Guest guest Posted May 9, 2005 Report Share Posted May 9, 2005 This is about the arthritic foot. a I thought you would be especially interested. It is from a lecture I found online that actually covers just about the whole RA bundle. The site is a podiatry site. Hence the concentration on feet. Here is the site - it's not a real optimistic statement of the facts but it sounds fairly accurate to me. At the end there is a paragraph about management of RA http://www.latrobe.edu.au/podiatry/rheumatology/rheumatology_lecture_2.htm Annette Early involvement of the foot • •many cases start with symmetric involvement of metatarsophalangeal joints – presents as " metatarsalgia " - often also metacarpophalangeal joints. • •more likely to be lateral MPJ's in early stage – can be tender to palpation - seen as MPJ oedema on dorsum and widening of forefoot – may be painful on compression • •plantar or interdigital bursitis and/or flexor tendonitis may be initial presenting complaint – can be detected by ultrasound, often before being symptomatic.This may present as 'spreading' of the toes. Three case reports on spreading of the toes as presenting feature of rheumatoid arthritis • rearfoot and ankle can also be an initial presentation of disease process • •radiologically – juxta articular demineralisation in affected joint; rarely get joint space enlargement at this stage; cysts, bony erosions are prime feature – occur at margin not covered by articular cartilage – usually on medial side of joint, except in fifth MPJ in which lateral side is affected early • •radiographic changes in the foot early in rheumatoid arthritis is indicative of a more aggressive form of the disease Late Involvement of the foot • •progressive foot deformities are invariably seen in all those with rheumatoid arthritis at later stages • •generally most have either a predominant involvement of forefoot or rearfoot • •pre-existing biomechanical/pathomechanical foot disorders will exacerbate foot symptoms Forefoot: • •lateral deviation of toes, clawing of toes, subluxation of MPJ's. MPJ deformities occur in almost all cases within 10 years --> reduced foot function. Digital lesions develop from increased pressure • •hallux valgus (may have pre-existed ? made worse by rheumatoid arthritis). Incidence increases with increased duration of disease. • •anterior displacement of plantar fat pad --> increased risk for plantar lesions and pain • •spread of forefoot (splaying) & plantar depression of metatarsal heads. • •plantar hyperkeratosis and bursitis • •forefoot supinatus Mid/rearfoot: • •midfoot involvement --> collapse of midfoot arch structure – can occur early with minimal symptomatic joint involvement – may be reason for higher incidence of plantar fasciitis in rheumatoid arthritis • •rearfoot pain common (but less common than forefoot involvement) – pain from involvement of joint or achilles tendonitis or retrocalcaneal bursitis (may get erosions on x-ray from bursitis) • •subtalar involvement --> palpable swelling behind malleoli • •ankylosis of tarsal bones may occur late in the disease • •valgus rearfoot (can be very disabling) – initially flexible, then limited range of motion at subtalar joint --> later may progress to ankylosis. The rearfoot going into valgus is most likely due to the disease process in the joint, a weakness and laxity in supporting structures and an inability of the foot to counter the normal early stance phase pronation. • •impingement of the calcaneo-fibular ligament has been suggested as the cause of lateral pain in the rearfoot • •tendon sheaths around rearfoot may become affected • •posterior tibial dysfunction. Tears of the posterior tibial tendon are common in those with 'flat feet'. • •radiographically – talocalcaneal sclerosis; loss of joint space, osteophytes, angular changes associated with flat/pronated foot, erosions uncommon in midfoot & rearfoot Other foot involvement: • •plantar heel pain – in 2-3% - calcaneal spurs more common. Fibrosis of the plantar heel fat pad has been demonstrated • •changes in composition of fatty acids of heel pad have been shown ? increased fat viscosity --> decreased ability of heel to absorb shock. • •tarsal tunnel syndrome can occur at any stage – sometimes it occurs in initial stages • •subcutaneous nodules – most commonly