What is Rheumatoid Arthritis?
Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes pain, stiffness, and swelling in the joints, frequently symmetrical (if one foot has it, the other one will). In RA, the joint lining (synovium), normally smooth and shiny, becomes inflamed, painful and swollen. The disease, which lasts over a long period of time, can cause damage to cartilage, bone, tendons and ligaments. RA can also cause inflammation in the blood vessels and the outer lining of the heart and lungs. RA cannot be cured, but with proper care, it can be controlled or brought into remission.
One main factor separates RA from other types of arthritis. In RA the joints that are involved are symmetrical. About 2.1 million Americans have RA. Other common forms of arthritis are osteoarthritis, gout, ankylosing spondylitis, lupus, psoriatic arthritis and juvenile rheumatoid arthritis.
What is Rheumatoid Foot and Ankle?
Though the majority of arthritis sufferers are over 50, people of all ages are potential victims. About 90 percent of rheumatoid arthritis sufferers have arthritis of the foot or ankle. When you have arthritis of the foot, you develop pain and limited motion and cannot walk as well. If left untreated, this pain can grow worse, eventually becoming so excruciating that you can no longer walk even short distances. Also, if left untreated, the foot and ankle may eventually become deformed.
Because the human foot contains 33 joints, it is more susceptible to arthritis. About 90 percent of RA patients will complain of problems with the midfoot and forefoot while 67 percent will have problems with the hindfoot and ankle. The ankle is usually the last joint to be involved with RA.
The ankle is the joint between the leg and foot that joins the two bones of the lower leg, the shinbone (or tibia) and the calf bone (fibula) with the talus, allowing the foot to move up and down. The talus and the calcaneus, the heel bone beneath it, carry the weight of the body on the hind foot and the metatarsal heads and toes carry the weight on the forefoot.
The normal ankle joint moves the foot up and down, and also has a slight side-to-side rotation. A capsule of ligaments (the tough, sinewy tissue that binds bones together) surrounds the ankle and stabilizes the joint. Ligaments are lined with a thin synovial membrane that helps lubricate the tissue, providing ease of motion. Rheumatoid arthritis is the result of chemical irregularities in the synovial fluid of this membrane.
In addition to supporting weight, the foot acts as a shock absorber. It serves to balance and adjusts the body to uneven surfaces. Your ankle joint is submitted to as much as 63 tons of pressure with each mile you walk. Because the feet are very small in comparison to the rest of the body, the impact of every step exerts tremendous force upon them.
Causes of Rheumatoid Foot and Ankle
No one knows exactly what causes RA, but there are many thoughts about what might contribute to it. A sudden and traumatic injury such as a broken bone, torn ligament, or ankle sprain can cause the injured joint to become arthritic in the future. Heredity, or the genes you get from your parents, may be a factor in determining who gets rheumatoid arthritis. Some researchers think certain infections or chemicals might cause the disease. Many studies are being done to see if this can be determined.
Some people think hormones may play a role. But this, too, is still uncertain, even though women are more apt to suffer from RA than are men. RA is an autoimmune disease, which means your own immune system starts to attack some of your tissues. Symptoms develop as the result of many other factors as well, including:
- Bacterial and viral infections
- The use of prescription and/or illegal drugs
- Contact with certain chemicals
- Traumatic injury such as a broken bone, torn ligament, or sprained ankle
- Bowel disorders such as ileitis and colitis
- Obesity, which often aggravates arthritic conditions
Symptoms of Rheumatoid Arthritis
Symptoms of rheumatoid arthritis can come and go. The most common symptoms of RA are pain, swelling and stiffness in one or more joints. The pain may be similar to a headache or toothache. In some people, the joints can feel hot. Some people may have a fever. You may become anemic—you may have a lower number of red blood cells than normal.
On days when RA acts up, some people may lose their appetites, be tired, and have trouble sleeping.
Sometimes lumps of tissue develop near the affected joint, usually near the elbow joint. These are called rheumatoid nodules.
Occasionally, RA sufferers will develop inflammation of the lining that surrounds the heart and lungs. Also common are dry eyes and a dry mouth due to inflammation of tear glands and saliva glands.
Symptoms of Rheumatoid Foot and Ankle
Ninety percent of all people with rheumatoid arthritis have RA of the foot or ankle. When you have arthritis of the foot, your way of walking is affected. Left untreated, the pain may eventually become so excruciating that you can no longer walk even short distances. Besides causing severe deformities of the joints of the foot, rheumatoid foot and ankle is often accompanied by general fatigue and weakness. People who suffer from this condition frequently develop related forefoot problems such as bunions, hammer toes, and claw toes. Corns, or even ulcers, may develop on the foot. As you can imagine, shoe fitting particularly for the woman's' foot is difficult.
