Foot Problems in Charcot-Marie-Tooth Disease

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Foot Surgery for Charcot-Marie-Tooth (CMT) Foot Disorders

A simple guide to high-arched foot problems in CMT and how surgery can help — from Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, London & North London.

At a Glance: Foot Surgery for Charcot-Marie-Tooth Disease

What is CMT?A condition you are born with that affects the nerves to your feet, legs and hands. Some muscles become weaker than others.
What happens to the foot?The arch gets higher, the heel tips inwards, the toes curl (claw toes) and the foot may drop when you walk. Doctors call this a “cavovarus” foot.
Common problemsPain on the outside edge and ball of the foot, going over on the ankle, falls, hard skin and trouble finding shoes that fit.
TestsA careful examination, a simple block test, X-rays taken standing up and a 3D standing scan (Weight-Bearing CT).
First treatmentExercises with a physiotherapist, insoles and ankle braces.
SurgeryStraightening the bones, moving tendons to rebalance the foot and, if the foot is stiff or worn, fusing joints. Every operation is planned for your foot.
RecoveryAbout 6 weeks in a cast if your joints can be kept; about 12 weeks if joints are fused.
Who to seeMr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon — RNOH Stanmore and private clinics in London & North London.
01

What Is Charcot-Marie-Tooth Disease?

Charcot-Marie-Tooth disease (CMT) is a condition that runs in families. It affects the nerves that carry messages from the spine to the muscles and skin. You may also hear it called hereditary motor and sensory neuropathy (HMSN). Over time, CMT slowly weakens and thins the muscles furthest from the body — in the feet, lower legs and hands — and can reduce feeling in these areas.

Because some muscles get weaker sooner than others, the stronger muscles slowly pull the foot out of shape. At first the foot is still flexible and can be pushed back into a normal position. Over the years, though, the soft tissues tighten and the joints wear, so the foot becomes stiff and can become arthritic.

There are more than 80 different genetic types of CMT. The most common is CMT type 1, which makes up 40–50% of all cases. Within this, type 1A is the most common form.

02

How Common Is It?

CMT affects between 8 and 41 people in every 100,000 worldwide — roughly 5,000 to 28,000 people in the UK. About 7 in 10 people with CMT develop a change in the shape of their feet, and about 3 in 10 eventually need foot surgery.

CMT is also the most common reason for having high arches in both feet. In one study of 148 people seen in clinic with high arches and inward-tipping heels on both sides, almost 8 in 10 turned out to have CMT. This rose to 9 in 10 when someone else in the family had similar feet. So if you have high arches in both feet, it is worth being checked for a nerve condition.

03

Why Does CMT Change the Shape of the Foot?

In CMT, the muscles weaken in a typical pattern. Some muscles stay strong while the muscles that should balance them get weaker. This muscle imbalance is what changes the shape of the foot, and understanding it helps us plan the right treatment:

  • Foot drop — the muscle at the front of the shin that lifts the foot (tibialis anterior) gets weaker, so the toes can catch on the ground. The muscles that lift the toes try to help, but this makes the toes curl more.
  • Heel tipping inwards (hindfoot varus) — a strong muscle on the inner side of the ankle (tibialis posterior) overpowers a weaker muscle on the outer side (peroneus brevis), pulling the heel inwards.
  • High arch (cavus) — a strong muscle on the outer side (peroneus longus) pulls the bone behind the big toe (the first metatarsal) downwards. To keep the foot balanced on the ground, the heel then tips further inwards. Doctors call this a forefoot-driven heel problem.
  • Claw toes — the small muscles inside the foot weaken. The long tendons then pull the toes up at the base and bend them down at the middle joints.
04

What Are the Symptoms?

  • Pain along the outside edge of the foot and under the ball of the foot
  • A wobbly ankle — going over on your ankle often, poor balance and falls
  • Hard skin (calluses) on the outside edge of the foot and under the ball of the foot
  • Broken bones on the outside of the foot (fifth metatarsal fractures), from too much pressure on that side
  • Claw toes rubbing in shoes, causing corns or sores on top of the toes
  • Tripping or catching your toes when you walk, because of foot drop
  • Difficulty finding shoes that fit comfortably
Good to know: A mild CMT foot is sometimes first noticed as what looks like a sports injury — an ankle that keeps rolling, pain in the tendons on the outside of the ankle, or a stress fracture in the foot that will not heal. If the heel position causing the problem is not spotted, treating the injury on its own is less likely to work.
05

What Tests Might You Need?

