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⇓).