Rheumatoid arthritis (RA) is a condition that causes inflammation in many joints of the body but particularly affects the hands, feet, wrists, ankles and knees. It tends to occur symmetrically: for example, if your right big toe is swollen and painful, chances are your left big toe will be too. As well as joint pain and stiffness, symptoms include muscle aches, anaemia (a low blood count leaving you feeling tired) and fever. The stiffness tends to be worse in the morning and after rest.
Unlike osteoarthritis, which is caused by wear and tear, RA is a chronic inflammatory disease where a faulty immune system attacks the tissue that lines and cushions the joints, leaving them swollen, painful and stiff. RA tends to affect the smaller joints such as the fingers and toes first, so feet are often one of the first places to be affected. Symptoms are usually felt in the toes first and then the back of the feet and the ankles. The joints may become enlarged and even freeze in one position so they can’t be fully extended.
The metatarsal-phalangeal joints are often affected (where the long bones of the feet meet the toes) and can result in hallux valgus (a condition in which the big toe is angled excessively towards the second toe) and hammer toe deformities (where the toes curl up in a claw-like shape). Each of these deformities can cause further problems: for example, if you have hammer toes, you’ll be more likely to develop corns on the tops of your toes.
If the joints in the middle of the foot are affected, the arch can collapse, leading to a flat foot deformity and spreading of the forefoot (where the front section of the foot becomes wider). The fatty pads on the balls of the feet may slip forward, causing pain on the balls of the feet and backs of the toes. If this happens, it can feel as if you are walking on stones.
If the joint where the heel bone meets the ankle (the joint that lets you rotate your ankle) is affected, it can lead to a condition known as valgus hindfoot (where the heel bends outwards), making it difficult to walk.
The severity of the symptoms vary from person to person. According to Arthritis Research UK, about one in 20 people will have RA that becomes progressively worse leading to severe damage in many joints, while around one in five will have mild RA that causes few problems beyond a little pain and stiffness.
Any kind of foot deformity will cause an uneven distribution of pressure as you walk, making you more likely to develop corns, callus and ulcers.
You may also get rheumatoid nodules – fleshy bumps that usually occur below the elbows but can appear on the hands and feet too. They may form over bony areas such as the heels and occur in 30% to 40% of people with rheumatoid arthritis.
Women are more prone than men to developing RA, although anyone can contract the disease. It tends to affect people over the age of 40.
You can help yourself by understanding as much as possible about your disease and treatment. The best starting point is the website for the charity Versus Arthritis, which has numerous downloadable leaflets on all aspects of arthritis.
There could be many other causes of your joint pain but if it is arthritis, the sooner you are diagnosed the more effective treatment will be. Many rheumatology departments have early arthritis clinics which your GP can refer you to.
Your doctor can make a clinical diagnosis using blood tests (which may show changes in the blood caused by inflammation) and x-rays (which can show up damaged joints). It is likely your feet will be x-rayed because the changes caused by RA often appear in the feet before they appear in other joints.
Your GP will decide the most appropriate treatment for you. Your treatment will depend on how advanced your RA is. Drugs available include analgesics, non-steroidal anti-inflammatory drugs (NSAIDS) which reduce pain and swelling, and disease-modifying anti-rheumatic drugs (DMARDS) which slow down the effects of the disease on the joints. If your arthritis is advanced, you may be prescribed corticosteroids. It may take a while to find the drug that’s right for you but it’s worth persevering.
Specialist teams of rheumatologists, podiatrists/chiropodist, physiotherapists and occupational therapists, along with specialist nurses, will provide the most effective care and treatment for arthritic patients, especially those with RA.
There are many things a podiatrist can do to make walking less painful.
These are a special type of insole that can be fitted into your shoes. They will help you walk in such a way as to minimise the pressure on your affected joints.
As well as a moulded insole, your podiatrist will help you find shoes that are roomy enough to accommodate your foot – and orthoses – without adding unnecessary pressure. If your toes are beginning to stiffen or curl, for example, it’s important for you to wear a shoe with an extra deep toe box. Your podiatrist may make a plaster of Paris copy of your foot, so a shoe can be tailored to your exact foot shape.
Your podiatrist can also provide protective shields for your toes, and/or padding to relieve pressure and reduce friction.
Surgery can correct any bunions and hammer toes caused by RA. If your joint cartilage has been completely destroyed and the joints in your foot have been dislocated to the extent that it’s extremely painful to walk, they can be fused together (a process known as arthrodesis). This involves removing the joint cartilage (the substance that allows the bones to glide over each other). The bones are then held together with screws, plates or a rod and will eventually merge into one solid bone. Although this results in a loss of movement in that particular joint, it can reduce pain.
Any secondary problems such as ulcers and corns that have been caused by foot deformities can also be treated.
The ECCH MSK Physiotherapy service will now be looking after MSK Podiatry issues. Visit their website or self refer here