Some new research on the rheumatoid foot

NewsBot · Jan 9, 2010

Forefoot disease activity in rheumatoid arthritis patients in remission: results of a cohort study.
van der Leeden M, Steultjens MP, van Schaardenburg D, Dekker J.
Arthritis Res Ther. 2010 Jan 7;12(1):R3.

INTRODUCTION: The aim of our study was to investigate the presence of disease activity in the metatarsophalangeal (MTP) joints of the forefoot in rheumatoid arthritis (RA) patients in remission according to the Disease Activity Score based on 28 joints (DAS28) remission criterion.

METHODS: A total of 848 patients with recent-onset RA were included from 1995 through 2007. The DAS28 and pain and swelling of the MTP joints were assessed annually. The data were analyzed using descriptive techniques.

RESULTS: On average 35% of the patients fulfilled the remission criterion of DAS28 < 2.6 during the first eight years of RA. On average 29% of these patients had at least one painful MTP joint, and on average 31% had at least one swollen MTP joint during follow-up. Forty percent, on average, had at least one involved MTP joint (pain and/or swelling).

CONCLUSIONS: Painful and/or swollen MTP joints were detected in a substantial proportion of patients classified as being in remission. Therefore, examination of the foot joints - irrespective of the patient's state of remission - seems indicated in order to provide optimal foot care.
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NewsBot · Jan 24, 2010

Development of a Novel Stocking for Foot Sole Pain in Patients with Rheumatoid Arthritis
Hiroaki Matsuno and Tatsuma Utsunomiya
Journal of the American Podiatric Medical Association Volume 100 Number 1 10-13 2010

Background: We sought to investigate the clinical efficacy of the Fuß-sole (Kuroda, Osaka, Japan), a newly developed stocking, in patients with severe foot pain attributable to rheumatoid arthritis.

Methods: The Fuß-sole stocking incorporates a plantar insole made of breathable fabric. Twenty patients with rheumatoid arthritis and severe foot pain were enrolled in this study. Clinical efficacy was evaluated using the Japanese Orthopaedic Association's foot-scoring system. Outcome measures were evaluated before and after a 1-month trial of the Fuß-sole stocking.

Results: Use of the Fuß-sole stocking resulted in significant improvements in foot pain, activities of daily living, and total scores.

Conclusions: Use of the Fuß-sole improves the quality of life of patients with rheumatoid arthritis
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NewsBot · Mar 2, 2010

Combination joint-preserving surgery for forefoot deformity in patients with rheumatoid arthritis.
Niki H, Hirano T, Okada H, Beppu M.
J Bone Joint Surg Br. 2010 Mar;92(3):380-6.

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy. The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0 degrees (20 degrees to 67 degrees ) to 9.0 degrees (2 degrees to 23 degrees ) and from 14.1 degrees (9 degrees to 20 degrees ) to 4.6 degrees (1 degrees to 10 degrees ), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one. With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.
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NewsBot · Mar 2, 2010

Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction.
Popelka S, Hromadka R, Vavrik P, Stursa P, Pokorny D, Jahoda D, Sosna A.
BMC Musculoskelet Disord. 2010 Feb 27;11(1):38. [Epub ahead of print]

BACKGROUND: The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture.

METHODS: Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery.

RESULTS: The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case.

CONCLUSIONS: Early isolated talonavicular arthrodesis provides excellent pain relief and
prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.
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NewsBot · Jun 12, 2010

Foot deformities in patients with rheumatoid arthritis: the relationship with foot functions.
Göksel Karatepe A, Günaydin R, Adibelli ZH, Kaya T, Duruöz E.
Int J Rheum Dis. 2010 May 1;13(2):158-163.

Aim: The aim of this study was to investigate foot deformities in patients with rheumatoid arthritis (RA), to detect frequency of deformities and to assess the relationship between foot deformities and foot functions.

Methods: Anteroposterior and lateral radiographs of 40 patients and 40 control subjects were studied. The hallux valgus (HV) angle, intermetatarsal angle between first and second metatarsals, intermetatarsal angle between first and fifth metatarsals, and calcaneal pitch were measured on radiographs. Foot functions were measured by the Foot and Ankle Outcome Score (FAOS).

Results: The frequency of foot deformities in RA patients was determined as 78.8%. The most frequent foot deformity in RA patients was HV (62.5%), followed by metatarsus primus varus (MPV) (41.3%). MPV and splaying of the forefoot deformities were significantly more frequent in RA patients than the control group (P < 0.05). Mild to moderate effect on FAOS subscales was observed in RA patients. There was a slight, but significant correlation between the foot deformities and the FAOS subscales except for quality of life subscale.

Conclusions: In this study, it has been shown that foot deformities are frequent in patients with RA and that there is slight deterioration in foot functions related to RA. Our results indicated that foot deformities have small, but clinically important changes on foot functions. There is a need for more studies, which evaluates the foot deformities, to further explore the relationship between the foot deformities and foot function in patients with RA.
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NewsBot · Jun 18, 2010

Improvement in symptoms and signs in the forefoot of patients with rheumatoid arthritis treated with anti-TNF therapy
Catherine J Bowen, Christopher J Edwards, Hooper Lindsey, Keith Dewbury, Madeleine Sampson, Sally Sawyer, Jane Burridge and Nigel K Arden
Journal of Foot and Ankle Research 17 June 2010

Background
Inhibition of tumour necrosis factor (TNF) is an effective way of reducing synovitis and preventing joint damage in rheumatoid arthritis (RA), yet very little is known about its specific effect on foot pain and disability. The aim of this study was to evaluate whether anti-TNF therapy alters the presence of forefoot pathology and/or reduces foot pain and disability.

Methods
Consecutive RA patients starting anti-TNF therapy (infliximab, etanercept, adalimumab) were assessed for presence of synovial hypertrophy and synovitis in the 2nd and 5th metatarso-phalangeal (MTP) joints and plantar forefoot bursal hypertrophy before and 12 weeks after therapy. Tender MTP joints and swollen bursae were established clinically by an experienced podiatrist and ultrasound (US) images were acquired and interpreted by a radiologist. Assessment of patient reported disease impact on the foot was performed using the Manchester Foot Pain and Disability Index (MFPDI).

Results
31 patients (24 female, 7 male) with RA (12 seronegative, 19 seropositive) completed the study: mean age 59.6 (SD 10.1) years, disease duration 11.1 (SD 10.5) years, and previous number of Disease Modifying Anti Rheumatic Drugs 3.0 (1.6). Significant differences after therapy were found for Erythrocyte Sedimentation Rate (t=4.014, p<0.001), C-reactive protein (t=3.889, p=0.001), 28 joint Disease Activity Score (t=3.712, p=.0.001), Visual Analog Scale (t=2.735, p=0.011) and Manchester Foot Pain and Disability Index (t=3.712, p=0.001). Presence of MTP joint synovial hypertrophy on US was noted in 67.5% of joints at baseline and 54.8% of joints at twelve weeks. Presence of plantar forefoot bursal hypertrophy on US was noted in 83.3% of feet at baseline and 75% at twelve weeks. Although there was a trend for reduction in observed presence of person specific forefoot pathology, when the frequencies were analysed (McNemar) this was not significant.

Conclusions
Significant improvements were seen in patient reported foot pain and disability 12 weeks after commencing TNF inhibition in RA, but this may not be enough time to detect changes in forefoot pathology.
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NewsBot · Jul 10, 2010

The rheumatoid foot: a systematic literature review of patient reported outcome measures
Steven Walmsley , Anita E Williams , Mike Ravey and Andrea Graham
Journal of Foot and Ankle Research 2010, 3:12doi:10.1186/1757-1146-3-12

Background
The foot is often the first area of the body to be systematically affected by rheumatoid arthritis. The multidimensional consequences of foot problems for patients can be subjectively evaluated using patient-reported outcome measures (PROMs). However, there is currently no systematic review which has focused specifically upon the PROMs available for the foot with rheumatoid arthritis. The aim of this systematic review was to appraise the foot-specific PROMs available for the assessment and/or evaluation of the foot affected with rheumatoid arthritis.

Methods
A systematic search of databases was conducted according to pre-defined inclusion/exclusion criteria. PROMs identified were reviewed in terms of: conceptual bases, quality of construction, measurement aims and evidence to support their measurement properties.

Results
A total of 11 PROMs were identified and 5 papers that provided evidence for the measurement properties of some of the PROMs. Only one of the PROMs was found to be RA disease-specific. The quality of construction, pretesting and presence of evidence for their measurement properties was found to be highly variable. Conceptual bases of many of the PROMs was either restricted or based on reductionist biomedical models. All of the PROMs were found to consist of fixed scales.