  • A careful examination — Mr Welck will look at your feet from the front, side and back, watch you walk, test the strength of each group of muscles (scored from 0 to 5), and check how flexible your foot is, how loose your ankle ligaments are and how tight your calf and Achilles tendon are.
  • The Coleman block test — you stand with a small block under the outer edge of your foot, which lets the big-toe side drop down. If your heel straightens, the heel is still flexible and the problem is being driven by the front of the foot. This helps decide which operation you need.
  • X-rays taken while standing — these show how the bones line up when you put weight on the foot, and whether there is any arthritis.
  • Weight-Bearing CT — a 3D scan taken while you stand, showing exactly how the bones sit under your body weight, with less radiation than a standard CT scan. Mr Welck uses it to assess the foot and to plan surgery.
  • MRI scan — to look at the joint surfaces, any arthritis and the tendons.
  • Nerve tests and genetic tests — usually arranged by a nerve specialist (neurologist) to confirm CMT and which type you have.
Please note: If your reflexes are unusually brisk, or one side is very different from the other, the cause may be in the spine rather than CMT, and further tests will be needed.
06

Treatment Without Surgery

Most people start with treatment that does not involve an operation. This will not stop CMT getting worse, but it can make you more comfortable, steadier and better able to walk:

  • Physiotherapy — stretching tight calf muscles and the tissue under the foot (plantar fascia), strengthening exercises and balance training.
  • Corrective insoles if your foot is still flexible — for example, a wedge under the outer heel and a dip under the big-toe joint to help straighten the foot.
  • Cushioning insoles if your foot is stiff — these spread the pressure. A corrective insole on a stiff foot tries to push it into a shape it cannot reach, which causes pain.
  • Ankle braces (ankle–foot orthoses or AFOs) for foot drop and a wobbly ankle.
  • Footwear advice — shoes with a deep, wide toe area and good ankle support.

Even if you do not need surgery, it helps to see a foot and ankle surgeon early, as part of a team that includes a neurologist, physiotherapist and orthotist (brace and insole specialist). This means any surgery you need later can be carried out at the right time.

07

Surgery for the CMT Foot

Surgery is considered when the foot is painful, keeps giving way or no longer sits flat on the ground, even after insoles, braces and physiotherapy. Whether your foot is flexible or stiff, the aim is the same — to put the foot back under the ankle, and the foot flat on the ground. To do this, surgery aims to:

  1. Straighten the heel so it sits directly under the ankle.
  2. Lift the bone behind the big toe so it is level with the others and no longer pulls the heel inwards.
  3. Rebalance the tendons so the foot is less likely to slip back out of shape.

Most people need a combination of the operations below, usually done at the same time. Because every CMT foot is different, the exact combination is sometimes only finalised during the operation.

Straightening the Heel (Calcaneal Osteotomy)

If your heel is still flexible, the heel bone (calcaneus) is cut and moved outwards so it sits under the leg. No joints are fused. The bone can be slid across, or a small wedge of bone can be removed, or both — research shows that doing both gives the biggest correction.

Fusing the Back of the Foot (Double or Triple Fusion)

If your heel is stiff, worn out (arthritic) or too badly bent to straighten without fusing, the joints at the back of the foot are fixed together in a better position. This is called a double or triple fusion (arthrodesis). You lose some side-to-side movement of the foot, but people usually walk better than they would with a foot that is only partly corrected.

Lowering the High Arch (Metatarsal Osteotomy & Midfoot Wedge)

If only the bone behind the big toe is pointing down, a small wedge of bone is removed from its base to lift it up. If the whole front of the foot is pointing down, a wedge of bone is removed from the middle of the foot instead. Mr Welck plans these corrections in 3D using Weight-Bearing CT and, where helpful, uses 3D-printed cutting guides made for your foot.

