Possible Joint Disfigurements in Rheumatoid Arthritis

By Linda Rath | April 23, 2024 

Rheumatoid arthritis (RA) symptoms often start in the small joints of the hands and feet, especially the knuckles, first finger joints, wrists and the joints that connect the feet to the toes. In the past, a rheumatoid arthritis diagnosis meant deformities were likely to follow, especially in these joints, usually due to long-term uncontrolled disease. Today, they are much less likely, according to Mark Figge, MD, chief emeritus of the Surgical Arthritis Service at Hospital for Special Surgery in New York City. 

“Now, with markedly improved drug therapies, we still see arthritic changes, but they happen later in life and are much less severe. Usually only one or two joints are affected, as opposed to nearly every joint being involved. The patients are healthier with better bone and skin quality as a result of their increased activities and less reliance on [corticosteroids],” he explains. 

Yet, as Dr. Figge notes, arthritic changes can still happen. When they do, they can alter both the appearance and function of affected joints. 

Causes of joint deformities
In RA, certain immune system cells — mostly T cells and B cells — migrate to the joint lining (the synovium), where they cause inflammation. This can lead to the formation of abnormally thick tissue called pannus, which can damage cartilage and surrounding ligaments and tendons. As a result, joints lose their shape and alignment. 

Types of deformities
In the early stages of RA, the feet may be affected slightly more than the hands, partly because they have the added stress of bearing the body’s weight. Extra pounds may make the problem worse. One small study of 82 people with RA found that ankle pain occurred more often with higher body weight, more severe symptoms and longer disease duration. Another study involving 230 people with RA found that those with a higher body mass index (BMI) had more foot pain and more limited mobility but not more deformities. 

Common foot deformities

• Bunion (hallux valgus). A bony lump at the base of the big toe joint, this is one of the most common foot problems in the general population, usually due to an injury or inherited problem with foot anatomy. Whether tight shoes or high heels cause bunions is controversial. Bunions are also common in people with RA — the result of erosion in the joint that causes the toe to shift or dislocate, crowding the other toes and pushing the big toe joint out. Finding shoes to fit a foot with a bunion can be challenging, but roomy, wide, comfortable shoes are key. Over-the-counter shoe inserts or prescription orthotics that help distribute pressure evenly may also help.
• Flat feet (pes planus). The medial longitudinal arch runs the length of the foot. It’s braced by thick bands of ligaments and tendons and acts as a support for the rest of the body. It’s normally the highest of the foot’s three arches, but in people with flat feet, this arch virtually disappears so that the entire bottom of the foot touches or nearly touches the ground. Estimates vary as to how many healthy people in the U.S. have flat feet, but the number is generally higher in Black people and in those who have RA. Flat feet are usually painless, but because they don’t disperse shock the way they should, they can alter the mechanics of the knees, hips and spine. They’re also a leading cause of plantar fasciitis.  Arch supports, stretching the Achilles tendon and physical therapy can help prevent these problems.
• Hammertoe. This is an unusual bend in the middle joint of one or more toes, usually the second, third or fourth. Mallet toe, a similar condition, affects the joint(s) nearest the toenail. In the later stages, muscles and tendons can become more rigid so it’s harder to uncurl the toes. As with many foot problems, shoes that have a wide, deep toe box are essential to keep pressure off of the raised joint. Toe-stretching exercises and off-the-shelf or custom orthotics that help hold toes in the right position may also help. It’s possible to straighten hammertoes and mallet toes; it just takes some time and patience.
• Claw toe. This is another condition like hammer and mallet toe, except both the toe’s middle and top joints are bent, so they look something like a claw. The same advice as for hammertoe and mallet toe applies:
  • Choose shoes with an extra-deep toe box and good arch support
  • Use pads or inserts to support the toe
  • Stretch and strengthen toes with specific exercises
  • Use a splint or tape to hold the toe in the right position

Common hand deformities
Arthritic fingers may be more disabling and affect your life more than bent toes, although these problems are much rarer these days, especially when RA is well controlled. Finger deformities can include:

• Boutonniere deformity. In this condition, the middle joint of the finger won’t straighten while the upper joint bends upward. It happens when RA or an injury damages the tendon on the top of the finger that helps straighten the middle joint. This can be reversed with a splint that keeps the middle joint straight. It must be worn continuously for up to eight weeks. Exercises to strengthen the joints, especially the joint at the top of the affected finger, are also important.
• Swan neck deformity. This condition also affects a finger’s middle joint, which bends backward while the tip bends down, mimicking the curve of a swan’s neck. It’s the mirror image of a boutonniere deformity. In RA, it can result when inflammation weakens the joint at the tip of the finger and the extensor tendon slips out of place. The most common treatment is using a ring splint to hold the finger in the right position, or extension block splints, which can help correct excessive movement of the middle joint.
• Ulnar deviation (ulnar drift). This occurs when chronic inflammation of the knuckle joints causes the fingers to bend toward the outer side of the forearm. Splints can help realign the joints and relieve pain.

Working with an occupational therapist­ can be a big help, too. They can design an exercise program as well as splints. They can also teach you how to do everyday tasks more easily and how to make your environment better suit you and your needs.

Surgery
Surgery is seldom needed for arthritic changes in the hands and is usually a last resort when more conservative methods fail. Although surgical procedures have improved considerably, they’re still prone to complications, and many people never achieve a fully functional or aligned joint through surgery.