Conclusions
There is a need to develop an RA-disease and foot-specific PROM with a greater emphasis on a biopsychosocial conceptual basis, cognitive pre-testing methods, patient preference-based qualities and evidence to support the full complement of measurement properties.
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NewsBot · Jul 28, 2010

Plantar shear stress distribution in patients with rheumatoid arthritis: relevance to foot pain.
Yavuz M, Husni E, Botek G, Davis BL.
J Am Podiatr Med Assoc. 2010 Jul-Aug;100(4):265-9.

Background: Rheumatoid arthritis is an autoimmune disease that causes chronic, progressive joint inflammation; it commonly affects the joints of the feet. Biomechanical alterations and daily pain in the foot are the common outcomes of the disease. Earlier studies focusing on plantar pressure in such patients reported increased vertical loading along with peak pressure-pain associations. However, footwear designed according to the pressure profiles did not relieve symptoms effectively. We examined plantar shear and pressure distribution in patients with rheumatoid arthritis and compared the findings with those of controls, and we investigated a potential relationship between foot pain and local shear stresses.

Methods: A custom-built platform was used to collect plantar pressure and shear stress data from nine patients with rheumatoid arthritis and 14 control participants. Seven patients reported the presence of pain under their feet. Pressure-time and shear-time integral values were also calculated.

Results: Peak pressure, pressure-time integral, resultant shear-time integral, and mediolateral shear stress magnitudes were higher in the complication group (P < .05). An association between peak shear-time integral and maximum pain locations was observed.

Conclusions: Increased mediolateral shear stresses under the rheumatoid foot might be attributable to gait instability in such patients. A correlation between the locations of maximum shear-time integral and pain indicate the clinical significance of plantar shear in patients with rheumatoid arthritis.
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NewsBot · Aug 22, 2010

Assessment of the natural history of forefoot bursae using ultrasonography in patients with rheumatoid arthritis: A twelve month investigation.
Bowen CJ, Hooper L, Culliford D, Dewbury K, Sampson M, Burridge J, Edwards CJ, Arden NK.
Arthritis Care Res (Hoboken). 2010 Aug 18. [Epub ahead of print]

OBJECTIVES: The aim of this study was to determine the natural history and clinical significance of forefoot bursae, over a 12 month period, in patients with rheumatoid arthritis (RA).

METHODS: Patients with RA (N=149) attending rheumatology outpatient clinics were assessed at baseline. 120 participants, mean age 60.7 (+/-12.1) years and disease duration 12.99 (+/-10.4) years, completed the 12 month follow up (98 female: 22 male, 93 rheumatoid factor positive: 24 rheumatoid factor negative: 3 unknown). Musculoskeletal ultrasound (US) was used to identify forefoot bursae in all participants. Clinical markers of disease activity (wellbeing-VAS, ESR, CRP, DAS28) and foot symptoms (LFIS) were recorded on both occasions.

RESULTS: Presence of US detectable forefoot bursae was identified in 93.3% of returnee (N=120) participants (individual mean=3.7, range 0-11) at baseline. Significant associations were identified between bursae presence and patient reported foot impact for impairment/footwear (LFIS(IF)), (baseline: r=0.226, p=0.013; 12 month: r=0.236, p=0.009), and activity limitation/participation restriction (LFIS(AP)), (baseline: r=0.254, p=0.005; 12 months: r=0.235 p=0.010). After 12 months, 42.5% of participants had an increase in the number of US detectable forefoot bursae and 45% of participants had a decrease. Changes in bursae number significantly correlated with changes in LFIS(IF) (r=0.216, p=0.018) and LFIS(AP) (r=0.193, p=0.036). No significant associations were identified between changes in bursae and changes in global wellbeing VAS, ESR, CRP or DAS-28.

CONCLUSION: The findings of this study suggest that forefoot bursae may regress or hypertrophy over time in patients with RA and that these changes may be associated with self reported foot impairment and activity restriction.
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NewsBot · Sep 15, 2010

Is cavus foot affected by midfoot flattening in rheumatoid arthritis?
M. Bouysset, F. Coury, M. Bonnin, J.C. Vianey, J.-P. Duivon, N. Sprunck, C. Nemoz, J. Damiano and J. Tebib
Médecine et Chirurgie du Pied DOI: 10.1007/s10243-010-0292-6

Objective
The painful feet are likely to flatten in rheumatoid arthritis (RA), and there is an optimal time to prescribe plantar orthoses in rheumatoid arthritis to correct deformity of the subtalar joint complex. We aimed to determine which type of foot is likely to become flattened to improve localized treatment of the rheumatoid foot.

Methods
Three hundred and two rheumatoid feet (RF) in 151 patients with RA were compared with 200 feet in 100 consecutive patients with neck pain (control group, CF). The two groups were homogeneous for sex, age, and laterality of the foot. Lateral weight-bearing radiographs were obtained for each foot. Feet were classified as cavus, normal, and flat according to their angular variations.

Results
On radiographs in weight-bearing, the frequency of cavus foot was similar in both groups regardless of age, before and after age 50 years. The frequency of normal foot was slightly lower in rheumatoid than in control feet (P = 0.036), while flat foot was much more frequent in rheumatoid feet (P = 0.0005). The frequency of flat foot increased significantly with age in both groups, and this increase occurred earlier in the RF group (P = 0.05). Intragroup comparison showed that the frequency of flat foot was higher after age 50 in both the RF (P = 0.026) and the CF (P = 0.002) group, and in the CF group, the increase of flat foot was more marked after 50 years than in the RF group.

Conclusion
On the whole, the cavus foot did not flatten in RA or flattens less. Preventive plantar orthoses and appropriate footwear are therefore particularly indicated in the painful “normal” RF to avoid flat foot and in painful flat RF to avoid worsening of the flat foot.
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NewsBot · Oct 5, 2010

Patients with inflammatory arthropathies undergo feet surgery later in the disease course than hand surgery.
Osnes-Ringen H, Kvien TK, Henriksen JE, Dagfinrud H.
Clin Exp Rheumatol. 2010 Sep 24. [Epub ahead of print]

OBJECTIVES: Inflammatory arthropathies often results in functional impairment and joint damage and deformity. Hand and foot are frequent locations for surgical interventions. Our objective is to compare disease duration, patient reported health status measures and use of medication in patients with inflammatory arthropathies referred for hand or foot surgery.

METHODS: Patients referred for hand or foot surgery at the Diakonhjemmet Hospital responded to mail surveys preoperatively, including AIMS2, HAQ, SF-36, EQ-5, and visual analogue scales addressing patient global assessment of disease activity, fatigue, general pain and pain in the actual joint. Data on disease duration, surgical treatment and medication were collected from the hospital records.

RESULTS: 116 patients (mean (SD) age 57 (13) years, 76% female) with inflammatory arthropathies underwent hand (n=52, mean (SD) age 55 (13) years) or foot (n=64, mean (SD) age 58 (13) years) surgery. Disease duration at the time of surgery was significantly longer for patients referred for foot vs. hand surgery (19 (13) vs. 13 (10) years, p=0.04). Patients undergoing foot surgery used more frequently biological or conventional disease-modifying antirheumatic drug at the time of surgery than patients having hand surgery (50% vs. 71%, respectively, p=0.02). Baseline values for the patient-reported health status measures were mainly similar for the two patient groups.

CONCLUSIONS: Patients undergoing surgical procedures in the foot had significantly longer disease duration and were more frequently on potent medication at the time of surgery than patients undergoing hand surgery. The observation may indicate that the impact of foot damage in inflammatory arthropathies is underestimated.
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NewsBot · Feb 8, 2011

Foot and ankle joint kinematics in rheumatoid arthritis cannot only be explained by alteration in walking speed.
Dubbeldam R, Nene AV, Buurke JH, Groothuis-Oudshoorn CG, Baan H, Drossaers-Bakker KW, van de Laar MA, Hermens H.
Gait Posture. 2011 Feb 3. [Epub ahead of print]

Rheumatoid arthritis (RA) manifests itself in the foot and ankle of RA patients. The foot and ankle joint kinematics of these patients differ from that of healthy subjects. However, the factors that lead to these differences are not yet fully understood. The aim of this study was to analyse the effect of walking speed and the disease process on foot and ankle joint kinematics of RA subjects. Gait recordings of 23 RA and 14 age-matched healthy subjects were performed and their foot and ankle joint kinematics were analysed during the stance phase of the gait cycle. Stance phase characteristics of the group of RA subjects and of the group of healthy subjects were compared. The healthy subjects walked at 100% (Vc), 75% (V75) and 50% (V50) of their comfortable walking speed. In a multi-level linear model significant differences between the two groups due to the factors walking speed and the disease process were analysed. The ankle dorsi-flexion, medial arch and hallux abduction motion at single-stance and toe-off were only influenced by the walking speed. The hallux maximum flexion at toe-off and the midfoot supination at single-stance were influenced by both the walking speed and the disease process. The hindfoot eversion motion at single-stance was only influenced by the disease process. In conclusion, the reduction of walking speed of RA subjects compared to healthy subjects does not explain all of the observed foot and ankle kinematics differences.
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NewsBot · Mar 4, 2011

Magnetic Resonance Imaging of the Rheumatic Foot According to the RAMRIS System Is Reliable.
Baan H, Bezooijen R, Avenarius JK, Dubbeldam R, Drossaers-Bakker WK, van de Laar MA.
J Rheumatol. 2011 Mar 1. [Epub ahead of print]

OBJECTIVE: In rheumatology, magnetic resonance imaging (MRI) is predominantly applied in the assessment and outcome measurement of rheumatoid arthritis (RA) in hands and wrists, leading to the development of the RAMRIS (RA-MRI-Scoring) system. It was initiated by the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT). The RAMRIS system has not been applied widely in the measurement of feet. We investigated the interreader and intrareader agreement of the RAMRIS scoring system in the assessment of feet in RA.

