Rheumatoid arthritis or RA is a systemic inflammatory disease which is chronic and of unknown etiology. It primarily involves the articular structures and synovial membranes of the joints (King and Worthington, 2006). The disease has a progressive course with main symptomatology being pain, swelling and stiffness of the affected joints. The hallmark clinical presentation of this condition is symmetric polyarthritis of the hands and feet (Gupta and Bhagia, 2009). This condition has an insidious onset and a progressive course with remission and reappearance of symptoms.
It can affect any organ in the body and hence is a systemic disease. Many patients with RA develop problems of foot and ankle making it difficult for them to walk. Podiatric problems of RA need special attention. In this assignment, I have presented a case of RA with podiatric problems addressed. Case scenario 35 year old Laura was referred by her general physician to our Department of Rheumatology for evaluation and treatment of joint pains. Laura was suffering from pain in the joints of her fingers of both the hands since over a month.
Initially she thought that she developed some allergic reaction to the new dish-washing powder she bought. But since the symptoms did not subside and she began to develop pain in other joints like knee and wrist, she saw her physician who referred her to us. On enquiry, Laura complained of morning stiffness in the affected joints, mild fever on and off, and tiredness. She had no other symptoms. Her past and family histories were unremarkable. Serum RF was positive. She did not have rheumatoid nodules at the time of presentation to the department. A diagnosis of RA was made and Laura was started on ibuprofen and methotrexate.
After the first visit, Laura was lost for follow up. After a couple of years, the patient came back with increased swelling in the joints of the hand and knee. This time she had rheumatoid nodules in the body. A nodule in the foot was bothering her with pain while walking. Serum acute phase reactants were elevated. She received a short course therapy of steroids. Methotrexate which was stopped was restarted. She was advised rest until resolution of symptoms. She was then referred to a podiatrist who gave her custom-made shoes to help her walk with comfort.
Discussion The etiology of RA is unknown. However some researchers attribute genetic predisposition, infectious triggers, psychological stress, hormonal changes and autoimmune response to the causation of the disease. Some research has shown that stimulation of the immune cascade by CD4+ T cells leads to the production of cytokines like tumor necrosis alpha or TNFa and interleukin-1 or IL-1. The consequences of the immune cascade are seen on the articular structures and synovial membranes of the joints and structures of other organs as well.
In the synovial membrane, the pathological changes include inflammation, followed by proliferation and then degeneration (King and Worthington, 2006). The prevalence of RA in the world and also in the US is about 1% (King and Worthington, 2006). The incidence is high among whites, almost 16%, when compared to other races (King and Worthington, 2006). In the African Americans, the incidence is 12% and amongst Asians and Pacific islanders, the incidence is 5-6% (King and Worthington, 2006). The incidence is predominantly higher amongst females, the female-male ratio being 3:1 (King and Worthington, 2006).
The age of onset of this insidious condition is usually between 25 and 50 years and the condition reaches its peak in the fourth and fifth decades of life. When the onset of the disease is at an age lesser than 16 years, it is known as juvenile RA or JRA (King and Worthington, 2006). In most of the cases, the onset of the disease is insidious, although in some it can occur abruptly. According to the American Rheumatism Association (King and Worthington, 2006), diagnosis of RA is made when 4 of the following criteria are met. 1. Morning stiffness of atleast one hour before onset of improvement.
2. Arthritis of minimum 3 joints 3. Arthritis of hand and wrist joints 4. Symmetrical involvement of joints. For example, both wrist joints, both hands, and so on. 5. Positive serum rheumatoid factor or RF 6. Presence of rheumatoid nodules 7. Evidence of RA in radiography Other clinical features include weakness, general malaise, fever of unknown origin, weight loss, tendonitis, myalgias and bursitis (King and Worthington, 2006). The typical presentation of joint involvement is polyarticular and symmetrical. The distal interphalangeal joints are spared.
Joints which are affected have edema, warmth, effusion and tenderness. Bursitis may also be there. In the late stages, the articular structures may get destructed and other features like swan-neck deformities, subcutaneous rheumatoid nodules, boutonniere deformities and ulnar deviation of the fingers at the middle carpo- phalangeal joints (King and Worthington, 2006). Clinical features may also reflect affectation of other organs like heart, lungs, liver, eyes, blood vessels and skin. In the heart, RA can cause carditis and pericarditis. Involvement of the liver can lead to hepatitis.
Lungs involvement can manifest as intrapulmonary nodules, pleuritis and interstitial fibrosis. In the eye, dryness of the eyes can occur and scleritis and episcleritis can also occur. Vasculitis is another important feature of RA (Gupta and Bhagia, 2009). In the skin subutaneous nodules and ulcers can occur (King and Worthington, 2006). There are many non-medication and medication therapies available for RA. The non-medication therapies include counseling, exercise and diet for weight reduction, stress reduction, physical therapy and surgery (Gupta and Bhagia, 2009).
