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T YPICALLY, THE DOWNWARD spiral toward lower extremity amputation in the diabetic patient begins with an open pedal ulcer. Preventing the foot ulcer, therefore, is an effective approach to amputation prevention in this patient population. As is the case in other areas of disease prevention, the management of risk factors is important. Certainly, ischemia, peripheral sensory neuropathy, history of a prior foot ulcer, and contralateral lower extremity amputation are well known risk factors for a new diabetic foot ulcer. 1 However, neuroarthropathy in the diabetic foot and ankle is a powerful risk factor for ulcer- ation that often lacks proper recognition and management. Loss of pain and proprioceptive sensation in the diabetic neuropathic foot can lead to progressive periarticular bony fragmenta- tion that eventually causes a loss of foot structure and an ulcer-producing foot deformity. This bony complication of an insensate foot is known as a "Charcot foot" due to its description by Jean-Marie Charcot, a French neurologist, in 1868. Timely recognition of the neuroar- thropathy cascade is critical. Following recognition of a possible acute Charcot Foot, t wo things should occur: 1) Offloading and protection of the affected foot and 2) Referral to a surgically trained podiatric physician. Specialist care will involve attempts at long-term offloading of resultant deformities. However, surgical offloading and/or stabilization is often necessary to salvage the unbraceable foot/ankle. Dr. Jeffrey Whitaker is Board Certified in Foot and Ankle Surgery by the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. He is Division Head and Associate Professor of Podiatric Surgery at Kent State University College of Podiatric Medicine in Independence, Ohio. ■ Reference 1. Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 1999;22(7):1029-35 Neuroarthropathy in the Diabetic Foot: A Significant Amputation Risk By Jeffrey M. Whitaker, DPM