During this session
we will consider foot problems
related to inflammatory
arthritis,
other possible causes
of foot problems,
medication, self-management,
managing
some common foot problems,
how to get help,
and other sources
of information.
So there are around
about 200 different types
of rheumatic disease
and they fall
into four main groups,
inflammatory arthritis,
osteoarthritis,
regional musculoskeletal pain,
and back pain.
And obviously,
inflammatory arthritis
is the group that
we are considering today.
So in these disorder
the joint lining,
the synovium becomes inflamed.
This can damage
the surface of the joint
and the underlying bone itself.
We usually find that
many joints are affected
and rheumatoid arthritis
is an example of this
as are psoriatic arthritis
and gout.
So this slide shows
a representation of a joint
badly affected
by rheumatoid arthritis.
Obviously, you can see
that the synovium
has become very inflamed
and it's started to erode away
the cartilage the underlying
bone itself.
The cartilage has become
quite thin.
We can also see
that the tendon sheath
has become inflamed.
And you would expect a joint
affected in this way
to become quite hot,
swollen, stiff, painful,
and potentially misshapen.
Obviously, not everybody's
joints are affected
to this extent.
So moving on to the foot,
what makes up the foot?
Twenty-six bones,
we tend to have long bones
comprising the front part
of the foot
and the rear of the foot
is made up of
more keep-like bones.
There are 19 muscles
and associated tendons,
intrinsic muscles begin
and end within the foot,
and extrinsic muscles
tend to originate within the leg
and end within the foot.
We have blood vessels,
obviously, arteries
bringing oxygen rich blood
to the tissues and veins,
then returning
the oxygenated blood
back to the lungs.
There are nerves,
sensory nerves responsible
for sensations such as feelings,
temperature, and pain,
and then motor nerves
obviously responsible
for initiating movement.
We all have different feet.
Some people may have
a particularly
high or low arch on their foot
or more mobile
or rigid foot type.
And these foot types
can be inherited.
Our lifestyles and activities
can also have an impact
upon our feet
and the foot appearance
and function,
as can injury or surgery.
So there's an awful lot
that can affect the foot.
Inflammatory arthritis
can make the foot more unstable
and at risk of changing shape,
and so you can imagine
how an inflammatory arthritis
can make a previously
symptom free foot condition
problematic.
So foot problems
can affect any of us.
As you can see from this slide,
we have a variety of concerns
in our clinics
from structural changes,
nail and skin conditions
to corns and calluses,
which left untreated
can develop into ulcers.
So up to 90 percent of people
with this condition
will report associated
foot problems.
For some people, the foot
is the first area of the body
to present with signs
and symptoms
of rheumatoid arthritis,
and for others
it may be months or years,
or they may never experience
any foot problems at all.
Okay, so when people
come into our clinics,
there are a number of ways
that they describe
their foot pains to us.
I'm sure
you're all familiar with
a number of these
descriptive words.
But the end shot is that
obviously they will affect...
Any of these pains,
any of these sensations
that you are feeling will affect
your activity and your function.
Okay, so as I mentioned earlier,
rheumatoid arthritis
can make foot more unstable
and at risk of changing shape.
You can see from the slide
deviated rear foot position
and collapse mid foot
which can cause overloading
and strain around
these soft tissue areas
and joint structures.
The foot can become widened,
toes can become
dorsally displaced,
which can cause friction
and damage
across the tops of the toes
and also on to the bone
of the foot.
Appropriate footwear
is important
in accommodating
these venerable areas
or surgery may be required
to realign the foot structure
and alleviate
these high pressure sites.
Substantial foot surgery
may result
in large differences
in foot length.
Sorry to interrupt you.
What does
dorsally displaced mean?
I mean, what does
that look like? Which one?
So dorsally displaced toes
are toes that,
instead of sitting
sort of straight
on to the end of the foot,
they rise up slightly.
So the middle...
These are dorsally displaced.
So they are sitting
just a bit higher up
onto the top of the foot.
