By Paul J. Betschart, DPM
Arthritis is a medical term that describes inflammation of a joint; swelling and tenderness are common symptoms. Joints are areas where 2 different bones contact one another. Some joints allow for motion to occur and some do not. The freedom of movement ranges from none (skull sutures/bones in the head) to fully mobile (hip, shoulder) with varying ranges in between. Each foot has 33 joints, each with different degrees of freedom of motion. With so many joints and with the strain the feet have to withstand, the feet are commonly affected by arthritis.
There are 2 main types of arthritis that affect the human body: inflammatory arthritis and degenerative arthritis, also known as osteoarthritis. Examples of inflammatory arthritis are rheumatoid, psoriatic, gout, lyme, and septic arthritis, and ankylosing spondylitis.
With inflammatory arthritis, something triggers an immune response in the soft tissues surrounding the joint, called the joint capsule. If left unchecked, the immune response can lead to weakening of the supportive structures around the joint – the ligaments and tendons – which can lead to instability, dislocation, and deformity. Inflammatory arthritis rarely damages the cartilage directly. However, the inflammatory response it causes can disrupt the synovial tissue, which is the main source of nutritional support, and that disruption can lead to secondary degeneration.
Degenerative arthritis is caused by abnormal wear and tear of the articular cartilage, the smooth tissue that cushions the ends of most bones. Degenerative arthritis is age-related: it is a slow, progressive process, occurring over many years. Most joints in the body will show degenerative changes over time, typically viewed as “normal aging.” However, abnormal alignments or traumatic events involving a joint, such as ankle sprains, can lead to earlier onset of degenerative changes and faster progression.
Arthritis is diagnosed through a combination of history, physical examination, imaging studies, and laboratory testing. Clues to the type of arthritis can be found in the history of the condition, for example, time of onset, speed of progression, location of symptoms, history of trauma, length of time stiffness, etc. Physical examination would reveal deformity, swelling, redness, increased temperature, and pain with palpation or motion. X-rays can identify deformities and provide radiographic clues to the type of arthritis, such as erosions, cysts, and joint space narrowing. Imaging – such as ultrasound, CT, or MRI – may also be needed for definitive diagnosis. Laboratory studies focus on identifying inflammatory and immune factors in the blood, as well as changes in the white blood cell count. Joint fluid analysis can also be helpful at arriving at a diagnosis.
Non-surgical treatment of arthritis focuses on three areas that work together:
Inflammation reduction: Inflammation can be reduced with oral medications, injectable medications, topical medications, and physical therapy modalities. Usually, some combination of modalities is used. Certain arthritic conditions, such as rheumatoid and psoriatic arthritis, are considered auto-immune conditions and may need to be treated with immune suppressive medications.
Joint support and stabilization: Joint support and stability are achieved with various orthopedic appliances, ranging from taping to rigid bracing. Selection of the appropriate appliance is based on clinical judgement and a patient’s unique needs.
Strengthening of surrounding musculature: Strengthening of the supporting musculature is achieved by employing specific exercises, commonly directed by a physical therapist or other health professional.
Medical illustration by Chyna LaPorte for Lower Extremity Review.
The majority of arthritis patients that I see in clinical practice as a podiatrist have degenerative arthritis. Most are painfully aware of it, some are not.
While any joint of the foot can be affected, the great toe joint, ankle, and sub-talar joints (figure below) are the most commonly problematic. After ruling out other issues and arriving at the diagnosis, treatment can be initiated. As mentioned previously, degenerative arthritis commonly has a low-grade inflammatory component. Reducing this inflammation is the first step in treatment, typically an injection of anti-inflammatory medication directly into the involved joint is the fastest way to reduce joint inflammation. Fluoroscopy or ultrasound can be helpful for joint identification and needle guidance. A short series of 2-3 weekly injections is usually effective at reducing this inflammatory component. Combination therapy with oral and/or topical anti-inflammatories can also be used.
Temporary immobilization of the affected joint using taping, bracing, or casting may be needed in some cases. Long-term stabilization of the involved joints is achieved using custom-molded foot orthoses which are created using a mold of the patients’ foot. With ankle involvement, ankle-foot orthoses (commonly called AFOs) may be needed.
Footwear is an important and commonly overlooked area to consider with arthritis patients. Areas to consider when selecting footwear for the arthritic patient are: accommodation of deformities, support and stability of the foot and lower extremity, and accommodation for orthoses and braces. Fortunately there are a number of manufactures that make a variety of shoes that are appropriate for the arthritis patient. Propet, New Balance, Anodyne, Vionic, and Dr Comfort are some of the brands that we recommend. But please note, professional sizing and fitting is important for a successful result. As a podiatrist, I often refer my patients to a certified pedorthist for appropriate shoe-fitting.
Should symptoms persist after anti-inflammatory measures are used, physical therapy modalities can be employed. Class 4 laser therapy is a newer modality that is very effective at reducing pain and inflammation. Applications of 10-20 minutes, 1-2 times a week for 3-4 weeks is a typical protocol. Other modalities that can be used include ultrasound, electrical stimulation, hydrotherapy, paraffin, and infrared.
Rehabilitation can begin after the inflammatory response is under control. Exercises prescribed are based on the joints involved and other patient specific needs. Consultation with a physiatrist or physical therapist may be needed.
Inflammatory arthritis may be treated in a similar manner. Input from the patient’s primary care doctor and rheumatologist should be sought for managing their medications, particularly for those on immune suppressants.
Anyone with persistent joint pain in their feet and legs should have an evaluation by a foot and ankle specialist right away. Like most medical conditions, early intervention is important to protect and preserve joint structure and function.
Anyone needing more information on arthritis the lower extremity is invited to contact me at my office in Danbury, CT, or visit our website for more information www.advancedfootandanklecenter.com.
Paul J. Betschart, DPM, FACFAS, is a podiatrist in private practice in Danbury, Connecticut. A Fellow of the American College of Foot and Ankle Surgeons, his goal is to help his patients achieve optimal health from the ground up.