When Charcot Hides in Plain Sight: A Case Worth Noting

There's a problem in diabetic foot care...

that doesn’t get enough attention: one of the most destructive conditions a diabetic foot can develop is also one of the most frequently missed. A recent case report out of the Philadelphia College of Osteopathic Medicine’s Georgia campus — presented by Nasir Abbasi, Jovante Dockery, Aribah Ali, Kevin Tang, and Dr. Vaishali Jadhav at PCOM Research Day 2026 — puts a sharp point on it, and adds a wrinkle worth sitting with.

The Case

The patient was a 37-year-old woman, recently postpartum, with type 2 diabetes. During her pregnancy she developed progressive swelling and pain in her right foot and ankle. Early imaging — an X-ray and ultrasound taken a few months prior — came back negative. But the symptoms didn’t resolve. They worsened, to the point of extreme pain, until she presented for further evaluation.

By the time she was properly assessed, the situation had changed. Her foot was diffusely swollen, red, and warm, with no ulcer or obvious injury. She had decreased strength and asymmetrical sensation on that side compared to the other leg. Repeat imaging told the real story: an MRI showed extensive bone marrow edema and fragmentation across the talus, calcaneus, and midfoot. It was Charcot neuroarthropathy and the foot was quietly coming apart at the joints.

Where this gets missed

Charcot is a condition where, in a foot that has lost protective sensation, a runaway inflammatory process drives the bone to break down — the body essentially dismantling its own architecture without the patient feeling the warning pain that would normally stop them. The authors make the key teaching point cleanly: in its early, active phase, Charcot looks like a lot of other things. A hot, swollen, red foot reads just as easily as cellulitis, gout, a blood clot, or inflammatory arthritis. And critically, early X-rays often look unremarkable, exactly as they did here. The diagnosis frequently only becomes obvious once damage is already underway.

That delay is the issue. Caught early and offloaded, a Charcot foot can often be stabilized. Caught late, it can lead to permanent deformity, ulceration, and in the worst cases, amputation.

The pregnancy pickle

What makes this case more than a standard reminder is the hormonal angle. The authors point to relaxin, a hormone that rises in pregnancy and loosens ligaments and tendons to prepare the body for childbirth, and note that relaxin appears to run higher in diabetic women, alongside estradiol’s effects on connective tissue. Their proposed idea: pregnancy-related ligament laxity, stacked on top of uncontrolled diabetes and neuropathy, may have created the conditions for Charcot to take hold in a relatively young patient.

It’s a compelling thread, and they back it with prior literature. But it’s worth being clear-eyed about what kind of evidence this is.

How much weight should this carry?

This is a case report. A detailed story about one patient. In the hierarchy of medical evidence, that sits at the foundation, not the top. A single case can’t tell us how common this scenario is, and it can’t prove that pregnancy hormones caused this woman’s Charcot, only that the two coincided in a biologically plausible way. The hormonal mechanism is a reasonable hypothesis resting on one observation, not a settled conclusion.

There are also gaps the poster format leaves open. The title promises a “misdiagnosis,” but we’re never told precisely what she was mistakenly thought to have, or for how long the wrong path was followed, which would have sharpened the lesson considerably.

None of that makes the report unimportant. Case reports exist for exactly this purpose: to wave a flag when something doesn’t fit the usual pattern. The thalidomide crisis was first caught through case reports. Their job is to make the rest of us look twice.

Our Conclusion

Set the hormones aside for a moment and the durable lesson is this: when a person with diabetes and neuropathy presents with a hot, swollen foot and clean early X-rays, Charcot belongs on the list, and a normal first film doesn’t clear it. If anything, this case suggests the patients we need to keep that suspicion alive for may be younger than the textbook stereotype, including during and after pregnancy.

That’s a conversation worth having across primary care, podiatry, OB, and endocrinology because the foot doesn’t hurt the way it should, and by the time it’s obvious, the window has often already started to close.