Rheumatoid arthritis in the ankle
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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Rheumatoid arthritis (RA) is a systemic, chronic, inflammatory autoimmune, disease that causes pain, stiffness, and swelling in the joints.
It is frequently symmetrical (if a joint on one side of the body has it, the same joint on the other side will have it also). In RA, the joint lining (synovium) becomes inflamed, painful and swollen. The disease causes damage to cartilage, bone, tendons and ligaments. RA can also cause inflammation in the blood vessels and the outer lining of the heart and lungs. RA cannot be cured, but with proper care, it can be controlled or brought into remission.
Approximately, 2 million Americans have RA.
Though the majority of arthritis sufferers are over 50, people of all ages are potential victims. About 90 percent of rheumatoid arthritis sufferers have arthritis of the foot or ankle. With arthritis of the foot, there is pain and limited motion and limited ability to walk as well. If left untreated, the pain and debility can grow worse, eventually becoming so disabling that patients can no longer walk even short distances. Also, if left untreated, the foot and ankle may eventually become deformed.
Because the human foot contains 33 joints, it is more susceptible to arthritis. About 90 percent of RA patients will complain of problems with the midfoot and forefoot while 67 percent will have problems with the hindfoot and ankle.
The ankle is the joint between the leg and foot that joins the two bones of the lower leg, the tibia and fibula, with the talus, allowing the foot to move up and down. The talus and the calcaneus, the heel bone beneath it, carry the weight of the body on the hind foot and the metatarsal heads and toes carry the weight on the forefoot.
The normal ankle joint moves the foot up and down. The joint responsible for this movement is called the tibial-talar joint. Just below the tibial-talar joint is the subtalar joint which is responsible for slight side-to-side rotation. Both joints can be affected by RA. A capsule of ligaments (the tough, sinewy tissue that binds bones together) surrounds the ankle and stabilizes the joint. Ligaments are lined with a thin synovial membrane that helps lubricate the tissue, providing ease of motion.
In addition to supporting weight, the foot acts as a shock absorber. It serves to balance and adjusts the body to uneven surfaces. The ankle joint is subjected to as much as 63 tons of pressure with each mile walked. Because the feet are small in comparison to the rest of the body, the impact of every step exerts tremendous force upon them.
The most common symptoms of RA are pain, swelling and stiffness in one or more joints. In some people, the joints can feel warm. Some people may have a fever. Anemia can develop.
Sometimes lumps of tissue develop near the affected joint, usually near joints. These are called rheumatoid nodules.
Occasionally, RA sufferers will develop inflammation of the lining that surrounds the heart and lungs. Also common are dry eyes and a dry mouth due to inflammation of tear glands and saliva glands.
People who suffer from RA frequently develop related forefoot problems such as bunions, hammer toes, and claw toes. Corns, or even ulcers, may develop on the foot.
Metatarsalgia, a general term for pain in the sole or the ball of the foot, is also very common. This indicates that RA is affecting the metatarsal joints of the toes.
Hindfoot problems can lead to a situation where the rear of the foot turns out. This is called hindfoot valgus. Hindfoot and ankle pain often affects the posterior tibial tendon. This is located along the medial (inside) part of the ankle. The peroneal tendon (outside part of the ankle) can also be affected.
Most patients first suspect arthritis when they experience tenderness in the foot and pain whenever the ankle joint is compressed.
The main goals in treating RA are to relieve pain, reduce swelling, slow down the damage to the joints, and improve the person’s ability to function. Medical management can improve symptoms and slow the progression of the disease.
Orthotics (shoe supports like pads and insoles) may be used. Drug therapy is critical to controlling disease.
Non-steroidal anti-inflammatory drugs (NSAIDS) may be helpful early on.
Corticosteroids (cortisone shots) can also help ease pain and swelling and help slow the damage to the joints. Also, splinting the ankle with braces may speed the healing process.
Disease modifying anti-rheumatic drugs, DMARDs, may help slow the progress of the arthritis, too.
• Antimalarial drugs
Newer drugs called biologics work well and can help put the disease into remission.
Surgical procedures may be considered in the event that conservative therapy does not bring about sufficient pain relief. Ankle replacement surgery, also known as ankle arthroplasty, is a new technique that has developed in recent years.
When other, more conservative methods of treating rheumatoid foot and ankle prove inadequate, joint replacement surgery may represent the best hope for long-term improvement to the ankle joint. Dramatic advances in the procedures and devices used to repair and replace the ankle may now bring relief to those people who suffer from chronic pain and loss of motion in the ankle joint.
Surgical procedures on the foot and ankle usually require a recovery and rehabilitation period of at least 4 to 6 weeks.
Surgery should always be undertaken when the patient is in the best possible health, with any other chronic conditions under control.
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