Inflammatory joint disease such as rheumatoid and psoariatic arthritis can have a significant effect in
regard to foot and ankle structure and function.
Rheumatoid arthritis is the most common form of inflammatory arthropathy and although characterised
by acute episodes of significant pain and inflammation is also progressive in nature and represents a
chronic disease process.
The course of rheumatoid arthritis varies significantly from mild forms which can be self limiting to a
severe disrupting phase with significant foot and ankle involvement.
The disease process is not unique to the lower limb and classically effects any synovial joint. However at
the onset of the disease process itself often the first manifestations of disease is at a foot and ankle level.
There tends to be a fairly characteristic pattern of involvement through the disease process itself.
Changes are seen predominantly in the early stage at the talo navicular (TN) joint.
One of the fundamentally important joints within the foot is called the sub talar joint (STJ).
Movie 1 below : shows clinical signs of swelling across the
sub talar joint line on the right side with a reasonably well preserved STJ on the left and this can have a
major effect in terms of foot and ankle function..
The ankle joint is also part of the disease process package although tends to be secondary in regard to
rear foot involvement at the sub talar joint. The TN joint represents the mid foot and because of this early stage involvement the earlier the disease process is picked up and managed from an orthotic perspective the greater the ability to maintain foot
and ankle function.
A number of researchers have looked at orthotic management in its early stage and there is a good level
of evidence to support orthotic management in this particular patient group. Beyond the acute flare up
stage the disease process follows a chronic pathway. The disease process is characterised by mild to
significant structural changes through the forefoot itself, photographs 1-3 illustrate some of the changes that can occur
in the inflammatory joint disease phase and much of the management is geared towards
accommodation for these deformities if they cannot be surgically corrected.
The photographs 1-3 Below
1.
2.
3. Conservative management
involves both footwear provision and also the provision of appropriate orthotic intervention to help
redistribute ground reaction force.
(see gait analysis section on this website).
Mark employs a large spectrum of orthotic management options to address presenting problems with
inflammatory joint disease. The different types of orthotic intervention can be seen elsewhere on this
website in both the ankle foot orthoses and foot orthoses section.
The videos below represents a male patient, aged 27 with inflammatory joint disease.
The patient was diagnosed with rheumatoid arthritis in 2007. As you are can see with the gait pattern
there is a marked degree of lateral transfer (movement sideways) and a short stride length. This is in
association with rear foot involvement with a stiff ankle and sub talar joint on examination. You can also see from the pictures 1 - 2 and 3 the degree of structural change in the forefoot.
1.
2.
3.
This is typical of inflammatory joint disease involvement and highlights the fact
that this can affect patients of any age. The objective in this particular case is to try and improve the
patient’s pain during movement and to accommodate for much of the structural changes seen.
Effective management of inflammatory joint disease requires a good working relationship between
various professions, this can include the rheumatology team in regard to the Consultant and
rheumatology nurse specialists, the Orthotist for provision of footwear and an Orthopaedic Surgeon with
a specialist interest in the foot and ankle and who is familiar with inflammatory joint disease to provide a comprehensive service to this patient group.