Moving Tendons to Rebalance the Foot (Tendon Transfers)

Straightening the bones is not enough on its own, because the muscle imbalance that caused the problem is still there. In a tibialis posterior tendon transfer, the strong tendon pulling the foot inwards is moved to the top of the foot, where it helps lift the foot instead — which also helps foot drop. In a peroneus longus to brevis transfer, the strong tendon pulling the big-toe bone down is joined to the weaker tendon on the outside of the ankle to make it stronger.

Other Procedures That May Be Needed

  • Calf release or Achilles tendon lengthening — to loosen a tight calf muscle or Achilles tendon. This is usually done first.
  • Plantar fascia release — loosening the tight tissue under the foot to help lower a high arch.
  • Ankle ligament reconstruction — to tighten a wobbly ankle. This works best when done together with straightening the heel; repairing the ligaments alone often fails if the heel is still tipped inwards.
  • Ankle fusion — if the ankle joint is badly worn and out of shape.

Straightening the Toes

A clawed big toe is usually treated with a Jones procedure. The tendon that pulls the big toe upwards is moved to the bone behind the big toe, so it helps lift the high arch instead, and the end joint of the big toe is fused to keep it straight. Clawed smaller toes may need their tendons released or moved.

When Is the Right Time for Surgery?

There is no single right answer. Operating while the foot is still flexible means the joints can often be kept rather than fused. In one study that followed patients for an average of 26 years, none of those treated this way later needed a triple fusion. On the other hand, the muscle weakness tends to get worse with age, so having surgery earlier may mean more time for a further operation to be needed later.

The decision is a personal one, based on the shape of your foot, your symptoms, how quickly things are changing and your daily life. It is made together — by you, your family, your surgeon, your neurologist and your physiotherapist — and is best done in a specialist centre that carries out this surgery regularly and has an experienced team.

What Is Recovery Like?

  • If your joints are kept (bone cuts and tendon moves): usually about 6 weeks in a plaster cast or boot, without putting any weight on the foot.
  • If joints are fused: usually about 12 weeks in a below-knee cast — no weight on the foot for the first month, some weight in the second month and full weight in the third.
  • Getting back on your feet: physiotherapy then helps you rebuild strength, balance and walking. Swelling can take several months to settle.

How Well Does It Work, and What Are the Risks?

The results of surgery are encouraging. In one study of 25 operations, the shape of the foot, pain levels and patients’ own scores of how well their foot worked all improved clearly, with no major complications. In another study of 33 patients followed for nearly five years, pain and function improved, although two feet later needed a triple fusion because the deformity came back.

As with any foot operation, there are risks. These include problems with wound healing, infection, irritation of the nerves in the skin, bones taking longer to heal, the foot slipping back out of shape, a long-lasting pain condition called complex regional pain syndrome, and the possible need for more surgery. Mr Welck will go through these with you in detail before you decide.

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore — one of the UK’s leading specialist orthopaedic hospitals, which other hospitals refer complex cases to — and an Honorary Associate Clinical Professor at UCL. His practice is dedicated entirely to the foot and ankle.

  • Complex foot and ankle reconstruction, including correction of the CMT high-arched foot and revision (repeat) surgery
  • Weight-Bearing CT expertise — he researches 3D standing scans and 3D-printed cutting guides made for each patient
  • Team approach — working closely with neurologists, physiotherapists and orthotists
  • Research-active and a published author, with more than 50 published research papers; member of the BOFAS Education Committee
  • Specialist training abroad, including a fellowship at the Foot and Ankle Institute in Baltimore

His practice also includes total ankle replacement and sports injuries such as Achilles tendon tears and ruptures. Patients come to see him from across London, North London, Hertfordshire, the UK and overseas.

09

Frequently Asked Questions

Does everyone with CMT need foot surgery?

No. About 7 in 10 people with CMT have some change in the shape of their feet, but only about 3 in 10 ever need an operation. Many people manage well for years with exercises, insoles and braces. Surgery is usually only considered when the foot no longer sits flat on the ground, is painful or keeps giving way, or when insoles and braces no longer help.

Will surgery stop my CMT from getting worse?

No. CMT affects the nerves, and surgery cannot change that. What surgery can do is fix the shape and balance of the foot — straightening the bones and moving tendons — so that your foot is steadier, more comfortable and easier to fit into a brace. Because the muscle weakness can slowly get worse over time, some people need another operation later in life.