METHODS: Twenty-nine patients with RA who had radiological damage and/or arthritis underwent MRI. Two experienced readers independently read both complete sets. One reader read 6 random sets after the initial session, in order to assess the intrareader agreement. For evaluation of the intrareader and interreader reliability, quadratic-weighted κ scores were calculated per joint and lesion.

RESULTS: For the forefeet, interreader scores were excellent, ranging from 0.77 (bone edema) to 0.95 (bone erosion). Hindfoot interreader agreement scores were highest for erosion (0.90) and synovitis global score (0.88), but edema and synovial thickness agreement were also acceptable (0.83 and 0.86). Intrareader scores were on the whole slightly lower, but excellent.

CONCLUSION: Reliability (interreader and intrareader agreement) in the assessment of the rheumatoid foot according to the RAMRIS method is excellent.
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NewsBot · Apr 21, 2011

Use of conservative and surgical foot care in an inception cohort of patients with rheumatoid arthritis.
Backhouse MR, Keenan AM, Hensor EM, Young A, James D, Dixey J, Williams P, Prouse P, Gough A, Helliwell PS, Redmond AC.
Rheumatology (Oxford). 2011 Apr 18. [Epub ahead of print]

Objectives. To describe conservative and surgical foot care in patients with RA in England and explore factors that predict the type of foot care received.

Methods. Use of podiatry and type of foot surgery were outcomes recorded in an inception cohort involving nine rheumatology centres that recruited patients with RA between 1986 and 1998 across England. Associations between patient-specific factors and service use were identified using univariate logistic regression analyses. The independence of these associations was then verified through multiple binary logistic regression modelling.

Results. Data were collected on 1237 patients with RA [66.9% females, mean (s.d.) age at disease onset = 54.36 (14.18) years, median DAS = 4.09 (1st quartile = 3.04, 3rd quartile = 5.26), median HAQ = 1 (0.50, 1.63)]. Interventions involving the feet in the cohort were low with only 364 (30%) out of 1218 receiving podiatry and 47 (4%) out of 1237 patients having surgery. At baseline, female gender, increasing age at onset, being RF positive and higher DAS scores were each independently associated with increased odds of seeing a podiatrist. Gender, age of onset and baseline DAS were independently associated with the odds of having foot surgery.

Conclusions. Despite the known high prevalence of foot pathologies in RA, only one-third of this cohort accessed podiatry. While older females were more likely to access podiatry care and younger patients surgery, the majority of the RA population did not access any foot care.
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NewsBot · May 27, 2011

We should not forget the foot: relations between signs and symptoms, damage, and function in rheumatoid arthritis.
Baan H, Drossaers-Bakker W, Dubbeldam R, van de Laar M.
Clin Rheumatol. 2011 May 26. [Epub ahead of print]

We studied rheumatoid arthritis (RA) patients with foot complaints to address the associations between clinical signs and symptoms, radiographic changes, and function in connection with disease duration. Secondly, we describe the contribution of several foot segments to the clinical presentation and function. In 30 RA patients with complaints of their feet, attributed to either signs of arthritis and/or radiographic damage, we compared radiographic, ultrasound, clinical, and functional parameters of the feet and ankle. Pain and swelling of the ankle were correlated weakly but statistically significantly with limitation and disability (0.273 to 0.293) as measured on the 5-Foot Function Index (FFI). The clinical signs of the forefoot joints did not influence any of the functional outcome measures. Radiographic scores for both forefeet (SvdH) and hindfeet (Larsen) were correlated with the total Health Assessment Questionnaire Disability Index (HAQ DI) and the 5-FFI limitation subscale. Pain and disease duration, more than radiographic damage, influence the total HAQ DI significantly. With the progression of time, structural damage and function of the rheumatic foot worsen in RA patients. Pain and swelling of the ankle contribute more to disability than radiographic damage of the foot and ankle.
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NewsBot · Jun 3, 2011

Therapeutic Foot Health Education for Patients with Rheumatoid Arthritis: A Narrative Review.
Graham A, Williams A.
Musculoskeletal Care. 2011 Jun 1. doi: 10.1002/msc.205. [Epub ahead of print]

PURPOSE:
Foot health interventions such as foot orthoses for people with rheumatoid arthritis (RA) reduce pain, improve function and improve overall quality of life. Additionally, patient education (PE) is considered essential in achieving good outcomes with interventions such as foot orthoses, footwear and self-care. The aim of this literature review was to identify evidence in relation to the content, use and delivery of PE in the management of RA foot problems.

METHODS:
An electronic search of the following databases was performed: PubMed, CINAHL, AMED, Medline and the Cochrane Library, between March 2000 and March 2010. In order to be included, studies had to be published in English, involve adults (>18 years) with RA, and assist in answering the research question. No publications regarding PE for the management of foot health-related problems in RA were found. However, other key terms emerged that embraced PE for people with RA and informed a further search. Thirty-two papers met the inclusion criteria and were reviewed with regard to the subject area, content of the paper, methodological issues and their key findings.

RESULTS:
The present review provides evidence for the effectiveness of PE for people with RA delivered via a staged approach, with the content and timing of education provision being driven by the needs of the patient.

CONCLUSIONS:
The effect of PE delivered from a podiatric context needs to be explored, and the nature and requirements of PE for individuals with RA-related foot problems from a patient and practitioner perspective requires investigation. Alternative and innovative ways of providing PE and, potentially, self-management need to be investigated and define
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NewsBot · Jul 22, 2011

A clinical classification system for rheumatoid forefoot deformity
Peter F. Doorn et al
Foot and Ankle Surgery; Volume 17, Issue 3, September 2011, Pages 158-165

Background and purpose
In the present study a classification system for the rheumatoid forefoot is reported with its intra- and interobserver reliability and clinical relevance. The classification is based on the sequence of anatomical changes resulting from the loss of integrity of the MTP joints, loss of motion and changes regarding the quality and position of the plantar soft tissues. It is hypothesized that with progression of the amount of deformity of the MTP joint(s), patients have more pain and functional loss.

Patients and methods
In total 94 patients were included in the study following precise inclusion criteria. The forefeet of the patients were classified according to the introduced classification system by two observers in order to determine the intra- and interobserver reliability. The relation of the suggested classification between pain, function scores, and plantar foot pressure measurements was examined.

Results and conclusion
According to the Cohen's kappa and the ICC, the intra- and inter-observer reliability were high. Despite the large variation between subjects in a certain grade, a clear trend was found between increase in classification and VAS for pain, FFI difficulty with activities, and plantar peak pressure under the metatarsals. The suggested classification is of clinical relevance and can be used to develop therapeutical algorithms and to test interventions.
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NewsBot · Dec 2, 2011

Misclassification of disease activity when assessing individual patients with early rheumatoid arthritis using disease activity indices that do not include joints of feet.
Bakker MF, Jacobs JW, Kruize AA, van der Veen MJ, van Booma-Frankfort C, Vreugdenhil SA, Bijlsma JW, Lafeber FP, Welsing PM.
Ann Rheum Dis. 2011 Nov 29.

OBJECTIVE:
To study whether assessment of rheumatoid arthritis (RA) disease activity in individual patients using the disease activity score in 28 joints (DAS28) or other instruments excluding joints of feet may lead to misclassification of disease activity.

METHODS:
A cohort of RA patients was classified into three 'regional radiographic damage progression' groups: predominantly progression in feet, similar progression in hands and feet and predominantly progression in hands; both in early (0-2 years) and later (2-5 years) disease. Baseline and mean DAS28, individual DAS28 variables and tender joint counts (TJC) and swollen joint counts (SJC) of the feet were compared between groups. The longitudinal relation of DAS28 with radiographic damage was investigated using a mixed model analysis with rheumatoid factor status, baseline joint damage and TJC and SJC of the feet as covariates.

