The foot is major cause of walking disability in those with rheumatoid arthritis

NewsBot · May 20, 2008

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The foot: still the most important reason for walking incapacity in rheumatoid arthritis: Distribution of symptomatic joints in 1,000 RA patients.
Grondal L, Tengstrand B, Nordmark B, Wretenberg P, Stark A.
Acta Orthop. 2008 Apr;79(2):257-61

Background and purpose Our knowledge of frequency of foot involvement in rheumatoid arthritis (RA) is still often based on a study from Finland in 1956. Great changes in the treatment of RA may have led to a different situation. We investigated the distribution of joint involvement in RA patients today, with special attention given to the feet and subjective walking ability.

Methods 1,000 RA patients answered a questionnaire concerning joints affected, joint surgery, foot problems, and subjectively experienced reasons for walking incapacity.

Results In 45% of the patients, the forefoot was involved at the start of the disease. In 17%, the hindfoot/ankle was involved at the start. Only hand symptoms were commoner. 80% of patients reported current foot problems, 86% in the forefoot and 52% in the hindfoot/ankle. Difficulty in walking due to the feet was reported by 71%. For 41% of patients, the foot was the most important part of the lower extremity causing reduced walking capacity, and for 32% it was the only part.

Interpretation After the hand, the foot was the most frequently symptomatic joint complex at the start of the disease, but also during active medical treatment. The foot caused walking disability in three-quarters of the cases and-4 times as often as the knee or the hip-it was the only joint to subjectively impair gait.
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Admin2 · May 20, 2008

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NewsBot · Oct 15, 2013

Quantifying gait deviations in individuals with rheumatoid arthritis using the Gait Deviation Index
A-C Esbjörnsson, A Rozumalski, MD Iversen, MH Schwartz, P Wretenberg, EW Broström
Scandinavian Journal of Rheumatology

Objectives: In this study we evaluated the usability of the Gait Deviation Index (GDI), an index that summarizes the amount of deviation in movement from a standard norm, in adults with rheumatoid arthritis (RA). The aims of the study were to evaluate the ability of the GDI to identify gait deviations, assess inter-trial repeatability, and examine the relationship between the GDI and walking speed, physical disability, and pain.

Method: Sixty-three adults with RA and 59 adults with typical gait patterns were included in this retrospective case–control study. Following a three-dimensional gait analysis (3DGA), representative gait cycles were selected and GDI scores calculated. To evaluate the effect of walking speed, GDI scores were calculated using both a free-speed and a speed-matched reference set. Physical disability was assessed using the Health Assessment Questionnaire (HAQ) and subjects rated their pain during walking.

Results: Adults with RA had significantly increased gait deviations compared to healthy individuals, as shown by lower GDI scores [87.9 (SD = 8.7) vs. 99.4 (SD = 8.3), p < 0.001]. This difference was also seen when adjusting for walking speed [91.7 (SD = 9.0) vs. 99.9 (SD = 8.6), p < 0.001]. It was estimated that a change of ≥ 5 GDI units was required to account for natural variation in gait. There was no evident relationship between GDI and low/high RA-related physical disability and pain.

Conclusions: The GDI seems to useful for identifying and summarizing gait deviations in individuals with RA. Thus, we consider that the GDI provides an overall measure of gait deviation that may reflect lower extremity pathology and may help clinicians to understand the impact of RA on gait dynamics.
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NewsBot · Nov 14, 2014

Foot and Ankle Characteristics Associated with Falls in Adults with Rheumatoid Arthritis.
Angela Brenton-Rule, Nicola Dalbeth, Priya Parmer, Sandra Bassett, Hylton B. Menz and Keith Rome.
American College of Rheumatology Conference; Boston 14-19 November 2014

