RA is a systemic disease—meaning it affects the whole body—and most people who have it take medications, such as disease-modifying anti-rheumatic drugs and biologics. However, there are certain treatments that can target the foot and ankle, and a foot and ankle specialist can work with a rheumatologist to provide a comprehensive management plan. Both non-surgical and surgical treatments are described below.
- Physical therapy can stretch and strengthen the joints in the foot and ankle and improve joint function. In addition to improving a person’s ability to walk and stay active, physical therapy can decrease the risk of future deformity.
- Foot massage can help keep the tendons and other soft tissues of the foot pliable and encourage blood circulation.
- Alternating cold and warm water footbaths can stimulate circulation in the foot. Cold footbaths or a cold compress alone can help decrease inflammation and swelling.
- Comfortable, supportive shoes can make walking more comfortable. High heels should be avoided. Rocker shoes may work for some people with limited ankle flexibility.
- Orthotics (shoe inserts) can relieve pressure on the foot, making standing and walking less painful. Orthotics tend to be most useful for people who have RA symptoms at the front or midfoot. Soft, custom-made shoe inserts can be expensive, but may be paid for by insurance. Orthotics cannot correct an existing deformity.
- Splinting or bracing can stabilize the foot joints and limit further deformity. For example, a custom ankle brace made from leather or molded plastic can stabilize a stiff, arthritic ankle and decrease mild to moderate pain.
- Steroid injections can reduce inflammation and pain; however, repeated injections can further damage soft tissue in the foot. These injections are used sparingly. They can be a useful short-term treatment for RA patients who must wait several weeks for newly prescribed medications or increased dosages to take effect in their bodies.
Several factors, such as overall health, age, expectations and lifestyle, determine whether a non-surgical or surgical approach is the best treatment option. Specialists in foot and ankle medicine and surgery (podiatrists and orthopedists) will tailor treatment for each individual patient.
Surgery is a consideration for these two groups:
- Those who cannot walk without pain
- Those whose foot and toe deformities cannot be managed with accommodative shoes or braces (often due to soft tissue irritation or skin breakdown—in severe cases, patients may only be able to wear sandals or socks)
A doctor may also recommend surgery if he or she thinks surgery will improve foot biomechanics and help prevent future joint degeneration. This may be a particularly important consideration for relatively young patients, because deformities of the foot can negatively affect other joints, such as the knees and hips.
The goals of most foot and ankle surgeries include:
- Relieving pain
- Fixing the physical deformity
- Improving function, so standing and walking are comfortable
- Increasing shoe options
In many cases there is more than one type of surgery that may be appropriate for a patient. For example, a patient with severely damaged big toe may have up to three possible options:
- Fusion eliminates the joint by mechanically fusing the two bones together with metal or plastic pins.
- Resection involves surgically removing cartilage and some bone at the joint to increase the joint space.
- Joint replacement involves cutting away cartilage and bone and replacing those natural joint structures with man-made implants.
A surgeon can decide if a patient is eligible for one or more surgeries, and talk to a patient about which option might be best for him or her. Some considerations include the patient’s health, expected recovery time, and—in some cases—the patient’s ability to be non-weightbearing during recovery.
Ultimately, it is up to the patient whether or not to have surgery. Patients must consider how their foot pain and disability limits everyday activity as well as estimate the potential benefit and risks of surgery. Patients can talk to their surgeons about the possible outcomes, recovery time, and reasonable expectations.
There is no known cure for rheumatoid arthritis, but foot and ankle pain can usually be managed with targeted treatment. The sooner steps are taken to prevent joint damage the better the chances for avoiding foot and ankle deformities.