Rheumatoid Arthritis of The Foot & Ankle

Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. It most often starts in the small joints of the hands and feet, and usually affects the same joints on both sides of the body.More than 90% of people with rheumatoid arthritis (RA) develop symptoms in the foot and ankle over the course of the disease.

Pathology

The joints of our body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes an overactivity of this lining. It swells and becomes inflamed, destroying the joint, as well as the ligaments and other tissues that support it. Weakened ligaments can cause joint deformities — such as claw toe or hammer toe. Softening of the bone (osteopenia) can result in stress fractures and collapse of bone.

Symptoms

The most common symptoms are pain, swelling, and stiffness. Unlike osteoarthritis, which typically affects one specific joint, symptoms of RA usually appear in both feet, affecting the same joints on each foot.

Ankle

Difficulty with inclines (ramps) and stairs are the early signs of ankle involvement. As the disease progresses, simple walking and standing can become painful.

Hindfoot (Heel Region of the Foot)

The main function of the hindfoot is to perform the side-to-side motion of the foot. Difficulty walking on uneven ground, grass, or gravel are the initial signs. Pain is common just beneath the fibula (the smaller lower leg bone) on the outside of the foot.

Midfoot (Top of the Foot)

With RA, the ligaments that support the midfoot become weakened and the arch collapses. With loss of the arch, the foot commonly collapses and the front of the foot points outward. RA also damages the cartilage, causing arthritic pain that is present with or without shoes. All of these changes in the shape of the foot can make it very difficult to wear shoes.

Forefoot (Toes and Ball of the Foot)

The changes that occur to the front of the foot are unique to patients with RA. These problems include bunions, claw toes, and pain under the ball of the foot (metatarsalgia). Although, each individual deformity is common, it is the combination of deformities that compounds the problem.

Claw_toe_deformity
Claw_toe_deformity_1CLAW TOE DEFORMITY IN RHEUMATOID ARTHRITIS

TREATMENT MODALITIES

Although orthopaedic treatment may relieve symptoms, it will not stop the progression of the disease. Specific medicines called disease-modifying anti-rheumatic drugs are designed to stop the immune system from destroying the joints

Non Surgical Treatment

Rest: Limiting or stopping activities that make the pain worse is the first step in minimizing the pain. Biking, elliptical training machines, or swimming are exercise activities that allow patients to maintain their health without placing a large impact load on the foot.
Ice : Placing ice on the most painful area of the foot for 20 minutes is effective. This can be done 3 or 4 times a day.
Nonsteroidal Anti-inflammatory Medication : Drugs, such as ibuprofen or naproxen, reduce pain and inflammation
Orthotics : An orthotic (shoe insert) is a very effective tool to minimize the pressure from prominent bones in the foot. The orthotic will not be able to correct the shape of your foot. The primary goal is to minimize the pressure and decrease the pain and callous formation. This is more effective for deformity in the front and middle of the foot.

Surgical Treatment

Fusion: Fusion of the affected joints is the most common type of surgery performed for RA. Fusion takes the two bones that form a joint and fuses them together to make one bonelike ankle & subtalar fusion.During the surgery, the joints are exposed and the remaining cartilage is removed. The two bones are then held together with screws or a combination of screws and plates.
TOTAL ANKLE REPLACEMENT(TAR): Patients with severe involvement of other joints around the heel or patients who have previously undergone a fusion on the other leg, may be more suited for ankle replacement. In addition, patients who have fusions within the same foot may be more suited for an ankle replacement.Newer generation ankle replacement implants have shown promising early results.

Toe_Ankle_ReplacementTOTAL ANKLE REPLACEMENT

ankle_fusionANKLE FUSION