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Author: Brandt R Gibson DPM

Article:
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.

About the author:
Brandt R. Gibson, DPM, MS is a podiatrist in American Fork,
Utah. His goal is to educate people and help them "optimize what
they were born with." For further educational materials and
recommended medical products, visit http://www.UtahFootDoc.com .
A free book on foot and ankle health can also be ordered at
http://www.MyFeetHurtBook.com .