plantar to central 3 metatarsal heads • •tenosynovitis of long flexors and extensors • •bursitis --> Morton's neuroma like symptoms • •atrophy of subcutaneous tissues (as part of disease process or secondary to corticosteroid use) • •longitudinal nail beading late in disease (may be due to vasculitis of nail bed) • •vasculitis --> skin ulceration and digital ischaemia • •stress fractures (due to osteoporosis) • •gait changes --> 'shuffling'; no heel contact or propulsive phases of stance (due to avoidance of pain and muscle changes). Knees and hips tend to be flexed. • •ankle oedema (may be due to hypoalbuminaemia or lymphatic blockage from knee joint effusions) • •venous insufficiency • •mild sensory neuropathy • •wound healing difficulty (vasculitis affects wound oxygenation; patient may be on corticosteroids or immunosuppressives) • •leg and foot ulcers (most due to venous insufficiency and vasculitis) • •side effects of corticosteroids --> skin problems, osteoporosis (may predispose to calcaneal stress fractures) Radiographic changes in foot Bilateral and symmetrical distribution of changes; periarticular osteoporosis (early) and generalised osteoporosis (late); uniform joint space narrowing; synovial cyst formation; central and marginal erosions; bony ankylosis; deformity; soft tissue swelling Management of RA • •Patient education and motivation (information on disease, treatment and prognosis – include spouses/caregivers) – many lay publications and organisations can help • •Exercise (especially range of motion exercises and aerobic fitness) – complete rest may be needed in acute phases • •Physiotherapy (patient education, swelling reduction, heat, cold, exercise, joint mobility, electrotherapeutic modalities) • •Joint protection – splinting and braces (especially during active phase) • Occupational therapy – eg using alternative ways of performing tasks to reduce strain on joints; household and personal aids • Good nutrition – especially for weight reduction if indicated and increased intake of omega-3 fatty acids has been suggested to be of benefit • Complementary/alternative therapies – used by up to 80% of those with rheumatoid arthritis • Surgical (eg fusion for cervical subluxation Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 10, 2005 Report Share Posted May 10, 2005 •plantar heel pain – in 2-3% - calcaneal spurs more common. I've been having a lot of " heel pain " (bottom of the foot). It has actually changed the way I stand. In the morning I can barely hobble to the bathroom door which is a whole 5 feet from my bed! I wondered if this was RA related. I go for my first rheumy appt. next Monday. I have a list of questions for him. > This is about the arthritic foot. a I thought you would be > especially interested. > > It is from a lecture I found online that actually covers just about > the whole RA bundle. The site is a podiatry site. Hence the > concentration on feet. Here is the site - it's not a real optimistic > statement of the facts but it sounds fairly accurate to me. At the > end there is a paragraph about management of RA > > http://www.latrobe.edu.au/podiatry/rheumatology/rheumatology_lecture_2 ..htm > > Annette > > Early involvement of the foot > • •many cases start with symmetric involvement of metatarsophalangeal > joints – presents as " metatarsalgia " - often also metacarpophalangeal > joints. > • •more likely to be lateral MPJ's in early stage – can be tender to > palpation - seen as MPJ oedema on dorsum and widening of forefoot – > may be painful on compression > • •plantar or interdigital bursitis and/or flexor tendonitis may be > initial presenting complaint – can be detected by ultrasound, often > before being symptomatic.This may present as 'spreading' of the toes. > Three case reports on spreading of the toes as presenting feature of > rheumatoid arthritis > > • rearfoot and ankle can also be an initial presentation of disease process > • •radiologically – juxta articular demineralisation in affected > joint; rarely get joint space enlargement at this stage; cysts, bony > erosions are prime feature – occur at margin not covered by articular > cartilage – usually on medial side of joint, except in fifth MPJ in > which lateral side is affected early > • •radiographic changes in the foot early in rheumatoid arthritis