RESULTS:
Early (n=265) and later (n=200) in the disease course, by definition, the classification procedure resulted in 25% as predominantly foot, 25% as predominantly hand and 50% as similar progressors. In early RA predominantly foot progressors had higher TJC and SJC of the feet compared with predominantly hand progressors (p<0.001), but DAS28 was similar. This was not seen in later disease. The longitudinal relation between DAS28 and radiographic progression was influenced by the region of progression (predominantly foot progressors vs others, p<0.001), suggesting that DAS28 underestimates disease activity in predominantly foot progressors. In this group, joint counts for the feet were independently related to radiographic progression.

CONCLUSIONS:
DAS28 underestimates actual disease activity and expected joint damage of individual early RA patients predominantly with disease in the feet.
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NewsBot · Jan 12, 2012

Foot health education for people with rheumatoid arthritis: the practitioner's perspective.
Graham AS, Hammond A, Williams AE.
J Foot Ankle Res. 2012 Jan 10;5(1):2.

BACKGROUND:
Patient education is considered to be a key role for podiatrists in the management of patients with rheumatoid arthritis (RA). Patient education has undoubtedly led to improved clinical outcomes, however no attempts have been made to optimise its content or delivery to maximise benefits within the context of the foot affected by rheumatoid arthritis. The aim of this study was to identify the nature and content of podiatrists' foot health education for people with RA. Any potential barriers to its provision were also explored.

METHODS:
A focus group was conducted. The audio dialogue was recorded digitally, transcribed verbatim and analysed using a structured, thematic approach. The full transcription was verified by the focus group as an accurate account of what was said. The thematic analysis framework was verified by members of the research team to ensure validity of the data.

RESULTS:
Twelve members (all female) of the north west Podiatry Clinical Effectiveness Group for Rheumatology participated. Six overarching themes emerged: (i) the essence of patient education; (ii) the content; (iii) patient-centred approach to content and timing; (iv) barriers to provision; (v) the therapeutic relationship; and (vi) tools of the trade.

CONCLUSION:
The study identified aspects of patient education that this group of podiatrists consider most important in relation to its: content, timing, delivery and barriers to its provision. General disease and foot health information in relation to RA together with a potential prognosis for foot health, the role of the podiatrist in management of foot health, and appropriate self-management strategies were considered to be key aspects of content, delivered according to the needs of the individual. Barriers to foot health education provision, including financial constraints and difficulties in establishing effective therapeutic relationships, were viewed as factors that strongly influenced foot health education provision. These data will contribute to the development of a patient-centred, negotiated approach to the provision of foot health education for people with RA.
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NewsBot · Jan 28, 2012

Joint preserving surgery for rheumatoid forefoot deformities improves pain and corrects deformity at midterm follow-up.
Bhavikatti M, Sewell MD, Al-Hadithy N, Awan S, Bawarish MA.
Foot (Edinb). 2012 Jan 24

BACKGROUND:
Rheumatoid arthritis is a chronic autoimmune disorder that commonly affects the metatarsophalangeal (MTP) joints. Conventional surgical treatment involves joint-sacrificing surgery to relieve pain and correct deformity.

OBJECTIVES:
We retrospectively reviewed 49 patients with rheumatoid forefoot deformities who underwent 66 joint preserving procedures with Scarf osteotomy of the first metatarsal and Weil's shortening osteotomy of the lesser metatarsals.

METHOD:
There were 5 males and 44 females with mean age 56.1 years and mean follow-up 51 months. All patients were evaluated clinically and radiologically with hallux valgus angle (HVA) and inter-metatarsal angle (IMA).

RESULTS:
Mean AOFAS score improved from 39.8 preoperatively to 88.7 at final follow-up. Subjectively patients reported their outcome as excellent in 49 feet (74%), good in 9 feet, fair in 7 feet and poor in 1 foot. Five feet had residual stiffness and 11 residual pain. Mean HVA and IMA decreased from 32° to 14° and from 15° to 11° respectively.

CONCLUSION:
In intermediate to severe stages of the disease, joint preserving surgery by Scarf osteotomy of the first MTP joint and Weil osteotomy of the lesser metatarsals may be performed as an alternative to joint-sacrificing procedures and should be considered as a complement to the various surgical treatments of the rheumatoid forefoot.
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NewsBot · Feb 4, 2012

Gait Analysis of the Lower Limb in Patients with Rheumatoid Arthritis: A Systematic Review.
Baan H, Dubbeldam R, Nene AV, van de Laar MA.
Semin Arthritis Rheum. 2012 Jan 31

INTRODUCTION:
In rheumatoid arthritis (RA), signs and symptoms of feet and ankle are common. To evaluate the dynamic function of feet and ankles, namely walking, a variety of gait studies have been published. In this systematic review, we provide a systematic overview of the available gait studies in RA, give a clinimetrical assignment, and review the general conclusions regarding gait in RA.

METHODS:
A systematic literature search within the databases PubMed, CINAHL, sportdiscus, Embase, and Scopus was described and performed and delivered 78 original gait studies that were included for further data extraction.

RESULTS:
The clinimetrical quality of the 78 included RA gait studies measured according a tailored QUADAS item list and proposed clinimetrical criteria by Terwee and coworkers are moderate. General conclusions regarding the walking abnormalities of RA patients point to a slower walk, longer double support time, and avoidance of extreme positions. Frequently found static features in RA are hallux valgus, pes planovalgus, and hind foot abnormalities.

CONCLUSIONS:
Gait studies in RA patients show moderate clinimetrical properties, but are a challenging way of expressing walking disability. Future gait research should focus on more uniformity in methodology. When this need is satisfied, more clinical applicable conclusions can be drawn.
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NewsBot · Feb 9, 2012

Remission in early rheumatoid arthritis defined by 28 joint counts: limited consequences of residual disease activity in the forefeet on outcome.
van Tuyl LH, Britsemmer K, Wells GA, Smolen JS, Zhang B, Funovits J, van Schaardenburg D, Felson D, Boers M.
Ann Rheum Dis. 2012 Jan;71(1):33-7.

Introduction The new American College for Rheumatology (ACR)/European League Against Rheumatism (EULAR) remission criteria are based on the assessment of 28 joints. A study was undertaken to study the consequences of remission misclassification due to residual disease activity in the feet on physical function and joint damage in the subsequent year in an observational early disease cohort.

METHODS:
All patients with rheumatoid arthritis at inclusion or at 1-year follow-up in the early arthritis cohort of the Jan van Breemen Institute, The Netherlands were included. ACR/EULAR remission definitions for trials and clinical practice were calculated twice, once using a 28-joint count and once using a 38-joint count that included the 10 metatarsophalangeal joints. Disease stability was defined as stable x-ray scores over 1 year (change ≤ 0 in Sharp/van der Heijde scores) and stable and low scores on the Health Assessment Questionnaire (HAQ change ≤ 0 and HAQ score consistently ≤ 0.5), all during the second year after inclusion. Analyses comprised residual disease activity (swollen or tender joints >0) in the feet of patients who fulfilled the candidate remission criteria using a 28-joint count and likelihood ratios of remission definitions to predict disease stability.

RESULTS:
Of 421 patients, 9-15% reached remission at 1 year using a 28-joint count. Of these, 26-40% showed activity in the feet. Misclassification due to reduced joint counts was observed in 2-3%. A state of remission increased the likelihood of stability of both x-ray and HAQ, with similar likelihood ratios for definitions using 38-joint counts and those using 28-joint counts.

CONCLUSION:
The ability of remission definitions with 28-joint counts versus 38-joint counts to predict long-term good radiological and functional outcome is similar. This confirms that inclusion of ankles and forefeet in the assessment of remission is not required, although inclusion of these joints in the examination is recommended.
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NewsBot · Mar 17, 2012

Prognostic indicators of foot related disability in patients with RA: Results of a prospective three-year study.
Hooper L, Bowen CJ, Gates L, Culliford DJ, Ball C, Edwards CJ, Arden NK.
Arthritis Care Res (Hoboken). 2012 Mar 15.

OBJECTIVE:
To determine the prevalence and natural history of foot-related disability in patients with RA. A secondary aim was to identify explanatory variables, including forefoot bursae, which are either associated with or predictive of disabling foot complications in patients with RA.

METHODS:
A longitudinal, prospective, cohort study recruited patients with RA from a rheumatology outpatient clinic. Data were collected at baseline (N=149), one-year (n=120) and three-year follow-up (n=60). Patient-reported disabling foot complications were evaluated using the subscales of the Foot Impairment Score; foot impairment/ footwear restriction (FIS(IF) ) & activity limitation/participation restriction (FIS(AP) ). Explanatory variables investigated included ultrasound detectable forefoot pathology and markers of disease activity.

RESULTS:
Disabling foot complications were highly prevalent on all occasions. Changes in foot impairment and activity limitation were significantly associated with fluctuations in disease activity (FIS(IF) : DAS28-ESR r=0.455, p<0.0001; ESR r=-0.356, p=0.008, FIS(AP) : DAS28-ESR r=0.433, p=0.001; ESR r=-0.439, p=0.001), and approaching a significant association with changes in forefoot bursae (FIS(IF) : r=0.255, p=0.063; FIS(AP) : r=0.255, p=0.063). Disease duration and forefoot bursae presence were significant prognostic indicators of foot impairment (p=0.009, p=0.012 respectively), explaining 16% of score variability in the final regression model. Disease duration, forefoot bursae and erosion presence were identified as significant prognostic indicators of activity limitation (p=0.006, p=0.019, p=0.002 respectively), explaining 35% of score variability in the final regression model.

