴. In these classifications, the authors propose patterns of joint involvement in the joint and ankle, which may occur individually or in conjunction with other areas. The Sanders and Frykberg classification describe type I to be the involvement of the metatarsophalangeal joints, type II occurs when the Lisfranc joint is affected, in type III the Chopart joint, and in type IV and V the subtalar joint and the calcaneus are involved, respectively¹³. The Brodsky and Rouse classification is now more widely used, and has somewhat different anatomical attributions.

Table 2: Brodsky anatomic classification of Charcot arthropathy foot

Type	Location	Involved joints
1	Midfoot	Naviculocuneiform, tarsometatarsal
2	Hindfoot	Subtalar, calcaneocuboid, talonavicular
3A	Ankle	Tibiotalar
3B	Calcaneus	Tuberosity fragmentation

It can be difficult to distinguish between the different clinical stages of Charcot joint, and in this context, classification systems are important tools to promote communication among physicians¹⁶. Despite their age, all three classification systems described above have demonstrated good to excellent inter- and intrareader reliability¹⁶.

Charcot joint remains a serious complication of diabetes, with a complex presentation and guarded prognosis. It is fundamental to understand the underlying pathophysiological mechanisms in order to treat the condition appropriately⁹. Up to date resources on this challenging condition can be consulted here. To explore the surgical treatment of Charcot arthropathy foot, read our article on surgical approaches.

References

Dardari D. An overview of Charcot’s neuroarthropathy. J Clin Transl Endocrinol. Dec 2020;22:100239. doi:10.1016/j.jcte.2020.100239
Schmidt BM. Clinical insights into Charcot foot. Best Pract Res Clin Rheumatol. Jun 2020;34(3):101563. doi:10.1016/j.berh.2020.101563
Fabrin J, Larsen K, Holstein PE. Long-term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care. 2000;23(6):796-800. doi:10.2337/diacare.23.6.796
Stuck RM, Sohn MW, Budiman-Mak E, Lee TA, Weiss KB. Charcot arthropathy risk elevation in the obese diabetic population. Am J Med. Nov 2008;121(11):1008-14. doi:10.1016/j.amjmed.2008.06.038
Svendsen OL, Rabe OC, Winther-Jensen M, Allin KH. How Common Is the Rare Charcot Foot in Patients With Diabetes? Diabetes Care. 2021;44(4):e62-e63. doi:10.2337/dc20-2590
Frykberg RG, Belczyk R. Epidemiology of the Charcot Foot. Clinics in Podiatric Medicine and Surgery. 2008/01/01/ 2008;25(1):17-28. doi:https://doi.org/10.1016/j.cpm.2007.10.001
Wukich DK, Sung W, Wipf SAM, Armstrong DG. The consequences of complacency: managing the effects of unrecognized Charcot feet. Diabetic Medicine. 2011;28(2):195-198. doi:https://doi.org/10.1111/j.1464-5491.2010.03141.x
Marmolejo VS, Arnold JF, Ponticello M, Anderson CA. Charcot Foot: Clinical Clues, Diagnostic Strategies, and Treatment Principles. Am Fam Physician. May 1 2018;97(9):594-599.
Trieb K. The Charcot foot. The Bone & Joint Journal. 2016;98-B(9):1155-1159. doi:10.1302/0301-620x.98b9.37038
Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot Foot in Diabetes. Journal of the American Podiatric Medical Association. 01 Sep. 2011 2011;101(5):437-446. doi:10.7547/1010437
Rosenbaum AJ, DiPreta JA. Classifications in brief: Eichenholtz classification of Charcot arthropathy. Clin Orthop Relat Res. Mar 2015;473(3):1168-71. doi:10.1007/s11999-014-4059-y
Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy. JBJS. 1990;72(5)
Sanders L. Diabetic neuropathic osteoarthropathy: the Charcot foot. The high risk foot in diabettes mellitus. 1991;
Brodsky JW, Rouse AM. Exostectomy for symptomatic bony prominences in diabetic charcot feet. Clin Orthop Relat Res. Nov 1993;(296):21-6.
Mohamad A, Carlo R. Midfoot Charcot Neuroarthropathy. Int J Foot Ankle. 2018/12/31/ 2018;2(2)doi:10.23937/ijfa-2017/1710021
Wukich DK, Raspovic K, Liu GT, et al. Are the Sanders-Frykberg and Brodsky-Trepman Classifications Reliable in Diabetic Charcot Neuroarthropathy? The Journal of Foot and Ankle Surgery. 2021;60(3):432-435. doi:10.1053/j.jfas.2020.03.003

Surgical Management of the Charcot Ankle2024-01-17

Charcot neuroarthropathy of the ankle is an especially challenging condition that often leads to instability and destruction of the joint with significant morbidity requiring an amputation in many instances^1-3. According to Brodsky et al., the ankle is affected in 9% of patients with Charcot neuroarthropathy, whereas the hindfoot is involved in 30-35%³. The overall goal of Charcot ankle reconstruction is to achieve a painless, plantigrade and stable foot, and thus avoid ulceration with subsequent infection^1,2. However, this procedure is also associated with a high complication rate^1,2.