is > indicative of a more aggressive form of the disease > > > Late Involvement of the foot > • •progressive foot deformities are invariably seen in all those with > rheumatoid arthritis at later stages > • •generally most have either a predominant involvement of forefoot or rearfoot > • •pre-existing biomechanical/pathomechanical foot disorders will > exacerbate foot symptoms > Forefoot: > • •lateral deviation of toes, clawing of toes, subluxation of MPJ's. > MPJ deformities occur in almost all cases within 10 years --> reduced > foot function. Digital lesions develop from increased pressure > • •hallux valgus (may have pre-existed ? made worse by rheumatoid > arthritis). Incidence increases with increased duration of disease. > > • •anterior displacement of plantar fat pad --> increased risk for > plantar lesions and pain > • •spread of forefoot (splaying) & plantar depression of metatarsal heads. > • •plantar hyperkeratosis and bursitis > • •forefoot supinatus > Mid/rearfoot: > • •midfoot involvement --> collapse of midfoot arch structure – can > occur early with minimal symptomatic joint involvement – may be reason > for higher incidence of plantar fasciitis in rheumatoid arthritis > • •rearfoot pain common (but less common than forefoot involvement) – > pain from involvement of joint or achilles tendonitis or > retrocalcaneal bursitis (may get erosions on x-ray from bursitis) > • •subtalar involvement --> palpable swelling behind malleoli > • •ankylosis of tarsal bones may occur late in the disease > > • •valgus rearfoot (can be very disabling) – initially flexible, then > limited range of motion at subtalar joint --> later may progress to > ankylosis. The rearfoot going into valgus is most likely due to the > disease process in the joint, a weakness and laxity in supporting > structures and an inability of the foot to counter the normal early > stance phase pronation. > • •impingement of the calcaneo-fibular ligament has been suggested as > the cause of lateral pain in the rearfoot > • •tendon sheaths around rearfoot may become affected > • •posterior tibial dysfunction. Tears of the posterior tibial tendon > are common in those with 'flat feet'. > • •radiographically – talocalcaneal sclerosis; loss of joint space, > osteophytes, angular changes associated with flat/pronated foot, > erosions uncommon in midfoot & rearfoot > > Other foot involvement: > • •plantar heel pain – in 2-3% - calcaneal spurs more common. Fibrosis > of the plantar heel fat pad has been demonstrated > • •changes in composition of fatty acids of heel pad have been shown ? > increased fat viscosity --> decreased ability of heel to absorb shock. > • •tarsal tunnel syndrome can occur at any stage – sometimes it occurs > in initial stages > • •subcutaneous nodules – most commonly plantar to central 3 metatarsal heads > • •tenosynovitis of long flexors and extensors > • •bursitis --> Morton's neuroma like symptoms > • •atrophy of subcutaneous tissues (as part of disease process or > secondary to corticosteroid use) > • •longitudinal nail beading late in disease (may be due to vasculitis > of nail bed) > • •vasculitis --> skin ulceration and digital ischaemia > • •stress fractures (due to osteoporosis) > • •gait changes --> 'shuffling'; no heel contact or propulsive phases > of stance (due to avoidance of pain and muscle changes). Knees and > hips tend to be flexed. > • •ankle oedema (may be due to hypoalbuminaemia or lymphatic blockage > from knee joint effusions) > • •venous insufficiency > • •mild sensory neuropathy > • •wound healing difficulty (vasculitis affects wound oxygenation; > patient may be on corticosteroids or immunosuppressives) > • •leg and foot ulcers (most due to venous insufficiency and vasculitis) > • •side effects of corticosteroids --> skin problems, osteoporosis > (may predispose to calcaneal stress fractures) > > > Radiographic changes in foot > Bilateral and symmetrical distribution of changes; periarticular > osteoporosis (early) and generalised osteoporosis (late); uniform > joint space narrowing; synovial cyst formation; central and marginal > erosions; bony ankylosis; deformity; soft tissue swelling > > > Management of RA > • •Patient education and motivation (information on disease, treatment > and prognosis – include spouses/caregivers) – many lay