CONCLUSION:
Despite advances in disease management, patients report disability associated with foot problems. Forefoot bursae should be considered for targeted therapy
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NewsBot · Jun 23, 2012

Reliability study of tibialis posterior and selected leg muscle EMG and multi-segment foot kinematics in rheumatoid arthritis associated pes planovalgus.
Barn R, Rafferty D, Turner DE, Woodburn J.
Gait Posture. 2012 Jun 19.

OBJECTIVE:
To determine within- and between-day reliability characteristics of electromyographic (EMG) activity patterns of selected lower leg muscles and kinematic variables in patients with rheumatoid arthritis (RA) and pes planovalgus.

METHODS:
Five patients with RA underwent gait analysis barefoot and shod on two occasions 1week apart. Fine-wire (tibialis posterior [TP]) and surface EMG for selected muscles and 3D kinematics using a multi-segmented foot model was undertaken barefoot and shod. Reliability of pre-determined variables including EMG activity patterns and inter-segment kinematics were analysed using coefficients of multiple correlation, intraclass correlation coefficients (ICC) and the standard error of the measurement (SEM).

RESULTS:
Muscle activation patterns within- and between-day ranged from fair-to-good to excellent in both conditions. Discrete temporal and amplitude variables were highly variable across all muscle groups in both conditions but particularly poor for TP and peroneus longus. SEMs ranged from 1% to 9% of stance and 4% to 27% of maximum voluntary contraction; in most cases the 95% confidence interval crossed zero. Excellent within-day reliability was found for the inter-segment kinematics in both conditions. Between-day reliability ranged from fair-to-good to excellent for kinematic variables and all ICCs were excellent; the SEM ranged from 0.60° to 1.99°.

CONCLUSION:
Multi-segmented foot kinematics can be reliably measured in RA patients with pes planovalgus. Serial measurement of discrete variables for TP and other selected leg muscles via EMG is not supported from the findings in this cohort of RA patients. Caution should be exercised when EMG measurements are considered to study disease progression or intervention effects.
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NewsBot · Jul 19, 2012

Quantitative assessment of foot structure in rheumatoid arthritis by a foot digitizer allows detection of deformities, even in the absence of erosions.
De Mits S, Mielants H, De Clercq D, Woodburn JJ, Roosen P, Elewaut D.
Arthritis Care Res (Hoboken). 2012 Jul 17.

OBJECTIVE:
Foot involvement is a major feature in RA, leading to structural deformities. Methods to allow a 3D evaluation of foot structure in RA, applicable in daily clinical practice have not been evaluated. This study assesses the use of a foot digitizer, a non-invasive 3D scanner collecting objective quantitative data of the feet, to evaluate the presence of foot structure abnormalities in an RA outpatient cohort.

METHODS:
Foot digitizer data of RA patients was compared with healthy controls. Subanalyses were performed to find relations with erosive disease and the presence of swollen and/or tender joints. Linear mixed models were applied with correction including gender, age, bodyweight and height, foot length, DAS 28, disease duration.

RESULTS:
Forty one percent of the patients showed more than one abnormal parameter, measured with the 3D foot scanner. Most differences found were located in the forefoot, the most frequently affected area of the RA foot. Strikingly, even in the absence of joint erosions, marked alterations were found. Comparable differences were also observed between the patients with and without swollen and/or tender joints. Additionally, alterations were not strongly related to foot pain and disability, suggesting its capacity to detect early changes in foot structure.

CONCLUSION:
The results highlight the impact of RA on foot structure, even in the absence of clinical signs of swelling or radiographic erosions. The foot digitizer offers a valuable tool to screen for such foot deformities, before the presence of erosions.
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NewsBot · Jul 26, 2012

MRI identifies plantar plate pathology in the forefoot of patients with rheumatoid arthritis.
Siddle HJ, Hodgson RJ, Redmond AC, Grainger AJ, Wakefield RJ, Pickles DA, Hensor EM, Helliwell PS.
Clin Rheumatol. 2012 Apr;31(4):621-9.

Previous cadaveric studies have suggested that forefoot deformities at the metatarsophalangeal (MTP) joints in patients with rheumatoid arthritis (RA) might result from the failure of the ligamentous system and displacement of the plantar plates. This study aimed to examine the relationship between plantar plate pathology and the rheumatoid arthritis magnetic resonance imaging score (RAMRIS) of the lesser (second to fifth) MTP joints in patients with RA using high-resolution 3 T magnetic resonance imaging (MRI). In 24 patients with RA, the forefoot was imaged using 3 T MRI. Proton density fat-suppressed, T2-weighted fat-suppressed and T1-weighted post gadolinium sequences were acquired through 96 lesser MTP joints. Images were scored for synovitis, bone marrow oedema and bone erosion using the RAMRIS system and the plantar plates were assessed for pathology. Seventeen females and 7 males with a mean age of 55.5 years (range 37-71) and disease duration of 10.6 years (range 0.6-36) took part in the study. Plantar plate pathology was most frequently demonstrated on MRI at the fifth MTP joint. An association was demonstrated between plantar plate pathology and RAMRIS-reported synovitis, bone marrow oedema and bone erosion at the fourth and fifth MTP joints. In patients with RA, 3 T MRI demonstrates that plantar plate pathology at the lesser MTP joints is associated with features of disease severity. Plantar plate pathology is more common at the fourth and fifth MTP joints in subjects with RA in contrast to the predilection for the second MTP reported previously in subjects without RA.
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NewsBot · Aug 3, 2012

Prognostic indicators of foot-related disability in patients with rheumatoid arthritis: Results of a prospective three-year study
Lindsey Hooper et al
Arthritis Care & Research Volume 64, Issue 8, pages 1116–1124, August 2012

Objective
To determine the prevalence and natural history of foot-related disability in patients with rheumatoid arthritis (RA). A secondary aim was to identify explanatory variables, including forefoot bursae, that are either associated with or predictive of disabling foot complications in patients with RA.

Methods
A longitudinal prospective cohort study recruited patients with RA from a rheumatology outpatient clinic. Data were collected at baseline (n = 149) and 1-year (n = 120) and 3-year followup (n = 60). Patient-reported disabling foot complications were evaluated using the subscales of the Foot Impairment Score (FIS): foot impairment/footwear restriction (FISIF) and activity limitation/participation restriction (FISAP). Explanatory variables investigated included ultrasound-detectable forefoot pathology and markers of disease activity.

Results
Disabling foot complications were highly prevalent on all occasions. Changes in foot impairment and activity limitation were significantly associated with fluctuations in disease activity (Disease Activity Score in 28 joints using the erythrocyte sedimentation rate [DAS28-ESR]: r = 0.455, P < 0.0001; ESR: r = −0.356, P = 0.008 and DAS28-ESR: r = 0.433, P = 0.001; ESR: r = −0.439, P = 0.001 for the FISIF and FISAP, respectively), and approaching a significant association with changes in forefoot bursae (FISIF: r = 0.255, P = 0.063 and FISAP: r = 0.255, P = 0.063). The presence of disease duration and forefoot bursae was a significant prognostic indicator of foot impairment (P = 0.009 and P = 0.012, respectively), explaining 16% of score variability in the final regression model. Disease duration, forefoot bursae, and erosion presence were identified as significant prognostic indicators of activity limitation (P = 0.002, P = 0.006, and P = 0.019, respectively), explaining 35% of score variability in the final regression model.

Conclusion
Despite advances in disease management, patients report disability associated with foot problems. Forefoot bursae should be considered for targeted therapy.
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NewsBot · Sep 4, 2012

Surgical treatment of hindfoot inflammatory diseases: 107 arthrodesis.
Munoz MA, Augoyard R, Canovas F; The French Association of Foot Surgery (AFCP).
Orthop Traumatol Surg Res. 2012 Aug 28

INTRODUCTION:
In rheumatoid diseases, hindfoot arthrodesis abolishes pain and corrects deformity. The choice between selective and double arthrodesis depends on whether the hindfoot malalignment is fixed or not. Indications for surgery are well codified. The various types of arthrodesis have never been assessed together on a large series. We here report a series that is substantial in numbers and in follow-up.

MATERIALS AND METHODS:
A continuous single-center retrospective study included patients with native hindfoot inflammatory disease treated by arthrodesis between 1996 and 2009.

