Foot Health: Some Foot Problems that Require Help

I'm going to talk about some of the more common foot problems that can occur with inflammatory arthritis. First of all it's not unusual for people, for patients to come in and stress at certain symptoms and how they describe their symptoms. These are some of the common phrases that we very often hear. With rheumatoid arthritis, you can get used to pain all the time so you don't always report it. That's very commonly spoken. It's like walking on marbles where the balls of the feet become very prominent and you can feel your joints a lot more when you're walking. "I can't walk without shoes on. It's too uncomfortable to go barefoot." Again, I'm sure you're all familiar with that phrase. "My toes been weeping for months, my shoes are being rubbing on it." "They're prone to wounds," and again, another common phrase, "My feet burn and feel hot. And I can't bear wearing a shoe." Very often you feel going through a flare. I am going to try to attempt to cover some of the commonly occurring foot problems. Inflammatory arthritis and the flare, you flare up. It's a temporary regression of the disease process itself. Your symptoms will include feeling very fatigued, flu like symptoms, increased stiffness, and joint pain. And you generally feel quite unwell. It's very difficult to predict when flares are going to happen and that's what makes it very difficult to control your disease sometimes or to live with inflammatory arthritis. Tibialis posterior tendonitis, I'm going to talk about that. That's inflammation along the tendon sheath of the tibialar posterior tendon. Pes planus is the flat footed appearance that we see, hallux valgus, the bunion joints that we see, and lesser toe deformities, and other occurrences such as bursae, neuroma, neuroma, swelling on the nerves, and rheumatoid nodules. And then towards the end, I'll speak about some commonly occurring skin changes such as wounds, vascular, and neurological changes, and the hot swollen joints. So when you're in a flare, you have to limit your activities, you have to pace yourself, you have to not feel guilty about leaving those non-essential tasks to one side and take care of yourself at this point in particular. It's always best to seek medical help as well in terms of temporary, maintaining the pain relief with paracetamol, co-dydramol, co-codamol medication. And particularly, where your feet are concerned, to elevate your feet, supporting your calves and your knees, and if your joints are swollen, if they are hot, cool them down with cool compresses, ice packs, 10 minutes at a time, preferably protecting your skin first with a tea towel or something and then put the cold ice pack on top, 10 minutes, take it off, and then a further 10 minutes. It's the heat that's doing the damage to the joints. Wearing lightweight cushioning footwear, because your feet are swelling up at that time in particular. And it's important also during a flare that you don't immobilize yourself completely. You do have a gentle range of motion to the joints otherwise that immobilization will cause greater stiffness. Tibialis posterior tendonitis. Inflammation of the posterior tibial tendon. A condition which can start further up the leg as the posterior tibialis tendon attaches itself to the top of the shin bone and then makes its way down on the inside of the ankle, underneath the ankle area around here and attaches itself to the mid foot, a bone called navicular. And it's a tendon which is designed to stop your foot from collapsing. Clinicians will grade the tendon, tibialis posterior tendon according to severity. The tendon, stage one, will have normal length and function but it will be inflamed. Stage two, briefly, you'll see that sort of collapsing of the foot starting to happen. Stage three, you might have stiffness in the rear foot, in the hind foot. And stage four, the loss of the function of the tendon, there's loss of tendon function completely and even the ankle joint itself can be prone to more of a collapsing effect. In the stages, during a day vary, for example, that you've got in the morning, stage two, and in the afternoon, stage four or is it more of a permanent stage, if you got stage four, it will always stay at stage four? It's not permanent. I believe I'm right in saying that once you've got to stage four where you really have got to the severity of the tendonitis, then it's always going to be an area of weakness. So it's always going to be advisable that you do have... Because I was just going to come on to some of the treatments for this... that you wear orthosis, that you wear specialized inserts to stop the foot from collapsing in and to support the tendon. So I have here a posterior tibialis tendonitis, it's a cast that we do use to support the tendon, to support the ankle joint. And we can inflate it on one side and that specifically inflates an area of the cast where the tendon would be functioning. Pass that around. So do you have to wait until you're diagnosed with this particular condition before you put one on, would you just think, "My foot really hurts today, I'll wear that for a couple of hours."