Deformities of the feet from rheumatoid arthritis
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The foot is often the first area that rheumatoid arthritis affects. The earliest signs of significant damage usually occur in the foot.
Many cases start with symmetric involvement of metatarsophalangeal joints. The patient may present with pain and very little swelling. It is not uncommon for a patient to be diagnosed with “metatarsalgia” – meaning pain in the ball of the foot.
The patient will complain of pain and tenderness with compression of the joints. Bursitis involving the ball of the foot and tendonitis involving the tendons along the bottom of the foot can occur. The patient may complain their foot is “wider.” This can present as ‘spreading’ of the toes.
The rearfoot and ankle can also be an area that disease strikes early. Magnetic resonance imaging and ultrasound are more helpful than x-ray for detecting early disease.
Progressive foot deformities are invariably seen in rheumatoid arthritis at later stages.
In the front of the foot (forefoot), there is lateral deviation of the toes (toes point away from the midline), clawing of toes, and subluxation of the toes in the ball of the foot. These deformities occur in almost all patients within 10 years if not treated aggressively and this leads to reduced foot function. Foot ulcers develop from increased pressure.
The big toe may turn out. This is called “hallux valgus” and the incidence increases with increased duration of disease.
There is thinning of the fat pad on the bottom of the foot which leads to increased pain.
The forefoot spreads and the metatarsal heads sink.
In the mid foot, there is collapse of the mid foot arch. This occurs early and may explain the higher incidence of plantar fasciitis in rheumatoid arthritis.
Rear foot pain is common (but less common than forefoot involvement). Pain arises from involvement of the joint or retrocalcaneal bursitis.
The subtalar joint of the ankle can be involved which causes swelling below the tibial talar joint. Progressive fusion of the tarsal bones occurs late in the disease.
Valgus (turning out) rearfoot is disabling. Initially, there is excessive motion in the subtalar joint because of laxity of ligaments; over time, because of progressive inflammation there is joint destruction which limits range of motion at the subtalar joint. Progressive disease leads to ankylosis (progressive fusion).
Tendon sheaths at the rearfoot may become affected, an example of which is posterior tibial tendinopathy. Tears of the posterior tibial tendon are common in those with “flat feet”. This leads to collapse of the rearfoot.
Plantar heel pain occurs frequently. Calcaneal spurs are more common. Loss of the planatar fat pad may decrease the ability of the heel to absorb shock.
Tarsal tunnel syndrome can occur at any stage.
Subcutaneous nodules can develop in the central three metatarsal heads.
There is tenosynovitis of the long flexor and extensor tendons in the foot.
Bursitis can cause pain mimicking Morton’s neuroma.
There may be atrophy of the subcutaneous tissues (as part of disease process or due to corticosteroid use).
Vasculitis, which is inflammation of blood vessels signifies the presence of severe disease. It causes skin ulceration and loss of blood flow to the foot.
Patients may experience wound healing difficulty as a result of vasculitis which affects wound oxygenation, as well as because of the medicines they may be taking such as corticosteroids or immunosuppressives.
Patients often have venous insufficiency.
Leg and foot ulcers may be present due to venous insufficiency and vasculitis.
Also, stress fractures can occur due to osteoporosis.
Patients develop gait changes. There may be ‘shuffling’ due to avoidance of pain and muscle weakness.
Ankle edema may occur as a result of reduce blood concentration of albumin or venous blockage from knee joint effusions.
Rheumatoid arthritis patients often have mild sensory neuropathy.
Corticosteroids, often used to treat RA, further aggravate skin problems, osteoporosis, and stress fractures.
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