RESULTS:
Around 80% of patients were followed up, for a mean 7 years. Fifty-four isolated talonavicular arthrodeses, 14 talocalcaneal arthrodeses and 39 double arthrodeses were performed. 96% of patients had rheumatoid arthritis and 4% spondylarthritis. 62% were completely pain-free at follow-up. The satisfaction rate was 91% and mean AOFAS score 70%. 6% of patients showed symptomatic non-union, mainly associated with talonavicular arthrodesis. In 22% of double arthrodeses and 11% of talonavicular arthrodeses, ankle status required surgical revision. In double arthrodesis, there was no correlation between hindfoot deviation and secondary deterioration in ankle status. Talocalcaneal arthrodesis was associated with radiologic hindfoot varus, both preoperatively and at follow-up.

DISCUSSION:
Non-union was the main complication in talonavicular arthrodesis. The rate of secondary ankle surgery was significantly elevated in double arthrodesis. These findings support Suckel's cadaver studies, which, in 2007, reported early deterioration in ankle status in double arthrodesis, due to mechanical overloading. Talocalcaneal arthrodesis proved reliable and simple, free of major complications and with a 100% satisfaction rate.

CONCLUSION:
Double arthrodesis showed the greatest benefit in terms of restoring foot architecture, but was associated with a higher rate of deterioration in ankle status. Preventive double arthrodesis is not recommended in case of isolated arthritis with reducible hindfoot malalignment.
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NewsBot · Sep 14, 2012

Foot and ankle kinematics in rheumatoid arthritis: The influence off foot and ankle joint and leg tendon pathologies.
Dubbeldam R, Baan H, Nene AV, Drossaers-Bakker KW, van de Laar MA, Hermens HJ, Buurke JH.
Arthritis Care Res (Hoboken). 2012 Sep 12.

Introduction From early onset of the disease, patients with rheumatoid arthritis (RA) suffer from walking impairments. Clinically, pathologic effects of RA on foot and ankle structures have been studied, but little is know how they relate to kinematic changes during gait. The aim of this study was to explore the relationship between clinically observed pathologies of foot and ankle joints and leg tendons and the corresponding gait kinematics.

Methodology Gait of 25 subjects with varying stages of RA disease was recorded and foot and ankle kinematics were assessed. Magnetic resonance imaging was performed of each subject: first metatarsal-phalange (MTP I), midfoot and hindfoot synovitis and erosion scores and leg tendon involvement were determined. The Joint Alignement and Motion score represented daily clinical assessment. The 95% confidence intervals (CI) of the correlation coefficient of the Spearman correlation tests were used to explore the relationships between the clinical and kinematic parameters.

Results Maximum MTP I dorsiflexion at pre-swing was related to reduced MTP I passive motion, MTP I synovitis and erosion, midfoot synovitis and erosion and hindfoot erosion. Midfoot pronation range of motion during single-stance was related to subtalar alignment and Achilles tendon involvement. Hindfoot eversion range of motion during single-stance was related to subtalar alignment and peroneus longus tendon involvement. Involvement of the tibialis posterior tendon could not be identified as an independent factor influencing foot or ankle kinematics.

Conclusions Our findings suggest moderate to strong relationships between foot and ankle gait kinematics and structural pathologies.
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NewsBot · Sep 14, 2012

Tibialis posterior tenosynovitis and associated pes plano valgus in rheumatoid arthritis: EMG, multi-segment foot kinematics and ultrasound features.
Barn R, Turner DE, Rafferty D, Sturrock RD, Woodburn J.
Arthritis Care Res (Hoboken). 2012 Sep 12.

OBJECTIVE:
To compare electromyographic (EMG), kinematic, kinetic and ultrasound (US) features of pes plano valgus associated with US confirmed tibialis posterior (TP) tenosynovitis in rheumatoid arthritis (RA) and healthy control subjects.

METHODS:
In this cross sectional study patients with RA and US confirmed tenosynovitis of TP underwent gait analysis including 3-D kinematics, kinetics and intramuscular EMG of TP and findings compared with a group of healthy individuals. The RA group also underwent B-mode and power Doppler US scanning of the TP tendon to assess and score levels of pathology.

RESULTS:
Ten patients with RA, median (range) disease duration of 3 (1-18) years and five control subjects were recruited. Compared to control subjects, the RA patients walked slower and presented with moderate levels of foot related disability. The mean (SD) DAS28 score was 4.6 (1.6). Increased magnitude of TP activity was recorded in the RA group compared to controls in the contact period of stance (p=0.007), in conjunction with reduced ankle joint power (p=0.005), reduced navicular height in the medial arch (p=0.023) and increased forefoot dorsiflexion (p=0.027). TP tendon thickening, fluid and power Doppler signal were observed in the majority of patients.

CONCLUSION:
This study has demonstrated, for the first time, increased TP EMG activity in the presence of US confirmed TP tenosynovitis in RA. Altered muscle function occurred in conjunction with suboptimal mechanics, moderate levels of tendon pathology and active disease. Targeted therapy may be warranted to reduce inflammation and mechanically off-load diseased tendon states
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NewsBot · Oct 2, 2012

THE EFFECT OF FOREFOOT RECONSTRUCTION ON LOADING IN RHEUMATOID FEET
C.J. Lever, A.J.F. Bing, S.O. Hill, P. Laing, and N.K. Makwana
J Bone Joint Surg Br 2012 94-BSUPP XLIII) 58.

Introduction Forefoot deformities are common in the rheumatoid population and lead to abnormal loading, plantar callosities and metatarsalgia. First MTP joint arthrodesis with lesser toe Stainsby procedures has become a popular method of reconstructing the rheumatoid forefoot but there is little data that reviews the clinical or biomechanical results of combining the two procedures.

Materials & Methods A prospective observational study was set up to review 10 rheumatoid patients (20 feet) undergoing bilateral first MTP joint arthrodesis via a medial approach with Stainsby procedures to all lesser toes via curved incisions with resection of two thirds of the proximal phalanx, repositioning of plantar fat pad, extensor to flexor interposition and temporary stabilisation with k wires. Clinical scoring and dynamic pedobarograph pressure measurements were taken pre operatively and at one year post surgery.

Results Nine female and one male patient with a mean age of 60.2 years were reviewed. Pre operatively there were 11 abnormal high pressure areas in 10 feet, reducing to 8 abnormal areas in 6 feet following surgery. Post operatively the mean pressure time integral increased under the first metatarsal and decreased under lesser metatarsals. Following surgery no patient suffered significantly from callosities or metatarsalgia and AOFAS scores improved.

Conclusion The post operative pressure time integrals suggest the medial weightbearing column is recreated with a reduction of abnormal pressures under the lesser metatarsal heads. These results show that first MTP joint arthrodesis with lesser toe Stainsby procedures reduces the number of abnormal high pressure areas under the forefoot and should be considered for deformity correction in the rheumatoid forefoot.
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NewsBot · Nov 29, 2012

Press Release:
‘Walking on marbles’ could be a thing of the past for arthritis patients

Researchers at the University of Southampton are to undertake a new stage of a study aimed at improving the health and mobility of those suffering from the common complaint of ‘walking on marbles’ associated with Rheumatoid Arthritis (RA) in the feet.

RA is the second most common form of arthritis in the UK, affecting almost 600,000 people, which results in the destruction of joints around the body caused by inflammation.

Forefeet often contain some of the first joints to be affected and those with the condition often say that they feel like they are ‘walking on marbles’. Mostly, people have thought that this was due to walking on foot joints that are affected by the RA.

The Health Sciences’ FeeTURA study however, developed new ways of assessing the forefeet through the use of diagnostic ultrasound and magnetic resonance imaging techniques. From this work, the team discovered that some of the swellings and associated feeling of ‘walking on marbles’ were related to inflamed bursae (a fluid-filled sac usually found in areas subject to friction) that had developed underneath the forefoot joints. These inflamed bursae were rarely detected by clinical examination.

The exact cause of the inflamed bursae is not known and a cure is yet to be found, however, the team is now looking at identifying inflammatory and mechanical markers to find the best ways of treating this complication in people suffering with RA. They will evaluate foot health treatments, such as targeted steroid injections, as well as medical management through the use of new drugs (called biologics).

This new stage of the study will be funded through a partnership between Solent NHS Trust and the Faculty of Health Sciences at the University of Southampton and supported by a National Institute for Health Research (NIHR) clinical academic fellowship.

During the first stage of the study, which took place between 2006 and 2009, researchers at the University of Southampton developed a technique to better evaluate the forefeet and diagnose the ‘marbles’ using diagnostic ultrasound. Participants’ who were assessed at the NIHR Wellcome Trust Clinical Research Facility (WTCRF), based at Southampton General Hospital, returned for re-assessment in the second stage of the study which discovered the changes that had occurred in the condition.

A third stage used an MRI scan to visualise the anatomical structures and ‘marbles’ more clearly in the forefeet (see photo) and resulted in researchers developing the first ever atlas to categorise the swellings originally identified in stage one.