Postoperative Management in Charcot Foot Reconstruction2024-01-10

The successful treatment of Charcot foot does not end with a completed surgery; success also requires a diligent postoperative care regime. This devastating condition mainly affects patients with diabetes and peripheral neuropathy, resulting in bone destruction and joint deformation¹. During the initial, inflammatory stage, the recommended treatment consists of off-loading with total contact casts or custom orthotics to prevent further damage, although surgical management is indicated in cases of severe instability or soft tissue compromise². After the acute stage, the focus of treatment is on deformity correction and foot reconstruction to prevent further damage and improve the patients’ quality of life².

Foot and Ankle Charcot Reconstruction with External Fixation2023-12-20

Surgical reconstruction of foot and ankle Charcot with external fixation is especially useful in the presence of poor bone quality, ulceration, compromised soft tissue, active infection, or osteomyelitis – cases in which the use of internal fixation is limited or contraindicated¹.

Charcot Foot Reconstruction Using Internal Fixation2023-12-12

Appropriate timing for surgical intervention is a matter of controversy among specialists¹. While in the past Charcot foot surgical reconstruction was mainly reserved to salvage the limb, today surgeons also perform operative corrections to ensure patients can use commercially available footwear instead of cumbersome orthoses¹. Regardless, the main goal of Charcot foot surgery, independent of the fixation method, is to create a stable and plantigrade foot. This article will discuss different approaches for Charcot foot surgery with internal fixation, focusing on midfoot reconstruction.

Expert Tips on How to Medically Diagnose Charcot Arthropathy2023-11-30

The diagnosis of Charcot neuroarthropathy of the foot and ankle can be challenging due to a lack of information in the patient's history, clinical assessment, imaging, and laboratory findings¹. It is assumed that one in four cases of acute foot and ankle Charcot are undiagnosed or misdiagnosed¹. However, correct diagnosis and effective treatment are crucial to avoid ulceration, worsening deformity, infection, or amputation¹.

Charcot Arthropathy Symptoms and Initial Stage2023-11-21

Charcot arthropathy occurs in the presence of peripheral neuropathy and metabolic abnormalities. Today it is seen more commonly in patients with long-standing diabetes^1,2. Its pathogenesis, although still largely unknown, involves several pro-inflammatory pathways, which stimulate osteoclastic activity³.

Medical Resources for Charcot Foot & Ankle Specialists2023-11-14

There is an overwhelming wealth of scientific literature available on Charcot foot. In this article, we gather and summarize some of the most interesting sources, including Charcot neuroarthropathy of the foot and ankle reviews, diabetic foot reviews, and diabetic foot care articles.

Charcot Surgical Reconstruction2023-11-14

Charcot foot, also called Charcot neuropathy, is a condition caused by a combination of peripheral neuropathy and vascular disorders that results in progressive joint damage and eventually foot instability¹. If left untreated, the consequences for patients are devastating, with reduced quality of life, inability to weight-bear, and an increased risk of amputation².

Surgical Approaches for Charcot Foot2023-11-14

Charcot neuroarthropathy is a rare, but devastating complication of diabetes¹. Progressive destruction of the bones and joints of the foot cause deformities and thus alter foot biomechanics¹. If not recognized nor treated properly, the disease can result in ulcer formation, infection, and progression of the disease with joint instability and bone destruction^2,3. In the worst case, limb amputation is required^4,5.

Tips for Timely Diagnosis of Charcot Foot and Ankle2022-01-17

It is known that around 9 per cent of patients with diabetic neuropathy and foot ulcers develop a Charcot foot and ankle. This pathology often goes unrecognized, particularly during the acute phase, until severe complications occur, such as an abnormal pressure distribution on the plantar fascia with bones weakened enough to fracture, followed by a marked foot and ankle deformation and, in the worst cases, by amputation. Thus, today, one of the most crucial questions is how to timely diagnose this condition.

Magnetic Resonance for Charcot Foot and Ankle Diagnosis2021-12-21

Charcot Foot and Ankle is a significant problem caused by peripheral neuropathy, with an estimated incidence of 0.3 to 7.5% in the diabetic population. This condition, which is also known as Charcot arthropathy, Charcot joint, or neuropathic arthropathy, affects the soft tissues, joints, and bones in the foot and ankle. If left untreated, it may lead to progressive foot deformity, ulceration, or osteomyelitis. In the most advanced stages, it may be necessary to resort to limb amputation.