How long does it take to recover from CMT foot surgery?

It depends on the operation. If your joints can be kept (bone cuts and tendon moves), you can expect about 6 weeks in a plaster cast or boot without putting any weight on the foot. If joints need to be fused, it is usually about 12 weeks in a below-knee cast: no weight on the foot for the first month, some weight in the second month and full weight in the third. Physiotherapy follows. Swelling can take several months to go down.

Can someone with CMT have an ankle replacement?

Sometimes, for a small number of carefully chosen patients who have ankle arthritis. A total ankle replacement only works well if the foot underneath it is straight and stable, and the muscles around it are balanced — which is often the difficult part in CMT. Any problem with the heel or the front of the foot has to be corrected first. For many people with CMT and ankle arthritis, an ankle fusion is the more reliable choice. Every case is different, and Mr Welck will talk through the options with you so that you can decide together.

Does CMT affect the Achilles tendon?

A tight Achilles tendon or tight calf muscle is common in people with CMT. It is often treated during surgery by lengthening the Achilles tendon or releasing the calf muscle. CMT does not usually cause an Achilles tear or Achilles rupture — these are normally sports injuries and are treated separately.

Can children have CMT foot surgery?

Yes. Surgery is sometimes advised during childhood or the teenage years, while the foot is still flexible. At this stage the joints can usually be kept. In one study of 21 children (average age 12½), surgery to rebalance the tendons and straighten the bones clearly improved the shape of the foot and meant the children fell over less often.

Can I have CMT foot surgery on the NHS?

Yes. CMT foot surgery is available on the NHS, usually in specialist foot and ankle units that work closely with nerve specialists (neurologists). It is also available privately. Mr Welck sees patients both at the Royal National Orthopaedic Hospital and in private practice.

Where can I see Mr Matthew Welck for CMT foot surgery in London?

Mr Welck sees patients at the Royal National Orthopaedic Hospital in Stanmore and at private clinics across London and North London. To book a consultation, call his secretary on 07547 395 270, email secretary@matthewwelck.com or use the appointments page.

10

Book a Consultation

If you or your child has CMT and a high-arched foot, a wobbly ankle or foot pain, seeing a specialist can make a real difference — whether the answer is insoles, a brace or surgery. Mr Welck will examine you, look at your scans and explain all your options clearly, so that you can make the decision that is right for you.

This page is for general information and does not replace a personal consultation. Treatment decisions should always be made with your own specialist.

Key References

  1. Pfeffer GB, Gonzalez T, Brodsky J, et al. A consensus statement on the surgical treatment of Charcot-Marie-Tooth disease. Foot Ankle Int. 2020;41:870–80.
  2. Laurá M, Singh D, Ramdharry G, et al. Prevalence and orthopedic management of foot and ankle deformities in Charcot-Marie-Tooth disease. Muscle Nerve. 2018;57:255–9.
  3. Nagai MK, Chan G, Guille JT, et al. Prevalence of Charcot-Marie-Tooth disease in patients who have bilateral cavovarus feet. J Pediatr Orthop. 2006;26:438–43.
  4. Guyton GP. Orthopaedic aspects of Charcot-Marie-Tooth disease. Foot Ankle Int. 2006;27:1003–10.
  5. Ward CM, Dolan LA, Bennett DL, et al. Long-term results of reconstruction for treatment of a flexible cavovarus foot in Charcot-Marie-Tooth disease. J Bone Joint Surg Am. 2008;90:2631–42.
  6. Ramdharry G, Singh D, Gray J, et al. A prospective study on surgical management of foot deformities in Charcot Marie Tooth disease. J Peripher Nerv Syst. 2021;26:187–92.
  7. Lin T, Gibbons P, Mudge AJ, et al. Surgical outcomes of cavovarus foot deformity in children with Charcot-Marie-Tooth disease. Neuromuscul Disord. 2019;29:427–36.
  8. Leeuwesteijn AEEPM, de Visser E, Louwerens JWK. Flexible cavovarus feet in Charcot-Marie-Tooth disease treated with first ray proximal dorsiflexion osteotomy combined with soft tissue surgery. Foot Ankle Surg. 2010;16:142–7.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 9 October 2026

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