Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic disease that attacks multiple joints throughout the body. About 90% of the people with rheumatoid arthritis eventually develop symptoms related to the foot or ankle. Usually, symptoms appear in the toes and forefeet first, then in the hindfeet or the back of the feet, and finally in the ankles. Other inflammatory types of arthritis that affect the foot and ankle include gout, ankylosing spondylitis, psoriatic arthritis, and Reiter's syndrome. The exact cause of RA is unknown, but there are several theories. Some people may be more likely to develop RA because of their genes. However, it usually takes a chemical or environmental "trigger" to activate the disease. In RA, the body's immune system turns against itself. Instead of protecting the joints, the body produces substances that attack and inflame the joints.

The most common symptoms of RA in the foot are pain, swelling, and stiffness. Symptoms usually appear in several joints on both feet. You may feel pain in the joint or in the sole or ball of your foot. The joint may be warm and the way you walk may be affected. You may develop corns or bunions, and your toes can begin to curl and stiffen in positions called claw toe or hammer toe. If your hindfoot (back of the foot) and ankle are affected, the bones may shift position in the joints. This can cause the long arch on the bottom of your foot to collapse (flatfoot), resulting in pain and difficulty walking. In some cases, you may develop lumps around your joints, called nodules, which may be particularly symptomatic when they occur in the foot.

Sometimes, arthritis symptoms in the foot are the first indication that you have RA. The appearance of symptoms in the same joint on both feet or in several joints is an indication that RA might be involved. X-rays may be necessary to see how much damage there is to the joints and if suspected, an extensive blood work-up may be necessary.

Many people with RA can control their pain and the disease with medication and exercise. Some medications, such as aspirin or ibuprofen, help control pain. Others, including methotrexate, prednisone, sulfasalazine, and gold compounds, help slow the spread of the disease itself. In some cases, an injection of a steroid medication into the joint can help relieve swelling and inflammation. Shoe wear modification may also be beneficial and exercise may also be beneficial.

Surgery can correct several of the conditions, such as bunions and hammer toes, associated with RA of the foot and ankle. In many cases, however, the most successful surgical option is fusion (arthrodesis). Fusion is often performed on the great toe, in the midfoot, in the heel, and in the ankle. In this procedure, the joint cartilage is removed; in some cases, some of the adjacent bone is also removed. The bones are held in place with screws, plates and screws or a rod through the bone. The surgeon may then implant a bone graft as well. Eventually, the bones unite, creating one solid bone. There is loss of motion, but the foot and ankle remain functional and generally pain-free. Replacing the ankle joint with an artificial joint (arthroplasty) may be possible. As in all surgeries, there is some risk. Infections, failure to heal, and loosening of the devices are the most common problems. Intravenous antibiotics and/or repeat surgery may be needed. Severe complications may require amputation, but this is rare. Surgical complications may be minimized by working closely with the entire medical team, including the primary care physician, rheumatologists, and other professionals to minimize the immunosuppressives utilized around the time of surgery both before and afterwards in order to maximize healing ad minimize the risk of infection.

Modified from the AAOS