And the amount at which
they move up or rather
that the more that they move up,
the more that they displace,
obviously, the more friction
you get across tops of the toes,
more pressure, and more problems
potentially you can get.
So one of our main aims within
rheumatology podiatry clinics
is to see our patients
as early as possible
to try and identify these
overloaded or at risk sites
and ensure that the feet
are well protected
and supported structurally
so that we keep them
looking like this.
So protection of the joints
is important.
We are aimed
to encourage stability,
avoid joints working
at the end range of motion,
and reduced fall risk.
Advice regarding
joint protection
can include footwear choices,
insoles, or foot orthosis,
and exercises
to improve strength,
mobility, and balance.
Moving on to medication.
DMARDs, Disease Modifying
Anti Rheumatic Drugs,
we're all familiar with these.
They tend to be given early
on in disease
and they've been shown
to have a positive effect
on disease inflammation
and joint destruction.
Certainly, on X-ray,
methotrexate has been shown
to slow down
or halt joint damage.
And they have important
place to play
in the battle against
inflammatory arthritis.
Ongoing research
and development
will always bring
newer medication options.
Over recent years,
biologic medications
have significantly helped
many people.
And there are a lot of different
biologic medications
on the markets now.
And these help to control
inflammatory levels,
which helps
to improve the symptoms
of inflammatory disease.
We do need to beware however,
that inflammation is normally
the way our bodies deal
with infection.
And so medications
that affect this process
will have a powerful effect
on the immune system
and that can reduce its ability
to fight off infection.
And this is compounded
by the fact
that the medication can mask
the usual signs of infection,
such as a fever or pain
or redness and inflammation.
So this slide just highlights
these factors really,
the medications, as I said,
can reduce the signs
and symptoms
of an inflammatory arthritis
by reducing joint damage
and helping
to increase mobility,
thus reduction
in immune response
and masking of the normal signs
of infection
can increase
the risk of infection.
And as you can see
in these photos,
any very slight redness
to the dorsum
or the top of the foot.
But when taking a look
underneath,
there is a little swelling
and peripheral redness
but the skin is definitely
not very happy.
And this is why it's important
to ensure
that you're checking your feet.
As I said, this is an example
of where you clearly have,
although there's
clearly an infection,
but with the medications
masking those usual signs,
it's not quite so
glaringly obvious straight away.
So prevention is key.
To prevent problems
you need to be self aware
from the podiatrist
points of view,
we encourage patients
to be in habit
of checking their feet
regularly.
You know,
it doesn't take very long,
may be half a minute just before
you get into bed every night,
just having a quick look
at the bottoms of the feet,
making sure
there's no cut so grazes
or anything of that nature.
And if you're looking at them
very regularly,
you can spot very quickly
whether or not
something is wrong.
A sore throat,
fever or skin wound
also need to be checked
and not left.
You need to be mindful that
common signs of problems
such as fever, redness,
or pain may not be obvious
as a result of the medication
that you are on.
If you have any concerns
regarding infection,
you need to ensure that these
concerns are checked by your GP
or your rheumatology team
to make sure
that it's safe to give yourself
your next injection.
So there are many things
to consider
that should help
with your arthritis.
Lifestyle choices are important,
good dietary choices,
controlling your alcohol intake,
obviously, stopping smoking,
maintaining healthy weight.
And your GP obviously
will ensure
that your blood pressure
and cholesterol
are kept within normal limits.
Exercise is very important
to maintaining function.
And it's important
to remember that exercise
will not damage your joint.
And everybody is different,
so to choose something
that suits you,
or ask to be referred
to an exercise program
if you feel that you need
some guidance.
Always be guided
by how you are feeling,
making sure
that you pace yourself
and listen to your body.
If you feel
you need a short break or rest
then have one.
You certainly won't benefit
from trying to keep on going
or trying to work
through the pain,
pacing yourself is something
that you'll hear very regularly
and it really
is a very important.
How do you be referred
to an exercise program?
Well, it'll vary
depending on where you live.
But the first access
would be via your GP.
