Systemic Arthritis & Foot disorders

Systemic Arthritis and Foot Disorders

By Dr Iain B McIntosh, BA(Hons) MBChB, former Chiropody Schools Inspector

In most patient contacts, the podiatrist deals with localised disorder or disease, but hidden in routine presentations will be the occasional early harbinger of systemic disease. There will be a canary among the sparrows and the health professional has to be alert to localised manifestations of general disease. Prompt referral rather than immediate treatment may be appropriate, but the same patient will often require considerable podiatric care once the diagnosis has been confirmed and medication instituted. Chronic conditions with localised podiatric problems often require prolonged, skilled foot care. Several systemic diseases can present with foot and nail pain and problems. One is Rheumatoid arthritis (RA), an autoimmune disease causing pain and joint deformity. Cells of the immune system malfunction and attack healthy joints. Early signs are stiffness, pain, and swelling in the hands and feet. The onset is gradual for some and immediate for others and ultimately joints in the ball or sole of the feet become too painful to walk on. As the disease progresses, pain and stiffness may spread to many joints1 . In RA, the immune system attacks the body’s own joint tissues, resulting in inflammation, with progressive damage to affected joints. It also attacks the fluid within joints as well as the joint lining, (the synovium). This becomes acutely inflamed, causing a warm and swollen joint. Continued inflammation, eventually thickens the synovium and causes cartilage and bone to erode, which leads to joint deformity and decreased range of motion. Muscles, tendons, and ligaments that surround and stabilise the joints may also weaken. Not everyone will have foot involvement with RA, but most sufferers are affected and in early presentation of the disease this can bring them to the podiatrist for attention. It is important that signs and symptoms of the systemic disease be recognised and prompt referral to family doctor and rheumatologist considered. Rheumatoid arthritis is the commonest type of inflammatory arthritis. Up to 90% of people with this condition will report associated foot problems.2 For some people, the foot is the first area of the body to present with signs and symptoms. Foot problems caused by RA commonly occur in the forefoot although RA can also affect other areas of foot and ankle. The most common signs and symptoms of RA-related foot problems, in addition to the abnormal appearance of deformities, are pain, swelling, joint stiffness and difficulty walking. RA typically changes a foot’s structure and shape. It affects the metatarsophalangeal (MTP) joints of toes. When persistently affecting the MTP joints, a gradual lateral shift in toes can occur. This causes feet to develop bunions (hallux valgus). RA may also cause shifting of the forefoot and loss of stability, leading to toe contractures, such as hammertoes. Toe contractures and changes in toe joint flexibility lead to calluses and pain beneath the ball of the foot. Other joints of the foot that can be affected include the ankle joint and the talonavicular joint, part of the foot arch. The foot can become destabilised and flat feet (pes planus) can develop. RA pain can be distinguished from osteoarthritis (OA). Multiple joints are usually affected at the same time with RA and the joint symptoms are generally symmetrical. Another feature is the tendency for RA to cause a longer period of morning stiffness with stiffness in affected joints for one or more hours after awakening, compared with the OA sufferer, whose joint stiffness may diminish after a few minutes of stretching or motion in the morning. Heel pain is common in people with RA. It occurs at the back or underside of the heel. Associated conditions include heel spur syndrome (plantar fasciitis) Achilles tendonitis, and retrocalcaneal bursitis occurs, when a fluid-filled sac (bursa) behind the heel bone becomes inflamed, causing pain and swelling. Bursa can often be found under the ball of the foot affected by RA .When RA inflames the synovium, the swelling can compress nerves and cause symptoms of a pinched nerve (nerve entrapment).Tarsal tunnel syndrome is a common nerve entrapment in the foot. Symptoms include burning, tingling, or shooting pain in the area of the foot arch and sole. Splinter haemorrhages - small areas of broken blood vessels- may occur on sides of toenails. Rheumatoid nodules appear as a lump beneath the skin, usually over bony prominence or tendon. In the foot, they may appear over the Achilles tendon, in the heel pad, or on the side of the big toe if hallux valgus is present. Nodules forming in soft tissues may be susceptible to rubbing from hosiery and footwear. Shape changes in the front of the foot and the toes can create pressure sites that develop corns and calluses. 3.4

Summary:

Deformities and conditions associated with RA may include: • Rheumatoid nodules, which cause pain when they rub against shoes or, if they appear on the bottom of the foot • • and pain when walking Dislocated toe joints Bunions • • Hammertoes Heel pain • Achilles tendon pain • Flatfoot ankle pain Diagnosis RA is diagnosed on the basis of history and signs observed on clinical examination as well as blood tests, x-rays and/ or other imaging tests. Treatment Pharmacological treatment can help in management, including its foot manifestations. Treatment focuses on medication prescribed by rheumatologist. The podiatrist can however do much to relieve pain and discomfort of RA-related foot problems. Podiatric care is aimed at reducing painful symptoms, supporting

joints of the feet and improving foot function. As well as a moulded insole, shoes roomy enough to accommodate foot and orthoses without adding unnecessary pressure are important. If toes are beginning to stiffen or curl, a shoe with an extra deep toe box is vital and protective shields for toes can relieve pressure and reduce friction. Orthotic devices. The early use of orthoses and medical management, may slow the development of joint changes.5 Customised orthotic devices provide cushioning for rheumatoid nodules, minimize pain when walking and give needed support to improve the foot’s mechanics. e.g. individualised insoles. Treatment for RA type of bursa usually involves reducing pressure over the ball of the foot with the use of insoles or orthoses.5.6.7

Advice on appropriate shoe wear to relieve pressure and pain and to assist with walking.

