The acute Charcot foot is characterized by bone fracture and dislocation, and is a rare complication of distal symmetrical neuropathy in diabetes. The cause is unknown, but it cannot be attributed solely to loss of protective sensation. However, recent advances in understanding the mechanisms of osteoclast activation have suggested that the key abnormality may lie in an enhanced inflammatory response to injury, which is itself linked to increased bone lysis. The recognition that the acute Charcot foot is essentially an inflammatory arthropathy suggests new options for the management of this potentially devastating condition.