publications > and organisations can help > • •Exercise (especially range of motion exercises and aerobic fitness) > – complete rest may be needed in acute phases > • •Physiotherapy (patient education, swelling reduction, heat, cold, > exercise, joint mobility, electrotherapeutic modalities) > • •Joint protection – splinting and braces (especially during active phase) > • Occupational therapy – eg using alternative ways of performing tasks > to reduce strain on joints; household and personal aids > • Good nutrition – especially for weight reduction if indicated and > increased intake of omega-3 fatty acids has been suggested to be of > benefit > • Complementary/alternative therapies – used by up to 80% of those > with rheumatoid arthritis > • Surgical (eg fusion for cervical subluxation Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 10, 2005 Report Share Posted May 10, 2005 Excellent make sure you have your questions written down, it's amazing the things we forget once we get into the doctors office because the doctor has his/her own adgenda on what they want to know. YOu get answering these questions and all of your questions fly out the window, leaving you frustrated after you leave. Dorey www.LivingWithRheumatoidArthritis.com ----- Original Message ----- From: " " <runyonc2001@...> <Rheumatoid Arthritis > Sent: Monday, May 09, 2005 8:12 PM Subject: Re: Foot Problems in RA ..plantar heel pain - in 2-3% - calcaneal spurs more common. I've been having a lot of " heel pain " (bottom of the foot). It has actually changed the way I stand. In the morning I can barely hobble to the bathroom door which is a whole 5 feet from my bed! I wondered if this was RA related. I go for my first rheumy appt. next Monday. I have a list of questions for him. > This is about the arthritic foot. a I thought you would be > especially interested. > > It is from a lecture I found online that actually covers just about > the whole RA bundle. The site is a podiatry site. Hence the > concentration on feet. Here is the site - it's not a real optimistic > statement of the facts but it sounds fairly accurate to me. At the > end there is a paragraph about management of RA > > http://www.latrobe.edu.au/podiatry/rheumatology/rheumatology_lecture_2 ..htm > > Annette > > Early involvement of the foot > . .many cases start with symmetric involvement of metatarsophalangeal > joints - presents as " metatarsalgia " - often also metacarpophalangeal > joints. > . .more likely to be lateral MPJ's in early stage - can be tender to > palpation - seen as MPJ oedema on dorsum and widening of forefoot - > may be painful on compression > . .plantar or interdigital bursitis and/or flexor tendonitis may be > initial presenting complaint - can be detected by ultrasound, often > before being symptomatic.This may present as 'spreading' of the toes. > Three case reports on spreading of the toes as presenting feature of > rheumatoid arthritis > > . rearfoot and ankle can also be an initial presentation of disease process > . .radiologically - juxta articular demineralisation in affected > joint; rarely get joint space enlargement at this stage; cysts, bony > erosions are prime feature - occur at margin not covered by articular > cartilage - usually on medial side of joint, except in fifth MPJ in > which lateral side is affected early > . .radiographic changes in the foot early in rheumatoid arthritis is > indicative of a more aggressive form of the disease > > > Late Involvement of the foot > . .progressive foot deformities are invariably seen in all those with > rheumatoid arthritis at later stages > . .generally most have either a predominant involvement of forefoot or rearfoot > . .pre-existing biomechanical/pathomechanical foot disorders will > exacerbate foot symptoms > Forefoot: > . .lateral deviation of toes, clawing of toes, subluxation of MPJ's. > MPJ deformities occur in almost all cases within 10 years --> reduced > foot function. Digital lesions develop from increased pressure > . .hallux valgus (may have pre-existed ? made worse by rheumatoid > arthritis). Incidence increases with increased duration of disease. > > . .anterior displacement of plantar fat pad --> increased risk for > plantar lesions and pain > . .spread of forefoot (splaying) & plantar depression of metatarsal heads. > . .plantar