Provision of appropriate padding to distorted toes and bunions

Treating of corns and calluses

Advice on exercise, which should be reduced when there are signs and symptoms of an acute ‘flare’ Osteoarthritis of the Foot Osteoarthritis is a condition characterized by the breakdown and eventual loss of cartilage in one or more joints with inflammation. Pain may be accompanied by swelling, tenderness, stiffness. The most common form of arthritis to affect the big toe joint is osteoarthritis, caused by degeneration of the articular cartilage. Osteoarthritis at the big toe joint may develop from problems with foot structure and functioning, resulting in excess wear-and-tear. Trauma such as a fracture or dislocation of the big toe can also result in osteoarthritis. Osteoarthritis is the most common type of arthritis affecting 14% of adults over 25 years and 34 % over 65. Seventy percent of people over 70 years old have x-ray evidence of osteoarthritis.1 OA is primary -underlying cause unknown (idiopathic) or secondary developing as a result of another medical condition or trauma at the joint e.g. a sports injury). Knees and hips are the joints most commonly affected by osteoarthritis. Pain and physical limitations make osteoarthritis a significant disease. Arthritis of the big toe is the most common site of arthritis in the foot, affecting 2.5 percent of people over the age of 50. The joint at the base of the big toe (MTP joint) is affected and the condition develops gradually over time.1 Some people with osteoarthritis will develop hallux rigidus, stiffness which usually affects adults between 30 and 60 years of age, and is often the result of a prior sports injury1. Sportsmen become susceptible to micro-trauma where loading, stressing, and extending movements are required of feet and sprains occur in the joint at the base of the big toe. “Turf toe,” the name given to these injuries, can also cause bone spurs or osteophytes to develop. Soccer and football played on artificial turf cause most toe injuries in sports. If not treated properly, turf toe can lead to hallux rigidus. People who have fallen arches, or excessive pronation of ankles, are susceptible to developing hallux rigidus. The marked stiffness of the joint, results in restricted big toe extension. If the arthritis advances, knobbly growths- bone- spurs may develop that resemble a bunion.

REFERENCES

1 https://www.arthritisresearchuk.org/arthritis-information/data-and-statistics/ musculoskeletal-calculator.aspx 2 Manual of Geriatrics. Musculo skeletal disorders 1990 Merck New Jersey USA 3 Textbook of Medicine ed Souhani R Mosham J 1990 Churchill Livingstone Edin 4 McIntosh I Managing the Aged foot 2003 Podiatry Review 18-20 5 McIntosh I Orthotics – valuable or useless devices 2015 Podiatry Review 6-8 6 Overview Of Custom And Prefabricated Foot Orthoses Mark A. Caselli, DPM and Ellen

Sobel, DPM, PhD Issue Number: Podiatry today Vol 14 .12 - Dec 2001 While bunions develop on the inside of the foot, bony spurs from advanced arthritis tend to form on top of the big toe joint. Like bunions, though, these bony enlargements can create a hallux valgus deformity in which the big toe points towards the second toe. Symptoms of osteoarthritis of big toe may include pain, a grinding sensation, stiffness, and swelling. Pain is generally most noticeable when standing and walking and there may be: • Pain, even during rest • Pain which worsens with use of the big toe, such as with jumping • Difficulty wearing shoes because of bone spurs • Difficulty wearing high-heeled shoes • Dull pain in the hip, knee, or lower back caused by changes in how someone walks • Limping Treatment. As with other joints, treatment of foot osteoarthritis targets relief of symptoms. Losing weight if overweight helps all weight-bearing joints. Drug treatments, topical medications, intra-articular injections fusion, or joint replacement may be recommended.8The podiatrist will manage presentations as for RA cases. Wearing orthotics or foot supports may be helpful. Shoe modifications (for example, shoe pads designed to stop movement under joint of the big toe, stiff soled shoes which also reduce movement at the joint, or adding a rocker bottom to shoes) and judicious padding can alleviate pain and reduce friction and discomfort. Advice to minimise stress on joints by wearing well-cushioned shoes. Choose shoes with lace-up fastenings or adjustable strap: There should be a centimetre between the end of longest toe and end of the shoe and room to accommodate any swelling and padding9 . Gout is a metabolic condition that can affect the big toe joint, when uric acid builds up in person’s forming crystals, which deposit into the big toe joint. Symptoms of gouty arthritis include a red, hot, and intensely painful joint. If untreated and recurrent, joint damage may occur. In addition, gout tophi may form as visible and/or palpable urate deposits on the toe. It can be challenging to distinguish between a gouty arthritis in the big toe joint and an infected joint. An elevated blood test to check uric acid levels confirms a gout attack. Treatment. An acute attack can be treated with colchicine, an antiinflammatory and dietary intervention and appropriate padding and advice on footwear, Psoriatic arthritis. Nails can be affected in people with psoriatic arthritis and be a guide to diagnosis.

Conclusion. Foot problems caused by systemic arthritic conditions can challenge podiatric skills but appropriate advice, orthotics and padding can alleviate much of the foot misery generated by these conditions and the podiatrist has an important role in their diagnosis and management.

7 Conceição CS1, Gomes Neto M, Mendes SM, Sá KN, Baptista AF. Systematic review and meta analysis of effects of foot orthoses on pain and disability in rheumatoid arthritis patients.

Disabil Rehabil. 2014 Sep 23:1-5. 8 Dulgeroglu, T., and H. Metineren. Treatment of End-Stage Hallux Rigidus Using Total Joint

Arthroplasty: A Short-Term Clinical Study. Journal of Foot and Ankle Surgery. 2017. 56(5): 1047-1051. 9 McIntosh I Management of elderly foot disorders 2012 Podiatry Review 6-8