Led by senior lecturer for Advanced Clinical and Expert Practice, Dr Catherine Bowen, this new stage of the treatment study will be carried out by clinical academic researcher, Lindsey Hooper, who recently won a prestigious special award from Wessex HIEC for the previously completed MRI work.

Dr Bowen comments: “Although more common in the UK than leukaemia and multiple sclerosis, awareness of the severity of rheumatoid arthritis is limited.

“Our linked study aims to significantly improve the lives of those affected by the condition in their forefeet, reducing the severity of the symptoms including pain, inflammation, poor sleep, fatigue and depression, and therefore helping improve their mobility and wellbeing.”

Lindsey Hooper adds: “This is an amazing opportunity to be involved in a study that is potentially life-changing for the many people suffering from this progressively debilitating condition.

“As I am maintaining my clinical role as a rheumatology podiatrist whilst also completing the research it means the findings can be fed directly back into clinical practice, so that local patients receive the most up-to-date care options.”
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NewsBot · Jan 4, 2013

Patterns of magnetic resonance imaging of the foot in rheumatoid arthritis: which joints are most frequently involved?
Buchbender C, Scherer A, Miese F, Sewerin P, Haferkamp A, Brinks R, Wittsack HJ, Antoch G, Schneider M, Ostendorf B.
Rheumatol Int. 2013 Jan 3

To investigate patterns of inflammatory MRI pathologies of the fore- and midfoot in rheumatoid arthritis (RA) and early RA (ERA) and their changes under therapy. In this prospective study, MRI data of the foot of 39 RA patients (29 female, 10 male; age: 54 ± 13 years; disease duration: 35 ± 37 months; baseline DAS28: 3.0 ± 2.0; medication: 29 DMARD, 1 biological, 9 symptomatic or non-specific treatment) were evaluated for synovitis in 314 joints, bone marrow edema and erosions according to RAMRIS criteria in a total of 585 joints. The change in joint pathology intensity was evaluated on follow-up MRI (time of follow-up: 8 ± 4 months) in 25 patients. Inflammation was generally more frequent in the metatarsophalangeal (MTP) joints (221/292; 76 %) than in the proximal metatarsal (47/292; 16 %) and tarsal bones (24/292; 8 %). The overall most frequently involved joints of the foot were MTP 5 (51/292; 18 %) and 1 (49/292; 17 %). Change under therapy was most frequently seen in the MTP 1 joint. Progress of inflammation in the MTP 1 was more frequently found in ERA patients than in patients with established RA (disease duration >12 months) (p = 0.002). In RA, the MTP joints, primarily MTP 5 and 1, are the predominant sites of inflammatory MRI pathologies of the foot. A change of inflammatory activity under therapy can be most frequently noted in the MTP 1 joint. This information might be helpful to improve effectiveness of MRI-controlled therapy approaches and clinical trials.
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NewsBot · Jan 30, 2013

Involvement of valgus hindfoot deformity in hallux valgus deformity in rheumatoid arthritis
Shutaro Yamada, Makoto Hirao, Hideki Tsuboi, Shosuke Akita, Masato Matsu****a, Shiro Ohshima, Yukihiko Saeki, Jun Hashimoto
Modern Rheumatology; January 2013

The involvement of valgus hindfoot deformity in hallux valgus deformity was confirmed in a rheumatoid arthritis case with a destructive valgus hindfoot deformity. Correction of severe valgus, calcaneal lateral offset, and pronated foot deformity instantly normalized hallux valgus deformities postoperatively. Thus, careful hindfoot status evaluation is important when assessing forefoot deformity, including hallux valgus, in rheumatoid arthritis cases.
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NewsBot · Mar 23, 2013

Assessment of foot and ankle muscle strength using hand held dynamometry in patients with established rheumatoid arthritis
Matthew Carroll, William Joyce, Angela Brenton-Rule, Nicola Dalbeth and Keith Rome
Journal of Foot and Ankle Research 2013, 6:10 doi:10.1186/1757-1146-6-10

Background
The foot and ankle are frequently affected in patients with rheumatoid arthritis (RA). One of the negative consequences of RA on the physical function of patients is a decrease in muscle strength. However, little is known about foot and muscle strength in this population. The aim of the study was to evaluate significant differences in foot and ankle muscle strength between patients with established RA against age and sex-matched controls using hand-held dynamometry.

Methods
The maximal muscle strength of ankle plantarflexion, dorsiflexion, eversion and inversion was assessed in 14 patients with RA, mean (SD) disease duration of 22 (14.1) years, and 20 age and sex-matched control participants using hand-held dynamometry.

Results
Significant differences were observed in muscle strength between the two groups in plantarflexion (p = 0.00), eversion (p = 0.04) and inversion (p = 0.01). No significant difference was found in dorsiflexion (p > 0.05). The patients with RA displayed a significantly lower plantarflexion-dorsiflexion ratio than the control participants (p = 0.03).

Conclusions
The results from this study showed that the RA patients displayed a significant decrease in ankle dorsiflexion, eversion and inversion when compared to the non-RA control group suggesting that foot and ankle muscle strength may be affected by the pathological processes in RA. This study is a preliminary step for the measurement of muscle impairments within the RA population.
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NewsBot · Mar 26, 2013

Contribution of assessing forefoot joints in early rheumatoid arthritis patients: insights from item response theory.
Siemons L, Ten Klooster PM, Taal E, Kuper IH, van Riel PL, Glas CA, van de Laar MA.
Arthritis Care Res (Hoboken). 2013 Feb;65(2):212-9.

OBJECTIVE:
To evaluate the contribution of assessing forefoot joints to the measurement range and measurement precision of joint counts in early rheumatoid arthritis (RA) using item response theory.

METHODS:
Baseline measures of tender and swollen joint counts were analyzed in 459 early RA patients from the Dutch Rheumatoid Arthritis Monitoring remission induction cohort. The contribution of forefoot joints was studied by evaluating their effect on the measurement range and measurement precision of measures based on 28-joint counts. In addition, the alignment between the patient and joint distributions was investigated to determine whether the forefoot joints were informative for measuring joint tenderness or swelling of an early RA patient.

RESULTS:
In total, 233 patients (50.76%) experienced tenderness and 200 patients (43.57%) experienced swelling in ≥1 forefoot joint. Forefoot joints were more informative for measuring joint tenderness than joint swelling, but did not significantly improve the measurement range and measurement precision of the 28-joint counts. Furthermore, including forefoot joints did not remove the existing discrepancy between the joint and patient distributions in both joint counts.

CONCLUSION:
Forefoot joints were frequently affected on an individual level, but did not significantly improve the measurement range or precision of 28-joint counts in patients with early RA. From a measurement perspective, reduced joint counts are appropriate for use on a population level. The contribution of assessing forefoot joints on an individual level requires further investigation. Additionally, the results should be cross-validated in patients with longer disease durations to determine whether the pattern of joint involvement is similar in later stages of RA.
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NewsBot · Jun 9, 2013

Foot involvement in early rheumatoid arthritis: a prospective study of ultrasound features
Lisa Newcombe, Jim Woodburn, Duncan Porter, Sarah Saunders, David McCarey, Monica Gupta and Debbie Turner
Journal of Foot and Ankle Research 2013, 6(Suppl 1):O42 doi:10.1186/1757-1146-6-S1-O42

Background
Foot involvement in early rheumatoid arthritis (RA) is highly prevalent. Our understanding of foot progression and persistence is limited. This study aims to investigate ultrasound features of foot disease in early RA patients over 12 months.

Methods
Patients with early RA were assessed prospectively for 12 months using high-resolution B-mode and Power Doppler (PD) ultrasound. A cumulative ultrasound score was derived to measure change in the presence of joint effusions, synovitis, erosions, PD, and tenosynovitis between baseline and 12 months. Change in scores was calculated alongside change in global disease (DAS28), disability (HAQ) and foot-related impairment (FIS-RAIF) and disability (FIS-RAAP) using FIS-RA subscales.

Results
Thirty early RA patients with a mean ± SD age of 48.8 ± 12.2 years and median (IQR) disease duration of 7.5 (4, 18) months were studied. Over 12 months, patient treatment with disease-modifying and biological drugs increased. Small or stable median (IQR) changes in global disability, foot-related impairment and disability and ultrasound features including joint effusions (-2 (-7, 2)), synovitis (1 (-1, 3)), erosions (0 (-2, 2)), PD (1 (-1, 3) and tenosynovitis (0 (0, 1)) were observed despite a threefold increase in patients entering remission (Baseline: n=5; Exit: n=15). Significant differences (p<0.05) were observed between change in synovitis scores and DAS28 response where synovitis deteriorated in non-responders (3 (0, 5)) and improved with good response (-1 (-2, 1)).

