Foot and Ankle Treatments
Inflammatory arthritis in the feet and ankles can be disabling, but different specialists can treat them in different ways.
By Jill Tyrer | Dec. 19, 2023
Foot health is a key consideration for many people with autoimmune arthritis. Experts at the 2023 American College of Rheumatology scientific meeting discussed foot and ankle involvement in rheumatic diseases, symptoms to watch for and different approaches to treatment.
Rheumatologist Philip Helliwell, a professor in clinical rheumatology at the University of Leeds School of Medicine in the U.K., focused on psoriatic arthritis (PsA). The feet are important to consider not only for PsA diagnosis but also for treatment. More than 60% of people with PsA have foot pain and deformities that can be debilitating.
Malformations in the forefoot, like bunions and claw toes, are far more common than in hindfoot deformities in PsA, Dr. Helliwell explained. Plus, feet have hundreds of entheses — sites where tendons insert into bone — and inflammation of these areas, called “enthesitis,” is a hallmark of PsA. People with enthesitis in areas like the Achilles tendon can be significantly disabled.
Dactylitis, marked by sausage-like fingers or toes, is another sign of PsA, and it’s more common in toes than in hands. But patients might not mention their foot problems and their doctor may focus on their hands, not their feet. Left untreated, these feet can worsen with skin symptoms and deformities.
Dr. Helliwell described one case in which the patient’s swollen toes and inflammation-related foot blisters were misdiagnosed as an infection. In fact, his toe was amputated before he finally got a correct diagnosis. He was treated with a biologic, which cleared up the foot symptoms.
“Remember to look at the foot and ankle,” Dr. Helliwell said. Some providers are reluctant to have a patient take off their socks and shoes, and patients may fail to mention foot symptoms.
While a rheumatologist can treat inflammation-related foot and ankle issues, a patient might also need to see a podiatrist to address mechanical problems.
Heidi Siddle, PhD, an associate professor and consulting podiatrist at the University of Leeds, discussed inflammation and mechanical problems with feet and ankles in rheumatoid arthritis (RA). Patients often describe the sensation as walking on pebbles, she said, and it can be quite painful, especially in the forefoot.
The joints that connect the toes to the foot may become partially dislocated, creating unevenness in the foot pads and causing the pebble sensation. Treatment involves targeting inflammation plus orthotic devices to address mechanical problems, Siddle explained.
In cases where a biologic controls the disease activity but the patient’s feet continue to be painful or deformed, the first steps are to identify the pressure points on the foot and to assess the patient’s footwear, she said. To reduce pressure on the joints at the base of the toes, shoes should be supportive, with laces, a thick, cushioning insole, and a rigid sole with a rocker shape that reduces the pressure through the forefoot. A custom insole can further reduce pressure.
When corticosteroid shots are given, using ultrasound guidance can result in more accurate injection sites and may lead the doctor to alter the planned injection or even the diagnosis, Siddle said. Using ultrasound also helps determine whether the foot problems are mechanical or inflammatory.
Injections can provide relief, but if the person goes back to walking the same way after the injections, the same problems will happen again. That’s why it’s important to address the mechanical problems, too, she said.
RA patients with these foot issues may develop calluses on the pads of their feet. Removing them can leave a wound, and a large randomized controlled trial found that those whose callus was removed had no better outcome than those who simply used additional offloading orthotics.
Some arthritis-related foot and ankle problems can’t be fixed with medications or orthotics. In that case, it might be time to consult a surgeon. Amgad Haleem, MD, PhD, an associate professor and director of clinical research at the University of Oklahoma College of Medicine and Health Sciences Center, specializes in foot and ankle surgery.
Rheumatologic care heads off a lot of foot and ankle problems that can result from disease progression, but sometimes it’s not enough. And sometimes the arthritis medications cause other problems, like numbness, or neuropathy.
When nonsurgical methods no longer help a foot deformity and it’s severe — meaning that it’s rigid — then surgery may be the answer. Before then, he said, patients should try braces, steroid injections or other nonsurgical treatments.
He discussed a range of conditions and potential treatments, such as tendinitis in the forefoot or hindfoot. These can be treated by bracing and possible steroid injections into the tendon sheath. But if the tendon is ruptured or is detached from the bone, surgery can help.
Like Siddle, he advocated a rocker shoe for taking the pressure off the midfoot and forefoot. Studies show rocker shoes improve pain, disability and activity limitations in patients whose feet are affected by rheumatoid arthritis, he said.
It is important that people with early RA affecting their feet be referred for orthotics, he added. The earlier the involvement and earlier the disease progress, the better the outcome is likely to be.
For advanced arthritis in the ankle, fusion can be a good surgical option. The joints that are fused are first realigned, which generally eliminates the pain. It also reduces the flexibility in the ankle, but it doesn’t significantly affect a person’s walking and it fixes the problem.
Similarly, he said, fusing the toe joints closest to the foot typically has good outcomes. It reduces some flexibility, but it also reduces pain and doesn’t significantly affect the patient’s walking.
Ankle replacements have a poor history and are “notorious for bad results,” he added, but they have come a long way and now have a high success rate.
Feet and ankles are important considerations in rheumatic diseases, but research has shown that they are often overlooked or ignored. Patients and rheumatologists must give them the attention they need, in partnership with a podiatrist to address mechanical issues. And when other methods fail, a foot and ankle surgeon has additional treatments that may provide pain relief and improved function.