There are several classes of pharmacological agents which are used to control symptoms in RA. The five classes of such medications are: NSAIDs or non-steroidal anti-inflammatory drugs, DMARDs or disease-modifying anti-rheumatologic agents, corticosteroids, biologic response modifiers and immunosuppressants (King and Worthington, 2006). When a patient presents with symptoms of RA, definitive diagnosis should be made as soon as possible and DMARD therapy instituted immediately. In the meanwhile, NSAIDs can be prescribed for relief of symptoms. Laura was treated with NSAIDs and DMARD initially.
It is important to start antirheumatologic drugs as soon as possible to spare the joints, otherwise, delay of even 2 to 3 months can result in irreversible joint damage (King and Worthington, 2006). Those patients with established diagnosis and have a flare-up situation should be managed with rest, DMARDs, 2 to 4 wk short course steroid therapy and NSAIDs. Some patients may need intraarticular steroid injections. If pain does not subside with NSAIDs, short course narcotic analgesics may be prescribed. Flare-ups present as increased pain, edema and dysfunction (King and Worthington, 2006).
Serum acute phase reactants are typically elevated in those in flare-up phase as was seen in Laura. In patients with splenomegaly and neutropenia, recurrent serious bacterial infections can occur and such patients must receive appropriate antibiotics. This condition is known as Felty syndrome. Sometimes Baker’s cysts can rupture and the diagnosis can be established by ultrasound. Treatment of Baker’s cyst includes rest, elevation of the leg, aspiration of the knee joint and needle puncture of the calf muscle where the ruptured cyst occurred (King and Worthington, 2006).
Podiatric problems in RA When the synovium of a joint thickens due to inflammation, it produces excess fluid into the joint along with plenty of inflammatory mediators. Both these damage the cartilage and bone of the joint. Foot problems arise because of these damages to various bones of the foot (American College of Foot and Ankle Surgeons, 2007). The most common foot problem seen in RA patients is foot pain. The pain can be either in the fore foot or rear foot or both. Fore foot is more commonly involved. The pain typically occurs near the ball of the foot and near the toes.
The next common problem is foot deformity. Other foot problems include abnormal gait, ankle pain, foot drop, knee pain, leg pain, short leg and ankle pain (Helliwell, 2003). Rheumatoid nodules may develop in the foot causing inconvenience in walking. They cause pain when they rub against shoes. Achilles tendon pain, hammertoes, bunions, and flat foot can also occur (American College of Foot and Ankle Surgeons, 2007). Foot problems in RA can affect the function of foot in terms of disability, pain and activity restriction.
These can be measured by Foot Function Index or FFI. FFI is an index which can be self-administered. There are many models of FFI (Appendix-1). Management of podiatric problems in RA Foot problems need to be addressed seriously in a RA patient to help the patient lead a comfortable life of mobility (Williams and Bowden, 2004). Most of the patients with foot problems need some help. Custom-made orthotic devices provide cushioning for rheumatoid nodules and help in the reduction of pain while walking. Accommodative shoes relieve pain and pressure while walking.
Severe inflammation in the joint may need aspiration of fluid by a surgeon or intraarticular steroid injections. Some patients may need surgery to relieve pain and deformity associated with RA (American College of Foot and Ankle Surgeons, 2007). Fore foot plantar callosities can be managed with scalpel debridement (Woodburn et al, 2000). Conclusion RA is a persistent systemic disease of unknown etiology that predominantly affects joints. The diagnosis is easy and RF is the main laboratory test to confirm the diagnosis. Anti-rheumatologic drugs are given to the patient but they do not cure the disease.
Over a period of time, the patient can develop many deformities, especially in the ankles and feet. These problems need to be addressed properly to allow mobility of the patient. References American College of Foot and Ankle Surgeons. (2007). Rheumatoid Arthritis in the Foot and Ankle. Footphysicians. com. Retrieved on 17th April 2009 from http://www. footphysicians. com/footankleinfo/Rheumatoid_Arthritis. htm Gupta, K. and Bhagia, S. M. (2009). Rheumatoid Arthritis. Emedicine from WebMD. Retrieved on 17th April 2009 from http://emedicine. medscape. com/article/305417-overview Helliwell, P.
S. (2003). Lessons to be learned: review of a multidisciplinary foot clinic in rheumatology. Rheumatology , 42, 142. King, R. W. and Worthington. (2006). Arthritis, Rheumatoid. Emedicine from WebMD. Retrieved on 17th April 2009 from http://emedicine. medscape. com/article/808419-overview Williams, A. E & Bowden A. P. (2004). Meeting the Challenge for foot health in rheumatic diseases. The Foot, 14(3), 154-158. Woodburn, J. , Stableford, Z. , Helliwell, P. S. (2000). Preliminary investigation of debridement of plantar callosities in rheumatoid arthristis. Rheumatology, 39, 652-4.