? Well, if this condition has been diagnosed, it's advisable that you use that cast. All the time. So you need to use it all the time, if you don't, "Oh, my foot hurts, I'll put one of those on." Yeah. That's a good point actually, because you've just reminded me that in stage two, very often, you can't actually raise your heel by... You know, you can't do a straight leg heel raise because you've lost that functional aspect of the tendon. So us as clinicians, we would then decide whether it is that tendon that's been affected, and we will issue you with one of those casts. And we would look also at the way your foot is functioning, whether or not you need an orthosis to stop the foot collapsing down, what we call pronation. Another condition that we see very often is a leg length discrepancy and an acute flattening of the foot. This can happen sometimes, unfortunately, it's unavoidable after a hip replacement or a knee replacement where the limb that's being operated on can appear slightly shorter after surgery forcing the then longer normal leg into more of a flatfooted appearance to help functionally shorten that leg. What we do is really simply add a heel raise or a full foot race to the shortened leg just to rebalance the patient. We also provide a variety of different foot orthoses, different devices, different functional devices for the management of pes planus, which is your flatfooted appearance. It's quite complicated movement of the joints of, what we call, the subtalar joint up here and the rear foot complex resulting in the foot bottom in and out. There's a variety of different appliances that we use, pre-fabricated devices, I'll just pass some of these round. Off the shelf, simple level one, level two devices to try and provide as much control as possible, stopping the foot from collapsing to more rigid, custom made devices, which are made individually for the patients... where we would cast the patient's foot in plaster of Paris and we would take a positive cast of the foot. And there is strong evidence to suggest that foot orthoses do reduce pain, improve functional ability, and normalize gait patterns. The pre-fabricated devices enable us as clinicians to timely issue these devices, very often at the first treatment if it's necessary and we can adapt to them easier by adding certain materials on to the devices if need be, so it can be done a lot quicker than a casted device. But sometimes the casted devices are needed if you need a much deeper heel cup to promote more rear foot stability and joint protection. In a way, I think I need a device for any different type of action, because standing is different than walking, and I notice if I use the device, and for example, I stand for long periods and actually, do more bad than any good. If I walk, then they help and that is... That's what they're designed for. They're functional devices and designed for locomotion, for normal walking. If you're standing for long periods of time anyway irrespective of what you're wearing, you might find your joints ache anyway. Yeah. Okay. Moving on to the forefoot and looking at some of the common problems that we see, the typical sort of bunion... it's known as hallux abducto valgus deformity. Again, clinicians will grade this according to severity from mild, moderate, to severe. And it's basically just a movement of the hallux here, the big toe that moves slightly inwards, exposing the head of the first metatarsal is what we call the medial eminence here. As clinicians, we are involved in protecting this area with various types of paddings, strappings and shields. In here sometimes we have, we use sort of gel paddings to shield the areas. There's variety of different toe protectors in there. In severe, in more severe cases, then the joint itself can be injected with steroid therapy, and obviously surgery is an option. Associated factors with this is that as the toe moves over, you can have again dorsalis displaced second toe, resulting in plantar callus, callus on the undersurface of the foot. It's again related to the pes planus, the flat footed appearance... and also a loss of movement of the ankle, what's called ankle equinus. Very often you can have in growing toenails as well. If it's a little bit more movable, if we as clinicians can move the digit, then we could splint them with night splints. I have an example of a night splint here. Which you might want to pass around, shows the picture. So that will hold the toe in a better position during the night to improve the positioning of the toe, if it's soft tissues that's mainly affected rather than a boney deformity. If it's something which is fairly rigid, fairly painful, then we would recommend or discuss surgical options as well or seeking a surgical consultation. Other lesser toe deformities, we can see hammer toes, different deformities in the toes which can be protected with silicone devices that we use, silicone props or different types of protection that we make to relieve pressure from the digits and give them more support. I think here we got retracted toes here, where the toes don't actually weight bear at all. So again, we need to make sure that we protect the tops of the toes, the prominent joints on the surface. And we've obviously discussed footwear and making sure that the footwear does accommodate all of these deformities. Moving on, bursae, nodules and neuromas are other common conditions that we see. Bursae form naturally as fluid filled sacs underneath the skin in between different tissues within the body to prevent friction between muscles and bones. Sometimes they can become inflamed and very often can appear on the soles of the feet across the metatarsal heads here. There is actually a digit here which has completely ride it up and it's almost sitting on top of the first toe. So there is an associated bursae formation around that and they're becoming flamed. Nodules tend