Metatarsalgia, a general term for pain in the sole or the ball of the foot, is also very common. This indicates that RA is affecting the metatarsal joints of the toes. Hindfoot and ankle pain often involves the posterior tibial tendon. The ankle itself is usually the last joint in the foot to be involved with RA.
Other symptoms may include a poor appetite, fever, and anemia. People with RA often have a lower number of red blood cells than normal.
Symptoms of RA tends to flare up in relation to stress, making some people lose their appetites, suffer extreme fatigue, or have trouble sleeping. Dry eyes and a dry mouth may result from inflammation of the tear glands and saliva glands. Joint pain may be ongoing and distracting, similar to a headache or toothache. In some people, the joints feel hot and fever develops. Other symptoms, which a doctor would see in x-rays, include tissue swelling, joint destruction, and malalignment.
Treatment of Rheumatoid Foot and Ankle
Arthritis of the foot and ankle can usually be detected fairly easily during a routine doctor's exam. Most patients first suspect arthritis when they experience tenderness in the foot and pain whenever the ankle joint is compressed. In assessing your particular case, your doctor will ask about your medical history and any other persistent or previous conditions of the foot and leg. He or she will inquire about your activities and occupation, as they may play a role in the progression of the disease. A complete and competent exam involves considering the possibility of associated injuries or conditions, such as RA in the joints of the knee and hip, diabetes, or the presence of a heart condition.
The main goals in treating RA are to relieve pain, reduce swelling, slow down the damage to the joints, and improve the person's ability to function. Medical management can improve symptoms and slow the progression of the disease. While there is no cure for rheumatoid foot and ankle, orthotics (shoe supports like pads and insoles) may be used. Some drugs can help control the disease. A rheumatologist will often suggest:
Nonsteroidal anti-inflammatories can be used and include:
- Acetylsalicylic acid (aspirin)
Corticosteroids (cortisone shots) can also help ease pain and swelling and help slow the damage to the joints. Drugs that are corticosteroids include prednisone and cortisone. There are also a group of drugs known as disease modifying anti-rheumatic drugs. These are also called DMARDs and they take much longer to act than the NSAIDs. Sometimes it can take weeks or months to begin to notice a change. But, the DMARDs may help slow the progress of the arthritis, too. There are more side effects to these drugs though and you will need to check with your doctor often. DMARDs include:
- Antimalarial drugs
- Gold compounds
Surgical Procedure for Rheumatoid Foot and Ankle
Surgical procedures, such as ankle joint replacement or surgery for a related condition such as bunion, may be considered in the event that conservative therapy does not bring about sufficient pain relief. Resection arthroplasty of the metatarsal heads plus orthotics is highly effective. Ankle replacement surgery, also known as ankle arthroplasty, is a new technique that has developed in recent years in response to the need to effectively improve an ankle joint that has been severely damaged by injury or some form of arthritis.
When other, more conservative methods of treating rheumatoid foot and ankle prove inadequate, joint replacement surgery may represent the best hope for long-term improvement to the ankle joint. Dramatic advances in the procedures and devices used to repair and replace the ankle may now bring profound relief to those people who suffer from chronic pain and loss of motion in the ankle joint.
Changes to the anatomy or structure of one part of the foot significantly affect the function of the others. If surgery looks like part of a treatment plan for you, it is important to be familiar with both the procedure and the rehabilitation process that follows. Surgical procedures on the foot and ankle usually require a recovery and rehabilitation period of at least 4 to 6 weeks.
Possible Complications of Surgery for Rheumatoid Foot and Ankle
Rheumatoid arthritis is a systemic condition that requires regular monitoring. It is important to discuss your response to medications with your doctor, as well as to try to maintain the best possible general health. Your mental and emotional health has a significant effect on the success of treatment.
In considering surgery for rheumatoid foot and ankle, it is important to work with a specialist to decide on the most effective treatment procedures. This involves evaluating and comparing the risks of surgery with the expected benefits. Although surgical procedures for rheumatoid foot and ankle are usually without any significant problems, there may occasionally be unforeseen complications associated with anesthesia, including respiratory or cardiac malfunction. The surgery itself may be complicated by infection, injury to nerves and blood vessels, fracture, weakness, stiffness or instability of the joint, pain, or the need for additional surgeries.
The use of alcohol, tobacco, or drugs, including mind-altering drugs, muscle relaxants, antihypertensives, tranquilizers, sleep inducers, insulin, sedatives, beta-adrenergic blockers, and corticosteroids, increases surgical risk. Surgery should always be undertaken when the patient is in the best possible health, with any other chronic conditions under effective management. Follow your surgeon's directions carefully, keeping in mind that recovery depends not on surgery alone but also on commitment to the rehabilitation process.
For many people, support groups may also help. You can contact the National Arthritis Foundation at 800.283.7800 to find some groups near you. Or find the chapters near you by visiting their Web site at http://www.arthritis.org/offices/
The information provided herein is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting a licensed physician.