And they will be able
to point you
in the right direction
and let you know if there's
anything available locally.
Also you could contact
your NRAS, local NRAS group,
may be see if they've got
anything running locally
or whether they could give you
any advice regarding that.
So now we're just going
to have a few brief slides
about looking after your feet
and some sort of general helps,
tips, hints and advice.
Okay,
so looking after your feet.
Obviously, you need to ensure
that you have
well fitting footwear.
You need to make sure
the footwear is obviously
wide enough for the foot
and long enough
so that you're not causing
any cramping
or rubbing of the digits
within the footwear.
When looking off your feet,
it's important to make sure
that you can carry out
your nail care
very well yourself,
if you are able to do that,
cutting them straight across,
just gently rounding
the corners,
and just filing them smooth
so that you don't catch them.
Using a cream, obviously,
to try and maintain
good skin condition
is very important.
Try and avoid
using anything too sharp,
a razor or anything like that
on your feet.
We have a lot of people
that come in
who have damaged themselves
using various implements
to try and achieve
their foot care themselves.
When looking after your feet,
all of these aspects are,
if you can manage them,
you know,
if you can't get down
to your feet
or if your grip strength is poor
and you're not able
to manage yourself,
then don't attempt to.
These are only advice tips,
if you're able to
and happy to get down
and do them.
So avoid using
sharp instruments yourself
and corn cures
and various treatments
like that,
we would always suggest people
try and steer clear of,
they tend to have
acid within them.
So if you put them
on the wrong place
or if you leave them
on for too long,
then they can cause more damage
and potentially create a wound.
As I said, corn plasters
can create more problems.
And this shows
a picture of effect
of a corn plasters on the skin.
Obviously,
somebody's put it over a corn
to try and remove
that corn themselves.
But it's actually macerated
and damaged
the surrounding skin.
And then this area now
is much more vulnerable
to tissue breakdown
and potentially
a wound developing.
So we would always advise
our patients to steer clear
of corn plasters.
Sometimes if you don't have
relatively normal nails,
as we would say, you just can't
manage your nails yourself,
you might have
a particularly involuted nail,
so a very curve nail plate,
particularly thicken nail.
You might have
had damage to the nail
which has caused the nail
to become
distorted and disfigured.
And as I said, you know,
sometimes it's just something
that you can't manage
and you need some help with.
So don't try and attempt it
if you're not happy
and able to do so.
So these ones definitely
would need help.
There's an ingrowing toenail.
Well, there's a couple
of ingrowing toenails actually.
The beginning of one on the left
and in the middle,
a full-blown one.
Fungal infections, here are
very thickened ruffle tip nail
and on the right there,
that's corn
underneath the nail plate.
Any other areas of discoloration
also beneath the nail plate
would need to be checked
for possible melanoma
or something of that nature.
So it's always good
if you're not sure
to get something looked at.
Athletes foot is very common,
tend to get it sort of
between the toes on the whole,
although you can obviously get
across the bottom surface
of the foot as well,
you tend to find the areas
will be particularly itchy,
red, and sore.
For athletes foot, on the skin
it's very easy to treat,
very quick to treat.
Usually, you would use
a typical treatment,
a cream or spray depending on
what you find easiest to apply.
The regularity of treatment
will vary
depending on which product
you purchase.
But you would usually find,
with a cream,
for example,
you would use it twice a day,
every day until symptoms go.
And then once
the symptoms have disappeared,
we advise you
to continue to use it
for approximately a week
to make sure
that all the fungal spores
have been killed.
Once you've sort of got rid
of your athletes foot,
it's a good idea to try and use
surgical spirit
between the toes,
that's astringent
so it'll dry the skin out,
because athletes foot
tends to thrive
in sort of warm
moist environments.
So when the toes are quite snug
and quite close together,
which we sometimes find
when people have got
an inflammatory arthritis,
it's very difficult to get in
between the toes
and dry adequately.
So you dry as well as you can,
but then if you use
surgical spirit as I said,
maybe once a day,
every other day,
that will help
to dry the skin out
and make sure that
that skin condition
is maintained.