Foot health is a key consideration for many people with autoimmune arthritis. Experts at the 2023 American College of Rheumatology scientific meeting discussed foot and ankle involvement in rheumatic diseases, symptoms to watch for and different approaches to treatment.
Rheumatologist Philip Helliwell, a professor in clinical rheumatology at the University of Leeds School of Medicine in the U.K., focused on psoriatic arthritis (PsA). The feet are important to consider not only for PsA diagnosis but also for treatment. More than 60% of people with PsA have foot pain and deformities that can be debilitating.
Malformations in the forefoot, like bunions and claw toes, are far more common than in hindfoot deformities in PsA, Dr. Helliwell explained. Plus, feet have hundreds of entheses — sites where tendons insert into bone — and inflammation of these areas, called “enthesitis,” is a hallmark of PsA. People with enthesitis in areas like the Achilles tendon can be significantly disabled.
Dactylitis, marked by sausage-like fingers or toes, is another sign of PsA, and it’s more common in toes than in hands. But patients might not mention their foot problems and their doctor may focus on their hands, not their feet. Left untreated, these feet can worsen with skin symptoms and deformities.
Dr. Helliwell described one case in which the patient’s swollen toes and inflammation-related foot blisters were misdiagnosed as an infection. In fact, his toe was amputated before he finally got a correct diagnosis. He was treated with a biologic, which cleared up the foot symptoms.
“Remember to look at the foot and ankle,” Dr. Helliwell said. Some providers are reluctant to have a patient take off their socks and shoes, and patients may fail to mention foot symptoms.
While a rheumatologist can treat inflammation-related foot and ankle issues, a patient might also need to see a podiatrist to address mechanical problems.
Addressing Mechanical Issues
Heidi Siddle, PhD, an associate professor and consulting podiatrist at the University of Leeds, discussed inflammation and mechanical problems with feet and ankles in rheumatoid arthritis (RA). Patients often describe the sensation as walking on pebbles, she said, and it can be quite painful, especially in the forefoot.The joints that connect the toes to the foot may become partially dislocated, creating unevenness in the foot pads and causing the pebble sensation. Treatment involves targeting inflammation plus orthotic devices to address mechanical problems, Siddle explained.
In cases where a biologic controls the disease activity but the patient’s feet continue to be painful or deformed, the first steps are to identify the pressure points on the foot and to assess the patient’s footwear, she said. To reduce pressure on the joints at the base of the toes, shoes should be supportive, with laces, a thick, cushioning insole, and a rigid sole with a rocker shape that reduces the pressure through the forefoot. A custom insole can further reduce pressure.
When corticosteroid shots are given, using ultrasound guidance can result in more accurate injection sites and may lead the doctor to alter the planned injection or even the diagnosis, Siddle said. Using ultrasound also helps determine whether the foot problems are mechanical or inflammatory.
Injections can provide relief, but if the person goes back to walking the same way after the injections, the same problems will happen again. That’s why it’s important to address the mechanical problems, too, she said.
RA patients with these foot issues may develop calluses on the pads of their feet. Removing them can leave a wound, and a large randomized controlled trial found that those whose callus was removed had no better outcome than those who simply used additional offloading orthotics.
What About Surgery?
Some arthritis-related foot and ankle problems can’t be fixed with medications or orthotics. In that case, it might be time to consult a surgeon. Amgad Haleem, MD, PhD, an associate professor and director of clinical research at the University of Oklahoma College of Medicine and Health Sciences Center, specializes in foot and ankle surgery.Rheumatologic care heads off a lot of foot and ankle problems that can result from disease progression, but sometimes it’s not enough. And sometimes the arthritis medications cause other problems, like numbness, or neuropathy.
When nonsurgical methods no longer help a foot deformity and it’s severe — meaning that it’s rigid — then surgery may be the answer. Before then, he said, patients should try braces, steroid injections or other nonsurgical treatments.
He discussed a range of conditions and potential treatments, such as tendinitis in the forefoot or hindfoot. These can be treated by bracing and possible steroid injections into the tendon sheath. But if the tendon is ruptured or is detached from the bone, surgery can help.
Like Siddle, he advocated a rocker shoe for taking the pressure off the midfoot and forefoot. Studies show rocker shoes improve pain, disability and activity limitations in patients whose feet are affected by rheumatoid arthritis, he said.
It is important that people with early RA affecting their feet be referred for orthotics, he added. The earlier the involvement and earlier the disease progress, the better the outcome is likely to be.
For advanced arthritis in the ankle, fusion can be a good surgical option. The joints that are fused are first realigned, which generally eliminates the pain. It also reduces the flexibility in the ankle, but it doesn’t significantly affect a person’s walking and it fixes the problem.
Similarly, he said, fusing the toe joints closest to the foot typically has good outcomes. It reduces some flexibility, but it also reduces pain and doesn’t significantly affect the patient’s walking.
Ankle replacements have a poor history and are “notorious for bad results,” he added, but they have come a long way and now have a high success rate.
Feet and ankles are important considerations in rheumatic diseases, but research has shown that they are often overlooked or ignored. Patients and rheumatologists must give them the attention they need, in partnership with a podiatrist to address mechanical issues. And when other methods fail, a foot and ankle surgeon has additional treatments that may provide pain relief and improved function.
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