#### Key points A 38 year old man was referred by his general practitioner to our diabetes foot clinic with a swollen red foot (fig 1⇓). He had had type 1 diabetes for 25 years, complicated with retinopathy, peripheral neuropathy, and nephropathy, and was being worked up for dialysis following a failed pancreas-kidney transplant. The absence of pain together with preserved pulses and intact skin raised a suspicion of acute Charcot foot. A plain radiograph of the foot showed fractures through the necks of the first three metatarsals (fig 2⇓). We offloaded the foot in a total contact cast and advised the patient to limit weight bearing. Magnetic resonance imaging (MRI) subsequently confirmed neuroarthropathic changes of acute Charcot (fig 3⇓). Fig 1 Acute Charcot foot Fig 2 Plain radiograph of the foot showing fractures through the necks of the first three metatarsals Fig 3 Axial T1 weighted MRI showing pathological fractures through the necks of the first three metatarsals (arrows) with oedema in metatarsal shafts and lateral cuneiform bones (arrow heads). These features, in a patient with diabetes and no history of trauma, suggest acute Charcot foot Charcot’s neuroarthropathy is a destructive process of bone and joint, typically seen in a foot that …