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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 weight bearing 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 weight bearing 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 weight bearing pressure on the plantar fascia. Cortisone injections (by a professional) can be tried directly into the heel (yes, it hurts). Footwear must be supportive and well-cushioned. The use of a foot roller and localized massage or physiotherapy can also be useful.