arthritis
do you have arthritis?
The term "arthritis" is difficult to define clearly. If foot
pain is not completely understood, and the pain seems to come from a
joint it is often called arthritis, especially if there is associated
swelling. What appears to be joint pain (and called arthritis) is often
soft tissue inflammation around the joint or simply a joint strain.
For a definitive diagnosis, positive x-ray findings and blood test evidence
are usually required. Arthritis pain can be barely noticeable and not
disabling, severe and disruptive to one's life and activities, or somewhere
in between. It can almost always be treated and often the symptoms eliminated.
If the arthritis condition is more severe, the symptoms can be minimized.
More severe cases may proceed to surgical treatment.
Most of the information in this section is directed towards
people who already have a diagnosis of the more progressive arthritis
conditions including rheumatoid arthritis, seronegative arthritis, and
psoriatic arthritis. These are the 3 most common foot problems that
(I see that) seem to plague people with arthritis. Everyone is absolutely
unique in the variety and extent of problems and pain they experience.
No generalizations can be made. There are typically 3 main areas of
pain and they are discussed separately below.
Problem: Metatarsalgia (pain in the ball of the foot)
This is the most common arthritis complaint I see in my
office. It may be mild and annoying or it can be quite debilitating.
Imagine if every step you take you feel pain as you come up onto the
ball of the foot. It's not pleasant - and often it's only possible to
minimize, not to eliminate the pain. Pain in the ball of the foot -
metatarsalgia - is multifactorial. Most people with arthritis have a
combination of problems leading to the pain. The most common would be
synovitis (joint inflammation). Synovitis is treated using anti-inflammatory
and other medications. After synovitis has been present for some time,
the joints that are affected tend to become looser. They can come out
of position more easily. This results in dropped metatarsal heads, deformities
of the toes and uneven weightbearing in the ball of the foot. Painful
callouses usually develop. The callouses can be trimmed, but the pain
usually is deeper in the joint. Any soft tissue structures in the ball
of the foot can become inflamed including the joint capsule, ligaments,
muscles, nerves and even blood vessels. When the ball of the foot hurts
consistently and chronically, the gait pattern tends to change. There
is less bending of the foot, which results in reduced use of the achilles
tendon and its associated muscles. In turn, the achilles tendon can
shorten and create other dysfunctional biomechanics in the foot and
lower extremity. Also, people with progressive arthritis tend to develop
bunions and HAV (hallux abductovalgus deformities). These deformities
cause increased pain and further shifting of weight to the smaller metatarsal
heads, which are not in a position to accept the extra weight.
Treatment is multi-faceted. The goal is to decrease weightbearing
on the painful areas. This can be done using pads, orthotics, shoe modifications
and callous trimming. Achilles tendon stretching is important and wearing
good quality runners or walkers is almost always helpful. Custom orthotics
are probably the best way to redistribute weightbearing and maintain
as normal foot function as possible, despite the chronic pain.
Problem: Ankle or Subtalar joint (below the ankle) Pain
People who have a diagnosis of arthritis may have severe pain and
swelling in the ankle and subtalar joint (the top joint of the foot
just below the ankle). There can also be associated tendonitis which
can further diminish normal function of these joints. It is difficult
to treat, because these joints must go through a range of motion every
step that is taken.
The most effective way to minimize inflammation is to stop walking
completely, for a short time. This can be counter-productive to one's
general health. Symptoms can be treated using rocker bottoms on shoes
and sometimes orthotics can be helpful. These joints may be fused eventually
to eliminate pain. Once fused, the gait pattern is significantly hindered
(but the pain is usually gone).
Problem:Heel Pain
The heel pain associated with arthritis can be very similar to a
simple plantar fasciitis. The pain with arthritis is usually more severe
and more difficult to treat. Also, there tends to be swelling and warmth
in other joints of the foot. Tarsal tunnel syndrome is a condition that
is more common in people with arthritis and can lead to heel pain, usually
with associated numbness and tingling. This condition results from swelling
in the ankle and subtalar joints and irritates the nerve going down
the inside of the ankle. It can result in localized pain, irritated
nerves in the heel and foot, numbness and weakness in the foot.
Treatment of heel pain in someone with arthritis is similar to treating
it in anyone. Custom orthotics are usually essential to relieve weightbearing
pressure on the plantar fascia. Cortisone injections (by a professional)
can be tried directly into the heel (yes, it hurts). Foot wear must
be supportive and well-cushioned. The use of a foot roller and localized
massage or physiotherapy can also be useful.
conditions sometimes associated with arthritis
leg length discrepancy
This may be a pre-existing condition which if left untreated may lead
to arthritis of the spine, hip, knee, or foot; or it may be a resultant
condition of arthritis due to shortening of one lower extremity only.
Usually symptoms are one-sided or opposite symptoms bilaterally. You
may feel lopsided and tend to bend one knee or hike one hip while standing.
Treatment is not straight forward. The simplest treatment is in-shoe
full length lifts. Heel lifts should rarely be used because it is important
to lift the entire limb, not just the heel. Consistency is the key -
the lift should be worn 90% of weightbearing time.
posterior tibial tendon dysfunction
This condition results in loss of strength of the muscle supporting
the inside of the arch and is more common in arthritis because of weakening
of the muscles and laxity of the joints due to chronic inflammation.
The posterior tibial tendon is an important stabilizer of the foot -
this condition must be treated aggressively and quickly, otherwise the
foot can completely and permanently flatten.
*** callousing ***
When bony structure changes due to the effects of arthritis, pressure
points usually develop - if they occur on the bottom of the foot, callousing
will often occur; the callous acts to increase pressure and should always
be removed by a professional. Callouses indicate that the bones have
changed position or the foot has shifted its weightbearing pattern.
With thorough examination and the use of proper padding techniques the
pressure can be alleviated to some extent. Callouses may also develop
over nodules and can be debrided carefully to decrease pressure. If
a callous is not removed, there is a risk of developing an ulceration
- which is a breakdown in the skin under the callous (like a wound underneath
the skin). Some people with arthritis have a difficult time healing
ulcerations because of the medications they are taking. Remember, that
callouses will almost always come back. Therefore, many people need
to see a podiatrist on a regular basis. Whatever you do, resist the
temptation to take a blade to your own foot. This can result in serious
injury (as you can probably imagine).
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