Treatments for foot arthritis
Treatment for rheumatoid arthritis is primarily medical, initiated by a rheumatologist and followed up by the general practitioner. Surgery is used only in case of irreversible destructive deformity causing pain on a daily basis.
As the foot is often involved in rheumatoid arthritis, regular clinical and radiological monitoring is needed. Forefoot (and hand) X-ray should be performed every 6 months during the first year, then annually for 3 years so as to assess progression and adapt medical and/or surgical treatment.
I/Medical treatment of foot arthritis
Apart from controlling inflammation by maintenance treatments or local injections, rheumatoid arthritis of the foot requires certain specific measures:
See French Health Authority (Haute Autorité de la Santé: HAS) guidelines.
a/Specific foot treatment
Standard medical practice should include regular examination of the feet, footwear and orthoses (expert opinion).
Patients with rheumatoid arthritis should be informed of foot hygiene rules, and the usefulness of chiropody-podiatry. They should be advised on footwear (expert opinion).
A chiropodist-podiatrist should be consulted to treat unguinal abnormalities and hyperkeratosis in feet affected by rheumatoid arthritis (expert opinion). Chiropody should be administered with caution and strict asepsis due to the high risk of infection and frequent healing problems in these patients. In 2007, access to prescribed chiropody care was hindered by national health insurance reimbursement levels that were much lower than the real cost to the patient.
Made-to-measure plantar orthoses are recommended for foot pain on weight-bearing or static disorder of the foot (expert opinion). Adapted monitoring of the foot and orthosis is recommended due to the great fragility of the foot affected by rheumatoid arthritis, especially when wearing corrective orthoses (expert opinion).
Plantar orthoses are indicated:
- for pain relief (level of evidence: 4);
- for correction of established deformity reducible under loading (expert opinion);
- for palliative purposes, to relieve pathological or painful contact areas (expert opinion). Orthoses should be made to measure, possibly thermoformed or thermomolded, in non-aggressive material (expert opinion).
Made-to-measure toe-spacers can have corrective or palliative effects, making footwear possible (expert opinion). Renewal of prescription should be founded on objective assessment of patient adherence to treatment and individual benefit: pain relief, and maintenance or improvement of functional capacity.
Extra-wide footwear or therapeutic footwear thermoformed on the patient’s foot is recommended in case of deformity with pain and difficulty with footwear (grade C). It reduces pain in walking and improves functional capacity (level of evidence: 4). Prolonged-use therapeutic footwear is indicated when other types have failed.
Made-to-measure therapeutic footwear may be prescribed for palliative purposes in case of major foot involvement.
Surgery is thus reserved to patients resistant to medical treatment and in daily pain, whether barefoot or shod. NB: surgery for rheumatoid arthritis is completely different from surgery for hallux valgus: the pathologies are not the same, treatment is not the same and the patients are not the same, and finally there is no comparison between the two.
Pain is caused by irreversible deformity. It is located adjacent to the big toe, on and between the lesser toes and under the foot.
In this disease, there is no means of correcting the deformity while sparing the joint: the result would be inadequate, and recurrence inevitable. The diseased joints have to be eliminated, and possibly replaced by implants or else simply fused.
Treatment of the base of the forefoot in rheumatoid arthritis thus associates:
- big-toe fusion (arthrodesis);
- resection of the other metatarsophalangeal joints or replacement by silicone implants;
- treatment of claw-toe (hammer-toe)
All foot deformities in rheumatoid arthritis, whatever the severity or the patient’s age, can benefit from surgery, recovering suitable footwear and, above all, pain-free walking.
This article was drawn up with the help of Dr. Sam Charhon, rheumatologist at the Lyon Clinique du Parc.