Rheumatoid Foot

Rheumatoid arthritis is a relatively common condition affecting joints throughout the body. While rheumatoid commonly affects middle-aged women, it can appear in anyone at any age and typically runs in families.

When people talk about arthritis, they are usually referring to osteoarthritis, or simple wear and tear of the joint cartilage. Rheumatoid arthritis is very different, caused by disease in the soft tissues around the joint, in particular the synovium. The synovium or synovial lining is a special membrane around many of the joints in the body that secretes lubricating fluid between and around the bones. In rheumatoid, this lining becomes inflamed resulting in pain, warmth and swelling. Severe rheumatoid can lead to gradual dislocation of the joints and deformity.

Rheumatoid arthritis can affect virtually any joint in the body but tends to occur in patterns, generally affecting the MCP and PIP (the knuckles) in the hand and the corresponding MTP joints in the feet. Specific deformities seen in the feet with rheumatoid arthritis include:

  • Bunion or Hallux valgus
  • Partial dislocation (‘subluxation’) through to complete dislocation of the toes
  • Heel may be twisted outwards (‘hindfoot eversion’)

Many people get good control of their pain through simple over-the-counter medications, however rheumatoid is a chronic disease that will probably require expert help sooner or later. Specialists that treat rheumatoid and its related conditions are called rheumatologists, however when deformity or pain is severe and not responsive to medications, orthopaedic surgeons may be asked to help.

Orthopaedic surgeons can help to treat:

  • Deformity associated with rheumatoid arthritis
    • Correcting deformities associated can also make footwear more comfortable and reduce the risk of ulcers and skin breakdown where the shoes rub the foot.
  • Pain
  • Stabilisation of the ankle or foot.

Symptoms

Rheumatoid arthritis sufferers typically have symptoms affecting both their joints and their general well-being. There are many many symptoms that may affect your day-to-day life, but these tend to wax and wane over time, often with no apparent reason.

Affected joints:

  • Pain – the ‘typical’ description of rheumatoid arthritis pain is realtively severe pain starting in the morning, worse with rest and better with movement. However there is a wide variety of experience between sufferers of rheumatoid arthritis. Patterns of pain include:
    • Episodes of pain in both feet. This can begin in different areas, for example the ankles, then move into other joints in your foot, including your toes and midfoot joints.
    • Pain affecting other joints, including the hands, hips and knees.
    • You may remember having painful episodes in the past before you were diagnosed with rheumatoid. These may have appeared out of nowhere and resolved without help.
  • Swelling
  • Subluxation (partial dislocation)
  • Deformity:

Other symptoms:

  • Tiredness, fatigue, loss of energy
  • Carpal tunnel – pain and tingling over the palm of the hand
  • Rashes and ulcers
  • Irritation in the eyes, cataracts
  • Dry mouth and eyes
  • Shortness of breath and chest pain
  • ‘Neurological’ symptoms, for example numbness, tingling, ‘foot drop’

In addition to all of the above, there are multiple side effects from the specialist drugs. The list of these side effects is long and should be discussed with your rheumatologist.

Risk Factors

Rheumatoid arthritis may affect anyone at any age. Some recognised risk factors are:

  • Female
  • Aged 35-55
  • Family history
  • Post-partum: Many women with rheumatoid arthritis notice their symptoms improve, sometimes even disappear completely when they fall pregnant, only to flare-up after they give birth. For some women, a post-partum flare is their first experience with rheumatoid arthritis.

The risk of developing complications with rheumatoid arthritis changes depending on the length and severity of your disease. Unfortunately, sufferers who have long-standing aggressive disease are more likely to develop serious complications.

Investigations

Some common tests used to diagnose rheumatoid arthritis and to assess the impact it is having on your foot include:

  • Blood tests. GPs and rheumatologists use a number of blood tests.
  • X-Rays. You may require X-Rays of multiple joints.
    • If you have affected joints in one foot the doctor may request X-Rays of both feet to compare the joints.
    • Doctors may also request chest and neck X-Rays to check the effects of rheumatoid arthritis on your lungs and spine.
  • Bone scan.

Treatment

There are a large number of medications available that provide good control of rheumatoid arthritis and its symptoms. Some medications, like panadeine and anti-inflammatories can be bought over the counter or prescribed by GPs. Other medications are more aggressive and are are prescribed by rheumatologists. These will not be discussed here, however information can be found at the Australian Rheumatology Association site.

Physical Therapy, Orthotics & Podiatry

Exercises and modified shoes can help relieve the symptom of arthritis and make walking easier.

  • Soft orthotics – these can be used when calluses are developing on the soles of the feet.
  • Corn shields can be bought at pharmacies
  • Ankle-foot orthosis – this brace is custom made to fit your foot, and helps to relieve pain, facillitate walking and prevent the development of deformities.
  • Arch supports

Surgery | First Steps

When symptoms of arthritis, including pain, deformity and difficulty walking, becomes significantly troubling an orthopaedic surgeon may be called to assess whether surgery can help.