Tips for the Prevention of Charcot Foot and Ankle2021-12-17

Charcot Foot and Ankle is a severe condition that, if left untreated, may lead to deformity, permanent disability, amputation or ultimately to the patient’s death. People with diabetic neuropathy are at high risk of developing Charcot Foot and Ankle, because of the decreased sensation and diminished ability to feel temperature, pain or trauma.

Computerized Tomography for Charcot Foot and Ankle Diagnosis2021-12-14

Charcot Foot and Ankle, also known as Charcot arthropathy or Charcot joint, is a condition caused by peripheral neuropathy, leading to the progressive degeneration and destruction of the soft tissue, joint, and bone. In modern society, the most common cause for this neuropathic neuropathy is diabetes mellitus, with long-term diabetic patients having an increased risk of developing the condition.

Radionuclide for Charcot Foot and Ankle Diagnosis2021-12-09

Early Charcot Foot Diagnosis is essential to a proper management, but this can be challenging. There are some factors that should increase clinical suspicion for acute Charcot arthropathy, namely if the patient presents with:

Radiography for Charcot Foot and Ankle Diagnosis2021-12-07

Charcot Foot and Ankle, also known as Charcot arthropathy, neuropathic arthropathy or Charcot joint, is a progressive condition that affects the bones, joints and soft tissue of the foot and ankle. It is caused by peripheral neuropathy. Today, diabetes is the most common cause for developing Charcot Foot and Ankle.

Charcot Foot and Ankle Diagnosis: The Multidisciplinary Approach2021-12-02

Patients with Charcot neuroarthropathy, a condition that affects the bones, joints, and soft tissues of the foot and ankle, greatly benefit from a timely diagnosis and appropriate treatment. However, Charcot Foot and Ankle diagnosis can be quite challenging, especially in an early stage, where acute symptoms can be similar to other conditions.

Charcot Foot and Ankle: Patient Questions and Doctor Answers2021-11-30

Linked to peripheral neuropathy, Charcot Foot and Ankle is one of the serious foot complications affecting people with diabetes. Foot injuries that go unnoticed due to the reduced pain sensation accumulate, and, over time, there is bone deformation, ulceration, and infection. In a worst-case scenario, amputation may be necessary.

Charcot Foot and Ankle Causes: Where the Pathology Starts2021-11-25

Charcot Foot and Ankle, also known as Charcot arthropathy, is a progressive, inflammatory condition that affects the bones, joints, and soft tissues in the feet of people with peripheral neuropathy. If left untreated, Charcot of the foot and ankle leads to severe deformity, ulceration, and – worst-case scenario – to limb amputation.

The Stages of Charcot Foot and Ankle Disease and The Importance of a Quick Diagnosis2021-11-23

When dealing with Charcot Foot Disease, a swift diagnosis is crucial to improve patient outcomes and avoid complications such as foot deformity, ulceration, and in a worst-case scenario, limb amputation. However, not all physicians are able to recognize the initial signs of a Charcot Foot and Ankle in their diabetic patients.

Emergency in Diabetic Foot and Ankle2021-11-16

Diabetic foot is one of the most important sources of morbidity in patients with diabetes, affecting 6.4% of patients worldwide. It is the most common cause of lower extremity amputation.

Charcot Foot and Ankle: Definition and Classification2021-11-12

Charcot Neuroarthropathy, also called Charcot Foot and Ankle, is a progressive and inflammatory condition that weakens the soft tissues, bones, and joints of the foot and ankle. This complex and challenging type of neuropathic arthropathy is commonly linked to diabetes. If left untreated, it can lead to devastating consequences, such as deformity, ulceration, and infection. In the worst-case scenario, it may result in limb amputation.

The Surgical Approach to the Charcot Foot and Ankle Treatment2021-05-24

Charcot Foot and Ankle is a complex, challenging and sometimes devastating inflammatory foot disease which causes loss of sensation, weakening of the bones and collapse of the weight bearing joints. Most often due to diabetes and underlying neuropathic arthropathy, it needs a multidisciplinary team approach in order to treat it properly and prevent amputation.

What Is Arthrodesis (Joint Fusion)?2021-05-06

Arthrodesis may be defined as the surgical immobilization of a joint by fusion of the bones. It is commonly referred to as joint fusion, also known as artificial ankylosis or syndesis. It can be performed in several parts of the body, and it is indicated in the presence of painful joints, often due to arthritis or osteoarthritis, with highly compromised mobility.

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RELATED APPLICATIONS

What is Charcot Foot?

Medical Classification of Diabetic Foot

Table 1: Modified Eichenholtz classification11

Table 2: Brodsky anatomic classification of Charcot arthropathy foot

Further Reading

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Table 1: Modified Eichenholtz classification¹¹