Always check inside your shoes.
Check inside with your hand,
it's quite handy.
You can pop your hand inside,
making sure there's no holes
within the shoe upper or liner,
which can sort of
damage the skin,
check there's nothing obviously
fallen into the shoes, stones.
I had a number of patients
come in with various stones
sat underneath the insoles
of their shoes.
They sort of walk in and say,
they're a bit
uncomfortable today.
You sort of pull
the liner of the shoe out
and there's stones
stuck in the liner of the shoe
and underneath the insoles.
So it's just important to just
try and have a regular check
of the insides of your shoes
and making sure there's no,
sort of, obvious foreign objects
or wear and tear
that needs to be addressed.
Trying and avoid
walking barefoot.
There are a number of reasons
we try to advise people
to avoid walking barefoot.
Number one
is to protect the tissues.
Obviously, if you're walking
around your house...
who knows, a stapler might have
fallen out of a letter
or, you know,
you might have dropped a glass
and not quite swept up
every last splinter.
So protecting the skin itself.
And also for joint protection
side of things,
to ensure the foot structure
itself is well supported
and kept in
as good alignment as possible
for the largest portion of time.
Avoiding direct heat.
Again, you know,
in relation to maintaining
the good condition of the skin,
this is obviously
not just sort of things
like radiators or heaters
placed directly near the skin,
but obviously,
simple things like sunshine.
I know that's something
not all of us know
very much about.
But avoiding sunburn
and that sort of thing.
And some of the medications
will make you more prone
to sun damage.
So as I've said before,
sort of, washing
and checking the feet daily
is a very important part
of your routine.
And noting any changes.
And if there's anything
that occurs
that you're not sure of
or that you need checked,
then don't leave it,
get it checked...
either via your GP,
which would usually be
your first port of call,
so they put you
in the right direction
of who to access for foot care
or via your rheumatology team.
So if you do need somebody
to have a look at your feet,
always ensure that you see
a chiropodist or podiatrist.
Obviously, we diagnose
and treat disorders, diseases,
and deformity
of the feet and legs.
The titles are protected
so you can't call yourself
a chiropodist or podiatrist
unless you are properly trained
to do so.
And this is protection
for you obviously,
to ensure that the person
who is looking and caring
for your feet
knows what they are doing.
When you have RA,
is it advisable to actually
be referred automatically
to a podiatrist,
perhaps particularity
at beginning
when you're diagnosed?
The guidelines do recommend
early referral,
but provision does vary greatly,
depending on where you live.
We certainly, here,
we try to see patients
as soon as we can
after referral to ensure
that we are doing
a baseline assessment
to see if there's anything
that we need to...
Any advice
we need to give individuals
or any support that needs to be
provided straight off.
And then also
we sort of use that as
a little bit of a session
to give general advice
on how to access podiatry
if they require sort of help
with general care as well.
So certainly, I definitely ask,
but the provision does vary.
The rheumatology team
may direct you to your GP.
But there should be
some provision for you.
Should you also be referred
every few years
just to double check
in case you miss?
Again, it varies across,
it varies geographically.
Here, once we have a patient
who's been referred to us,
we will try to do to
sort of an annual review.
So that we can ensure that
everything is kept an eye on.
And if required,
then we would also refer them
to community teams.
If we're happy within
the first three to five years
that everything is staying
relatively static,
we'll then discharge patients
but with advice
as to how to re-contact us.
An ideal opportunity
to raise this issue
would be your annual review
with your rheumatology team
and then they can obviously
put you in the right direction.
Thank you.
So again, moving on
to access for podiatry.
Under the NHS,
you should be able
to hopefully access podiatry
within your rheumatology team
or certainly within your GP,
you should be able to access
a community based service.
Or privately,
a private practitioner,
as I said, as long as you ensure
that they're calling themselves
a chiropodist podiatrist,
then they will be
appropriately qualified.
Some work places
well offer podiatry
and also some leisure centers
will also offer
podiatry as service.
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