How to do and evaluate DWI and DCE-MRI sequences for diabetic foot assessment

MRI evaluation of the diabetic foot is still a challenge not only from an interpretative but also from a technical point of view. The incorporation of advanced sequences such as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI into standard protocols for diabetic foot assessment could aid radiologists in differentiating between neuropathic osteoarthropathy (Charcot's foot) and osteomyelitis. This distinction is crucial as both conditions can coexist in diabetic patients, and they require markedly different clinical management and have distinct prognoses. Over the past decade, several studies have explored the effectiveness of DWI and dynamic contrast-enhanced MRI (DCE-MRI) in distinguishing between septic and reactive bone marrow, as well as soft tissue involvement in diabetic patients, yielding promising results. DWI, without the need for exogenous contrast, can provide insights into the cellularity of bone marrow and soft tissues. DCE-MRI allows for a more precise evaluation of soft tissue and bone marrow perfusion compared to conventional post-gadolinium imaging. The data obtained from these sequences will complement the traditional MRI approach in assessing the diabetic foot. The objective of this review is to familiarize readers with the fundamental concepts of DWI and DCE-MRI, including technical adjustments and practical tips for image interpretation in diabetic foot cases.