to be associated with more aggressive form of rheumatoid arthritis, exasperated by smoking. They can be the size of a pea or as large as a walnut. And they tend to be fibrous, quite hard, subcutaneous nodules just under the skin or around the joints. They do lie on certain internal organ sometimes as well, the heart, the lungs, and even on the vocal cords. They are mainly asymptomatic, but if they're next to any nerves, they will be irritated by the nerves and be painful. We will again protect them with the silicone devices, the gel pads that you've seen there, certain types of clinical padding. We'll look at the shoes again to see if anything needs to be modified on the shoes. Surgery is always an option in the cases where the nodules are quite large, even if the nodules will come back again, they will be removed. And they can be injected around the site as well to reduce the inflammation. Neuromas are swellings on the nerves. Again where the nerves become aggravated to an abnormal gait cycle where the arthritis has affected your joint so much that you're not walking adequately and it's functioning as you should be. So the nerves become affected and they can become swollen, very painful, and very often appear where the nerves bifurcate where they divide. And, again, they can be treated with steroid injections to reduce the inflammation. We'll look at non steroidal anti-inflammatory medication to reduce the pain in the area, but they will be surgically removed if they get to a certain size. And along with all of these where we're always looking at orthosis that's needed as well. That's just showing an injection from the dorsal surface of the foot injecting where there is a neuroma underneath the foot. Corns and callus, something we see very often. As clinicians, we will debride any corns or callus that is there, for obvious reasons, to protect the underlying skin. But it's always performed as part of a package of treatment where we're looking to make sure that the footwear is the right shape and size and has all the necessary factors to protect the feet along with any insoles that's needed to offload pressure from, as in this case, this area here, the plantar surface of the foot. And, of course, we debride it, we remove it. We want to remove it obviously, because if we don't, we can be in trouble in terms of pressure lesions. This is a slide showing when you have problems with the toes. If the toes are misshapen, if they are dorsalis displaced, hammer toes, retracted toes, you will automatically have a lot more pressure across the balls of the feet. Hence you will have corns and calluses developing. So these areas need to be debrided, and they need to be protected with the necessary insoles. And also as I mentioned earlier, the toes will be protected as well with various different types of padding, gel paddings and silicone devices. Foot wounds. When areas of corns and callus are not debrided, then you run the risk of developing increased pressure lesions, and very often that will result in the breakdown of the skin which can become an ulcer, and it can very quickly become an infected site. And this is the slide to show where there is lateral deviation and actual splaying of the toes over to the one side and the affects of... Because of the affects of the arthritis on the joints there, you can actually see a slight erosion there in the joint where the bone has been nibbled away by the arthritis as well. This can result in abnormal foot pressures resulting in corns, callus and eventual breakdown of the tissues. Over here you can see some such breakdown. If we very gently debride around that area, remove that callus, we could possibly find a breakdown in the skin that needs to be treated appropriately... and protected, and also the footwear needs to, make sure the footwear is protecting that area as well. And some early signs of tissue damage really require treatment as soon as possible. With any corns and callus, it needs to be looked at by health professional, a podiatrist who will remove again that area and then you can see there's a small breakdown in the tissue there which was underneath that. If it's not debrided, then you run the risk of infection really spreading over the wound, spreading underneath. And this is a slide showing a breakdown here with surrounding cellulitis, surrounding infection that's before you had your antibiotics, and then after you had your antibiotics and the necessary dressings and paddings to relieve the pressure on the area. Then the area is completely healed. It's healed but it's always vulnerable to breakdown. It should always be protected. If the treatment is not sought, then it can progress into something larger and more nasty, which obviously something like this requires quite urgent treatment, antibiotics etcetera. Just to recap, when I mentioned earlier about hot swollen joints being part of the flared up process which can occur from time to time. Also hot swollen joints can present themselves as an infection, as a septic arthritis. And in this slide it shows the big toe here which is quite red and inflamed, and that would be very painful, and you would know the difference between the pain, I'm sure. And if we look at the x-ray here in this particular patient, they have osteomylitis, they have infection of the bone. So it's just to recap that really seek advice with any hot swollen joints. Phone up the rheumatology department, seek advice from your local podiatrist or whoever you see... to get treatment and advice as soon as possible.