Relatively minor surgeries that are used to treat rheumatoid arthritis in the foot include:

  • Soft tissue debridement. Corns and calluses that do not heal with orthotics may need to be removed surgically. This can be done by podiatrists or surgeons, and usually requires only local anaesthesia.
  • Washing out the joint through arthroscopy. Arthroscopy is also known as key-hole surgery, and as such is minimally invasive with little pain and low risk. Flushing the arthritic joint can help relieve the irritation. Your surgeon can also take the opportunity to assess the degree of damage in your joint and trim or remove any tissue fragments.
  • Synovectomy – this procedure involves trimming the inflamed capsule surrounding the joint or the coating around tendons, for example synovectomy is often used to treat posterior tibialis inflammation.
  • Correcting deformities through minor procedures like osteotomy. This surgery essentially involves reshaping the bones and is used to correct deformities in the toes and metatarsals. The aim of this procedure is to correct the position of the bones so that:
    • ulcers do not develop over bony edges,
    • you can wear normal shoes,
    • walking is easier.

When these methods fail to relieve symptoms, you may begin to consider more radical surgery.

Surgery | Radical Operations

There are essentially two options for severely arthritic joints – fusion (arthrodesis) or replacement (arthroplasty). Choosing one of these over the other will depend on a variety of factors, including:

  • The severity of your disease and the health of your bones
  • The level of activity you expect after the surgery

In general, fusion operations will be chosen when a stable painless joint is needed. People who have arthrodesis tend to rapidly regain function they had lost from their arthritis, however they do lose all motion at their joint, making things like running or walking on uneven surfaces difficult. See Ankle Arthrodesis, Foot Arthrodesis and Big Toe Arthrodesis for more information.

Replacement operations in the foot are not often performed for a number of reasons. Only certain people will be eligible for replacement, often those with arthritis in other joints in their foot who need to maintain movement at the ankle. You will need to keep in mind that joint replacements will wear out over around 10 years and will need to be replaced. See Ankle Replacement for more information.

If you are considering radical surgery, it’s best to discuss all of these issues with your surgeon. Many people find that bringing a family member or close friend along to their appointment is invaluable – in them, you have a second set of ears to clarify the information provided and ask questions.

Seeking Advice

Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to

  • tell you about your problem
  • advise you of the best treatment methods
  • prescribe you medications
  • and if necessary, refer you to specialists and allied health for further treatment.

Specialists | Rheumatologists

Rheumatoid arthritis is best managed by a specialists called rheumatologists. These doctors will be able to discuss all the aspects of your treatment with you and help prescribe specialist medications to control your disease. Your rheumatologist will also be able to discuss when they think you might benefit from surgery.

Finding a good rheumatologist is very important in rheumatoid arthritis. This is a long-term disease and you will benefit most from your treatment if you feel able to communicate with your rheumatologist.

Specialists | Podiatrists

Podiatrists can help you take care of your feet and prevent further complications. You do not need a referral from a doctor to see a podiatrist, but your GP can help you find one nearby.

Internet

There are a number of websites that provide information and support:

  • Australia Rheumatology Association provides general information about many of the specialist drugs used to treat rheumatoid. In addition, it provides easy-to-understand information about different conditions treated by rheumatologists, including rheumatoid arthritis
  • Young Women’s Arthritis Support Group – this site provides everything from anecdotes to up-to-date news on rheumatoid arthritis. While the site is directed towards women, there are descriptions of operations and treatments that apply to everyone.

Prevention

A number of methods of treating rheumatoid arthritis also aim to prevent the development of complications. These include:

  • Speciailsit medications like prednisolone and methotrexate slow down the destruction of joint tissues
  • The ankle-foot orthosis prevents the development of deformities
  • Orthotics prevent corns, calluses and ulcers developing

Beyond this, simple things like maintaining a healthy weight and exercising help to reduce the strain on your feet.

F.A.Q. | Frequently Asked Questions

References

Abdo, R. V, Iorio, L. J., ‘Rheumatoid Arthritis of the Foot and Ankle’, Journal of the American Academy of Orthopaedic Surgeons, Vol. 2, No. 6, Nov/Dec 1994, pp. 326-332.

Jaakkola, J., Mann, R. A., ‘A Review of Rheumatoid Arthritis Affecting the Foot and Ankle’, Foot & Ankle International, Vol. 25, No. 12, December 2004, pp 866-874.

Nelissen, R., ‘The lower limb in the rheumatoid arthritis patient: Focus on the hind, mid and forefoot and the ankle.’, Current Orthopaedics, Vol. 21m 2007, pp 340-343.