Rheumatoid arthritis can cause significant pain and disability when if affects the foot. Dr Gibson discusses this entitity and some of the treatment options to help those with rheumatoid arthritis better understand their disease and options to help optimize their feet and keep them active.

Copyright (c) 2009 Mountain West Foot & Ankle Institute

Rheumatoid arthritis (RA) is a systemic disease that affects about 2.1 million Americans, mostly women and has been show to attack multiple joints throughout the body. It is estimated that 1.5 million women and 600,000 men are victims of this debilitating disease. Of these affected, approximately 90% of the people with RA eventually develop foot or ankle symptoms and deformity. In fact, many of the early symptoms of RA often include foot problems. Foot problems are more common than symptoms to the hand and only second to knee problems. These symptoms can lead to serious disability.

The exact cause of RA is still unknown, even with years of study. Some possible causes include inheritance from parents, chemical or environmental "triggers" all leading to a malfunction of the immune system. In RA, the immune system of the body turns against itself and damages joints causing cartilage damage and inflammation.

Symptoms

Symptoms often begin with pain, swelling and stiffness, but can also involve deformities. Typically the first joints affected in the foot include the metatarsophalangeal joints (the joints at the ball of the foot) and can include significant pain with pressure from standing, motion of walking or tightness of shoes and may also be warm from the inflammation. In other words, even simple activities may causes pain to the foot.

The pain then can affect other areas of the forefoot (front of the foot) including the toes caused by contractures of ligaments and tendons leading to bunions (turning of the big toe towards the other toes) or your other toes may begin to curl and get stiff (often called hammertoes or claw toes). As this occurs, calluses become a larger problem and may build up under the ball of the foot, at the joints of the toes or even at the tips of the toes. Care must be exercised to limit damage to the skin by allowing these calluses to become wounds.

Other areas that may be affected include the hindfoot (back of the foot) with heel pain from Plantar Fasciitis (inflammation of a ligament extending from the heel to the toes), tendonitis of the Achilles tendon or even bursitis (inflammation of a fluid filled sack at the back of the ankle). RA, as an inflammatory disease, may also include neuropathy (loss of nerve functioning including numbness or muscle weakness), vasculitis (inflammation of the blood vessels), ulcerations (wounds), necrosis of the toes or even gangrene. Sometimes entrapment injury to the nerves from RA can cause foot drop.

RA is a systemic disease and will commonly produce generalized symptoms of fatigue, fever, loss of appetite and energy, and anemia (poor oxygen distribution to the body) adding to the symptoms of tiring easily.

Diagnosis

In arthritic conditions, especially rheumatoid arthritis, it is important to establish a correct diagnosis. Often the symptoms in the foot or ankle may be the first indications of this diagnosis. A diagnosis is obtained through review of your medical history, your current occupation, and recreations activities you participate in and any previous history of problems to your feet or legs. One possible indication of RA is appearance of symptoms in the same joint on both feet or several joints in the feet. X-rays may also be obtained to clarify what joint damage is occurring. Blood test may show anemia or have an antibody called "the rheumatoid factor" which is often indicative of RA.

If you already have a diagnosis of RA, any symptom changes to your feet or ankles should be followed closely, as new swelling or foot pain may be the early signs of the foot or ankle being affected. There are usually treatments that can reduces the symptoms and possibly slow the progression.

Treatment

It is important to understand that RA is a progressive disease that currently has no cure. With this understanding it should also be understood that medications, exercises, conservative therapies and surgery can all be utilized to lessen the effects of the disease and may slow its progress. Medications are usually designed for one of three reasons: 1) Control pain, 2) Reduce Inflammation or 3) Slow the Spread of the Disease. Aspirin and non-steroidal anti-inflammatories (NSAIDs) like ibuprofen and anesthetic injections to the joints principally help control pain. Local cortisone injections help reduce inflammation locally. Ice and some topical medications (like Biofreeze) may also help reduce inflammation and the associated pain. Medications like methotrexate, minocycline, azothioprine, prednisone, sulfasalazine, and gold compounds, help slow the spread of the disease itself

Exercises usually include physical and occupational therapy modalities. Range-of-motion exercises, exercise in whirlpool or warm swimming pool, remaining active all help decrease the immobility produced by the disease.

Conservative therapies include custom shoe inserts (orthotics), braces (especially for foot drop), specialized shoes to better accommodate the foot changes, and protective padding. The most common padding required is for pressure points on the toes where calluses (thick skin) form and cause pain. Some of the easiest padding can include:

Gel Toe Caps - A compressive sleeve completely lined with gel that is easily slipped onto the toes to pad the joints and the tip of the toe. Reduces the pressure and is protective from callus formation or progression.

Gel Corn Pads - A compressive sleeve with gel padding to be easily applied to the toes to protect prominent joints of the toes and reduce callus formation or even wounds to these areas. Again this will reduce pressure and is protective from callus formation or progression.

Gel Crest Pads - A gel pad placed under the toes to flatten contracted toes and elevate toes from the weightbearing surface, reducing pressure to the tips of the toes. Protective from wound formation or callus formation to tips of toes.

Even with these or similar treatments, regular follow-up with a physician is important, because callus tissue should still be reduced on a regular basis (it just won't get bad as fast with protective measures).

Surgical intervention can also be undergone, including tendon release or lengthening, correction of single or multiple hammertoes or other foot deformities, bunion correction, metatarsal surgery, ankle surgery, joint implants, or complex foot surgeries to reduce risk factors.

The role of a qualified foot and ankle specialist or podiatrist may include major contributions to the management of this disease, including relief of pain and restoration of function. This can add not only to a reduction of disability but an improvement of walking, increased independence and the regular ability to engage in activities of daily living. Increased joy and happiness in life may then occur, as the foot and ankle are optimized to function even with this difficult disease.