Conclusions
A trend towards stable and persistent ultrasound features, foot impairment and disability despite an increasing proportion of patients entering remission supports earlier assessment and targeted foot care in early RA.
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NewsBot · Jun 12, 2013

PEDOBAGRAPHIC MEASUREMENTS OF RHEUMATOID FEET AND COMPARISON WITH CLINICAL PARAMETERS
Y. Yumusakhuylu, A. Icagasioglu, S. T. Turgut, E. Selimoglu, S. Murat, E. K. Gunal, B. Turgut
Annual European Congress of Rheumatology; Madrid 12-15 June 2013

Background: Foot involvement in rheumatoid arthritis (RA) have been reported to be 56-100% in different studies. Pedobarography is used for dynamic plantar pressure measurement and to point out deformities of rheumatoid feet.

Objectives: The aim of this study was to assess the use of pedobarographic measurements for the investigation of the relationship between plantar pressure alterations and disease activity, radiological changes and foot indexes in patients with RA.

Methods: Patients over 18 years of age with rheumatoid arthritis experiencing foot pain were included. Data on patients sociodemographics, foot symptoms, anatomical distribution, intensity and duration of pain and access to podiatry services were collected using questionnaires completed during outpatient visit. For the functional status the scores of disease activity scale of 28 joints (DAS 28) and Health Assessment Questionnaire (HAQ) was used. Foot function index (FFI) and Manchester Foot Pain and Disability Index (MFPDI) were also administered to all RA patients. Modified Larsen scoring was used to asess radiological changes. Pedobarographic measurements was used to analyze foot loading characteristics.

Results: A total of 104 feet of 52 RA patients (48 female, 4 male) with a mean age of 53,88±11,36 years was evaluated. DAS 28 scores did not correlate with the plantar pressure changes (p>0,05). We found a significant correlation between HAQ scores and right medial midfoot loading pressure (r=0,355; p<0,01). FFI scores were pozitively correlated with right lateral midfoot loading pressure (r=0,302; p<0,05). We did not found a relationship between MFPDI and plantar loading characteristics. The radiological scores were correlated with the left lateral hindfoot plantar pressure (r=0,286; p<0,05).

Conclusions: Pedobarographic investigation of rheumatoid feet may provide a concept for treatment planning and rehabilitative care.

References: 1. Tuna H, Birtane M, Taştekin N, Kokino S.Pedobarography and its relation to radiologic erosion scores in rheumatoid arthritis. Rheumatol Int. 2005 Nov;26(1):42-7.

2. Borman P, Ayhan F, Tuncay F, Sahin M. Foot problems in a group of patients with rheumatoid arthritis: an unmet need for foot care.Open Rheumatol J. 2012;6:290-5.
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NewsBot · Jun 12, 2013

APPLICATION OF PLANTOCONTUROGRAPHIC EXAMINATION TO THE ASSESSMENT OF FOOT STATICS DISTURBANCES IN PATIENTS WITH RHEUMATOID ARTHRITIS
S. Chwieśko-Minarowska, A. Kuryliszyn-Moskal, Z. Dzięcioł, K. Kaniewska
Annual European Congress of Rheumatology; Madrid 12-15 June 2013

Background: Rheumatoid arthritis (RA) is a chronic, inflammatory and multiple-system disorder of connective tissue leading to damage, deformation and functional impairment of joints.
It frequently affects joints and periarticular structures of feet that constitute a significant supporting element underlying normal gait and motion of the body centre of gravity.

Objectives: The aim of the study was to evaluate foot deformities on the basis of plantoconturographic examination in a group of patients with RA according to the severity of the disease.

Methods: The study was performed on 54 patients (43 women and 11 men). The control group consisted of 34 volunteers free of any disorders of the musculoskeletal system. Plantoconturographic examination was carried out by means of a CQST2K podoscope. The following parameters were applied to the assessment of the disturbances of foot statics: hallux valgus angle (α), Sztriter-Godunow index (KY), Wejsflog’s index (Wwp) and Clarke’s angle (CL).

Results: Markedly higher values of the alpha angle have been noted in RA patients in comparison with a control group. Moreover, values of the alpha angle were higher in patients in the third stage of radiological changes than those in the second one. On the other hand, values of the Clarke’s angle for the right foot were considerably higher in men in the second and third stage of RA compared to the control group.

Conclusions: Plantoconturographic examination can be consider as an to constitute a useful diagnostic tool for assessment and monitoring of foot deformities in RA patients. The most common deformities in RA patients include hallux valgus and transverse flat foot.

References: 1. Kuryliszyn-Moskal A, Kaniewska K, Konarzewski P, Dzięcioł Z. Współczesne metody diagnostyki i terapii zaburzeń wydolności statycznej stóp w przebiegu reumatoidalnego zapalenia stawów. Reumatologia 2012; 50, 6: 507-511

2. Hills AP, Hennig EM, McDonald M, Bar-Or O. Plantar pressure differences between obese and non-obese adults: a biomechanics analysis. Int J Obes Relat Metab Disord 2011; 25, 11: 1674-1679

3. Tuna H, Birate M, Tastekin N, et al. Pedobarography and its relation to radiologic erosion scores in rheumatoid arthritis. Rheumatol Int 2005; 26: 42
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NewsBot · Jun 12, 2013

RADIOGRAPHIC RELATIONSHIP BETWEEN HALLUX VALGUS DEFORMITY AND FORE-MID-HINDFOOT DEFORMITY IN RHEUMATOID ARTHRITIS: EVALUATION GROUPED BY THE EXISTENCE OF 2ND MTP JOINT DORSAL DISLOCATION
M. Hirao, H. Tsuboi, S. Akita, M. Matsu****a, S. Ohshima, Y. Saeki, J. Hashimoto
Annual European Congress of Rheumatology; Madrid 12-15 June 2013

Background: Several midfoot deformities are described to progress hallux valgus (HV) deformity [1]. Involvement of hindfoot deformity in the 1st ray deformity is also suggested [2]. In rheumatoid foot, complicated deformity in foot are often seen. Especially, dorsal dislocation of lesser toe MTP joint combined with HV is frequently observed in rheumatoid arthritis (RA) cases. Currently, clarified and comprehensive evaluations in RA foot deformity has not been done.

Objectives: In this study, relationship between radiographic findings through hind to forefoot and HV angle was evaluated in RA cases, while grouping by existence of 2nd MTP joint dorsal dislocation.

Methods: X-ray pictures at standing position in 160 RA feet and ankles were evaluated. 1st MTP Larsen grade, existence of 2nd MTP dorsal dislocation, HV・M1M2・M1M5 angle, shape of 1st mtetatarsal head [3] and position of sesamoid [4] which are index for pronation of 1st metatarsal, metatarsus primus varus (MPV) angle, M1M2 diastasis [5], angle between talus and navicular [6] (index for pronated foot), internal arch (IA) angle, Tibio-Calcaneal (TC) angle, distance between the axis of tibia and calcaneus (calcaneal lateral offset) were measured, and evaluated.

Results: M1M2 angle and HV angle correlated (R2=0.7) in the group without 2nd MTP joint dislocation (D0), while dislocation group (D2) showed relatively weak correlation (R2=0.3). The mean HV angle in D0 was 21±14.1°, while 45±16.8° in D2, that was significantly greater (P<0.001). Larsen grade and HV angle did not correlate in D0 cases, whereas correlated in D2 cases (R2=0.3). MPV angle correlated with M1M2 and HV angle (R2=0.5) in D0 group, but not in D2 group. M1M2 diastasis related to MPV angle in both group (R2=0.3). Pronated foot index correlated with IA angle (R2=0.3) in both group, furthermore enlargement of IA angle worsened the M1M2 angle expansion (R2=0.3) in D0 group. Calcaneal lateral offset had no direct relationship to HV, but correlated with M1M2 angle (R2=0.3), and pronated foot index (R2=0.5) in both group.

Conclusions: In RA cases, lateral offset hindfoot deformity is always involved in M1M2 angle expansion, followed by progression of HV. Correlation between M1M2 and HV angle was stronger in D0 cases than that of D2 cases. Especially, valgus hindfoot with flat foot deformity caused pronation of 1st metatarsal, leading to HV progression in D0 group, while 1st MTP destruction and 2nd MTP dislocation worsened HV in D2 group. The influence of hindfoot change also must be considered to evaluate the outcome after surgeries for HV. Furthermore, when 1st MTP joint preserved surgeries are selected for HV deformity in RA cases, adequate correction of 2nd MTP joint and making stable lateral support for hallux are strongly recommended to avoid the recurrence of HV.

References: [1] Tanaka Y, Takakura Y et al. J Bone Joint Surg [Am], 1995

[2] Bouysset M, Tebib J et al. J Rheumatol. 2002

[3] Okuda R, Kino****a M et al. J Bone Joint Surg [Am], 2007

[4] Hardy RH, Clapham JC. J Bone Joint Surg [Br], 1951

[5] Jaymes DG, Terrence MP. Physic Sportsmed. 2010

[6] Duncan JW, Lovell WW. Clin Orthop Relat Res. 1983
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