Rheumatoid Arthritis

Summary

Rheumatoid Arthritis (RA) is an autoimmune condition that affects the joints and causes swelling of the joint lining (synovium). This condition can involve any joint, but most commonly affects the small joints of the hands and feet. For example, RA can occur in the hindfoot or forefoot. RA is a condition that often requires the specialized care of a rheumatologist.  It is unknown how one develops this condition, but research is currently being done on the subject.  Family history often plays a role and it has been suggested that climate may also be a factor.  RA is more common in women in their thirties and forties, and symptoms tend to increase with age.  Some patients are referred for surgery in addition to other treatments.

Clinical Presentation

RA is characterized by a swollen, painful, and warm joint (or joints).  This condition typically affects multiple joints in the body. Symptoms tend to appear gradually, making it a difficult condition to diagnose. There are some blood tests that can help a rheumatologist determine the presence of the condition in a patient. A low blood level (anemia), positive rheumatoid factor, and a high erythrocyte sedimentation rate can be signs that a patient has RA.  With RA, a patient typically undergoes painful flare-ups rather than having continuous pain. These flare-ups tend to be acute and come and go in waves, (one flare can occur, with another flare-up not occurring for months after).  Although the flare-ups themselves are of concern, the damage that they cause to the joints are also problematic. Arthritic symptoms tend to present in the joints that have sustained cartilage damage from a RA flare-up. Even if the condition is completely managed, the damage from the flare-up must still be addressed.

Imaging Studies

X-rays can be helpful in diagnosing RA. A classic x-ray finding of RA is indents at the edge of the joint (peri-articular erosions).  This is characterized by the erosion of bone at the origination of a joint capsule. X-rays are also very useful for determining deformity, and/or loss of cartilage that can eventually occur at the most affected joints.  Rheumatoid nodules can also appear with RA, which are best visualized with an MRI.

Non-Operative Treatment

There is presently no cure for RA. Therefore, treatment of the condition is based on controlling the disease. As the medical profession has developed a better understanding of RA a more aggressive approach to treatment has become popular. There are now a series of potentially helpful treatment options available for patients with RA. Anti-inflammatory medications and injections are available in addition to disease modifying agents such as methotrexate and tumor necrosis factor (TNF) Inhibitors (Humera, Enbrel, Remicade, etc).  The goal of the treating rheumatologist is to get the condition under control and keep it under control –thereby minimizing the cartilage damage that can occur with RA. There is a wide range of how extensive the rheumatoid arthritic involvement can be for each patient. Each patient requires a specialized treatment plan to control his or her disease.  Some patients require constant medication, while others only need to be on it occasionally.  Aggressive treatment of flare-ups should be done to prevent permanent damage to the involved joints.

In the case of flare ups of the foot and ankle, considerable relief can be gained from the use of appropriate footwear and insoles.   The affected joints can be supported and kept more comfortable, but this does not take the place of medical management described above.   Certified pedorthists are experts in shoe fitting and customizations and are familiar with the problems resulting from RA.  When toe deformities are the main issue a comfort shoe characterized by a wide, deep toebox shoe is usually very helpful.  An orthotic and/or a rocker soled shoe can support RA involvement of the midfoot (arch) and ankle.   Some patients may benefit from the use of ankle bracing or even use of a removable walking cast boot

Surgical Treatment

Patients with foot and ankle deformities and/or cartilage loss secondary to RA may require reconstructive surgery.  Surgery if indicated is performed to address a specific problem that the RA has caused, for example, clawing of the toes, or loss of cartilage (arthritis) of a specific joint (ex. subtalar, talonavicular, or ankle joint).  Fusion of joints that have extensive arthritis may be very effective,.  Sometimes smaller procedures such as removing painful lumps associated with RA (rheumatoid nodules) can be helpful.

For some RA patients that have extensive arthritis involving the ankle joint a definitive procedure on such as an ankle fusion or an ankle replacement may be beneficial.

Prior to any surgery the surgeon and rheumatologist will review RA medications .  It may be important to temporarily stop taking certain medications while recovering from surgery.  Medications such as TNF inhibitors tend to suppress the immune system and may increase the risk of a post-operative infection.

Edited by Gwyneth Price, MD on Jan 21, 2013