hyperkeratosis and bursitis > . .forefoot supinatus > Mid/rearfoot: > . .midfoot involvement --> collapse of midfoot arch structure - can > occur early with minimal symptomatic joint involvement - may be reason > for higher incidence of plantar fasciitis in rheumatoid arthritis > . .rearfoot pain common (but less common than forefoot involvement) - > pain from involvement of joint or achilles tendonitis or > retrocalcaneal bursitis (may get erosions on x-ray from bursitis) > . .subtalar involvement --> palpable swelling behind malleoli > . .ankylosis of tarsal bones may occur late in the disease > > . .valgus rearfoot (can be very disabling) - initially flexible, then > limited range of motion at subtalar joint --> later may progress to > ankylosis. The rearfoot going into valgus is most likely due to the > disease process in the joint, a weakness and laxity in supporting > structures and an inability of the foot to counter the normal early > stance phase pronation. > . .impingement of the calcaneo-fibular ligament has been suggested as > the cause of lateral pain in the rearfoot > . .tendon sheaths around rearfoot may become affected > . .posterior tibial dysfunction. Tears of the posterior tibial tendon > are common in those with 'flat feet'. > . .radiographically - talocalcaneal sclerosis; loss of joint space, > osteophytes, angular changes associated with flat/pronated foot, > erosions uncommon in midfoot & rearfoot > > Other foot involvement: > . .plantar heel pain - in 2-3% - calcaneal spurs more common. Fibrosis > of the plantar heel fat pad has been demonstrated > . .changes in composition of fatty acids of heel pad have been shown ? > increased fat viscosity --> decreased ability of heel to absorb shock. > . .tarsal tunnel syndrome can occur at any stage - sometimes it occurs > in initial stages > . .subcutaneous nodules - most commonly plantar to central 3 metatarsal heads > . .tenosynovitis of long flexors and extensors > . .bursitis --> Morton's neuroma like symptoms > . .atrophy of subcutaneous tissues (as part of disease process or > secondary to corticosteroid use) > . .longitudinal nail beading late in disease (may be due to vasculitis > of nail bed) > . .vasculitis --> skin ulceration and digital ischaemia > . .stress fractures (due to osteoporosis) > . .gait changes --> 'shuffling'; no heel contact or propulsive phases > of stance (due to avoidance of pain and muscle changes). Knees and > hips tend to be flexed. > . .ankle oedema (may be due to hypoalbuminaemia or lymphatic blockage > from knee joint effusions) > . .venous insufficiency > . .mild sensory neuropathy > . .wound healing difficulty (vasculitis affects wound oxygenation; > patient may be on corticosteroids or immunosuppressives) > . .leg and foot ulcers (most due to venous insufficiency and vasculitis) > . .side effects of corticosteroids --> skin problems, osteoporosis > (may predispose to calcaneal stress fractures) > > > Radiographic changes in foot > Bilateral and symmetrical distribution of changes; periarticular > osteoporosis (early) and generalised osteoporosis (late); uniform > joint space narrowing; synovial cyst formation; central and marginal > erosions; bony ankylosis; deformity; soft tissue swelling > > > Management of RA > . .Patient education and motivation (information on disease, treatment > and prognosis - include spouses/caregivers) - many lay publications > and organisations can help > . .Exercise (especially range of motion exercises and aerobic fitness) > - complete rest may be needed in acute phases > . .Physiotherapy (patient education, swelling reduction, heat, cold, > exercise, joint mobility, electrotherapeutic modalities) > . .Joint protection - splinting and braces (especially during active phase) > . Occupational therapy - eg using alternative ways of performing tasks > to reduce strain on joints; household and personal aids > . Good nutrition - especially for weight reduction if indicated and > increased intake of omega-3 fatty acids has been suggested to be of > benefit > . Complementary/alternative therapies - used by up to 80% of those > with rheumatoid arthritis > . Surgical (eg fusion for cervical subluxation Quote Link to comment Share on other sites More sharing options...
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