Treating Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory condition that affects approximately 0.8% of the adult population worldwide, with a notable impact on foot health and mobility (NICE, 2022). For podiatrists, RA presents a unique challenge as it can lead to progressive joint deformities, pain, and compromised gait. This article explores effective strategies for managing foot complications in RA patients, with an emphasis on evidence-based treatments, patient-centred care, and interdisciplinary collaboration.

Understanding Rheumatoid Arthritis and Its Impact on the Foot

RA is an autoimmune disorder characterised by persistent inflammation that primarily affects synovial joints, including those in the feet. Studies show that up to 90% of RA patients experience foot involvement, with common symptoms such as forefoot pain, toe deformities, and midfoot instability (Grondal et al., 2010). The long-term implications include joint erosion, deformity, and even disability, making the role of the podiatrist critical in managing and improving patients' quality of life.

Hallux valgus and bunions
Hammertoes and claw toes
Pes planus (collapsed arches)
Rheumatoid nodules, which are subcutaneous lumps typically found on weight-bearing areas like the heels

Rheumatoid Arthritis Of the Foot

Evidence-Based Podiatric Interventions for RA

1. Orthotic Interventions

Research supports the use of custom orthoses to alleviate pain and improve functional outcomes in RA patients. A study by Woodburn et al. (2002) demonstrated that custom-made orthoses can reduce peak plantar pressures and significantly improve walking speed and comfort in RA patients.

Insoles and Arch Supports: Full-length insoles that offer metatarsal support can relieve forefoot pressure and distribute weight more evenly, helping to alleviate pain associated with hallux valgus and other deformities.
Rocker-Sole Footwear: Shoes with a rocker-bottom sole can also reduce metatarsal pressure, and studies indicate that they may improve gait by reducing joint load in the forefoot (Keenan et al., 2011).

2. Footwear Advice and Modifications

Appropriate footwear is vital for patients with RA. Shoes should provide adequate support, cushioning, and a wide toe box to accommodate deformities and reduce friction. Customised footwear may be necessary for severe cases, and advice on selecting supportive shoes can play a significant role in reducing daily pain.

3. Exercise and Physical Therapy

Exercise, when prescribed appropriately, can be beneficial for maintaining joint function and mobility in RA patients. The Royal College of Podiatry suggests gentle range-of-motion exercises to help preserve joint mobility and minimise stiffness.

Stretching and Strengthening: Daily stretching exercises for the Achilles tendon and plantar fascia can improve flexibility and reduce strain on inflamed joints.
Balance Exercises: Exercises like single-leg standing or gentle balance work can also reduce fall risk in RA patients with compromised stability.

4. Pharmacological Support and Collaboration with Rheumatologists

Managing RA requires a multidisciplinary approach. While podiatrists are not responsible for prescribing systemic medications, understanding these treatments and their side effects is important for holistic care.

5. Patient Education and Self-Management

Educating patients on managing their condition is a cornerstone of effective podiatric care. Teaching RA patients how to perform simple stretching exercises, choose appropriate footwear, and use orthotic supports can empower them to take control of their foot health.

Rheumatoid Arthritis Of the Foot

Case Study: Interdisciplinary Approach to RA Foot Care

A 55-year-old female patient with longstanding RA presented with severe forefoot pain, hallux valgus, and limited mobility. Following a comprehensive assessment, the podiatrist recommended custom orthoses to relieve forefoot pressure and arranged for a consultation with the patient’s rheumatologist. The patient was prescribed a new DMARD regimen, which helped to reduce joint inflammation.

Future Directions in RA and Podiatry

As treatment options for RA continue to evolve, podiatrists can play a crucial role in research and development by contributing data on the impact of foot deformities and exploring innovative solutions.

Conclusion

Treating RA patients requires a thoughtful, evidence-based approach that addresses both symptom relief and functional preservation. By implementing custom orthoses, providing footwear advice, and supporting patients with targeted exercise programmes, podiatrists can make a lasting impact on the lives of RA sufferers.

References

Grondal, L., et al. (2010). The foot: still the most important reason for walking incapacity in rheumatoid arthritis patients. Rheumatology International, 30(11), 1425-1430.
Keenan, M. A., et al. (2011). The clinical effect of foot orthoses on rheumatoid arthritis. Clinical Biomechanics, 26(5), 532-538.
Lund, H., et al. (2020). Exercise for the treatment of rheumatoid arthritis of the hand. Arthritis Care & Research, 67(10), 1509–1517.
National Institute for Health and Care Excellence (NICE). (2022). Rheumatoid arthritis in adults: management.
Woodburn, J., et al. (2002). A randomized controlled trial of foot orthoses in rheumatoid arthritis. Journal of Rheumatology, 29(7), 1377-1383.
Zhang, Y., et al. (2021). Additive manufacturing of foot orthotics: A review on design and material choices. 3D Printing in Medicine, 7(1), 1-15.