Background/Purpose: People with rheumatoid arthritis (RA) have an increasedriskoffalls.Theconsequencesoffallscanbedevastatingincluding lossofconﬁdenceandindependence,injuryanddeath.Thefootisacommon site of pathology in RA and foot problems are reported in up to 90% of patients with established disease. Previous studies in non-RA populations haveidentiﬁedthatfootandankleproblemsareassociatedwithfallsandfalls risk in older adults. The aim of this study was to determine whether foot and ankle characteristics are associated with falls in people with RA.
Methods: Adults with RA according to the 2010 ACR/EULAR classiﬁ- cation criteria were recruited from rheumatology outpatient clinics in Auck- land, New Zealand. All participants reported whether they had fallen in the preceding year, and the number of falls. The Prevention of Falls Network Europe (ProFanE) deﬁnition of, “an event that results in a person coming to rest unintentionally on the ground or other lower level”, was used to identify falls. RA characteristics, common fall risk factors, and foot and ankle variables were measured. Foot and ankle testing included foot deformity, plantar sensation, muscle strength, ankle range of motion, gait speed, peak plantar pressures, postural stability, foot pain and self-reported foot impair- ment. Univariate parametric and non-parametric analysis compared fallers and non-fallers on all variables to determine signiﬁcant differences. Logistic regression analysis identiﬁed variables independently associated with falls.
Results: Two hundred and one participants were prospectively recruited. At least one fall in the preceding 12 months was reported by 119 (59%) participants.Signiﬁcantfactorsassociatedwithfallsintheunivariateanalysis are presented in Table 1. Fallers had signiﬁcantly longer mean disease duration,moreco-morbidconditions,slowergaitspeed,highermid-footpeak plantar pressures and were more likely to have a history of stroke than non-fallers. Fallers also reported greater difﬁculty with the activities of daily living, increased fear of falling and greater self-reported foot impairment. In logistic regression analysis, including age, sex and all variables at a level of p0.15 in the univariate analysis, increased mid-foot peak plantar pressures (odds ratio 1.12 [for each 20kPa increase], p0.037) and self-reported foot impairment (odds ratio 1.16 [for each 3 point increase], p0.007) were independently associated with a fall in the preceding 12 months.
Conclusion: Elevated mid-foot peak plantar pressures and self-reported foot impairment are associated with falls in people with RA. Assessment of foot deformity, foot function and self-reported foot impairment may be of beneﬁt when considering falls prevention in people with RA.
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NewsBot · Apr 23, 2016

Is ankle involvement underestimated in rheumatoid arthritis? Results of a multicenter ultrasound study
Marwin Gutierrez , Carlos Pineda, Fausto Salaffi, Bernd Raffeiner, Tomas Cazenave, Gabriela A. Martinez-Nava, Chiara Bertolazzi, Florentin Vreju, Nevsun Inanc and 4 more
Clinical Rheumatology; 19 April 2016

The aim of this study is to investigate the prevalence of subclinical ankle involvement by ultrasound in patients with rheumatoid arthritis (RA). The study was conducted on 216 patients with RA and 200 healthy sex- and age-matched controls. Patients with no history or clinical evidence of ankle involvement underwent US examination. For each ankle, tibio-talar (TT) joint, tibialis anterior (TA) tendon, extensor halux (EH) and extensor common (EC) tendons, tibialis posterior (TP) tendon, flexor common (FC) tendon and flexor hallux (FH) tendon, peroneous brevis (PB) and longus (PL) tendons, Achilles tendon (AT) and plantar fascia (PF) were assessed. The following abnormalities were recorded: synovitis, tenosynovitis, bursitis, enthesopathy and rupture. BMI, DAS28, RF ESR and CRP were also obtained. A total of 432 ankles of patients with RA and 400 ankles of healthy controls were assessed. In 188 (87%) patients with RA, US showed ankle abnormalities whereas, in control group, US found abnormalities in 57 (28.5 %) subjects (p = 0.01). The most frequent US abnormality in RA patients was TP tenosynovits (69/216) (31.9 %), followed by PL tenosynovitis (58/216) (26.9 %), TT synovitis (54/216) (25 %), PB tenosynovitis (51/216) (23.6 %), AT enthesopathy (41/216) (19 %) and AT bursitis (22/216) (10.2 %). In 118 RA patients out of 216 (54.6%), a positive PD was found. No statistically significant correlation was found between the US findings and age, disease duration, BMI, DAS28, RF, ESR and CRP. The present study provides evidence of the higher prevalence of subclinical ankle involvement in RA patients than in age- and gender-matched healthy controls identified by US.
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NewsBot · Aug 25, 2017

Impact of midfoot and Hindfoot involvement on functional disability in Korean patients with rheumatoid arthritis.
Jeong HJ et al
BMC Musculoskelet Disord. 2017 Aug 24;18(1):365. doi: 10.1186/s12891-017-1726-7.

BACKGROUND:
Foot involvement in rheumatoid arthritis (RA) patients has been reported to severely affect functional capacity and quality of life. We aimed to determine the impact of midfoot and hindfoot involvement on functional disability in Korean patients with RA.
METHODS:
We evaluated the RA involvement and deformity of three regions of the foot (forefoot, midfoot and hindfoot) and ankle using conventional radiography in Korean patients with RA. We compared the clinical features between RA patients with and without foot or ankle involvement. Using multivariable logistic regression analyses, the impact of midfoot or hindfoot involvement on functional disability in RA patients was evaluated.
RESULTS:
Overall, 120 patients with a median age of 48.0 [interquartile range (IQR), 37-56] years and median disease duration of 58.0 (IQR, 10-89) months were included. The prevalence of foot or ankle RA involvement was 74 (61.7%). The number of patients with forefoot, midfoot, hindfoot and ankle involvement was 32 (43.2%), 24 (32.4%), 46 (62.2%) and 4 (5.4%), respectively. Compared to patients without foot or ankle involvement those with such involvement had greater disease activity and functional disability, more of them were treated with biologic agents, and they had a lower health-related quality of life. After adjusting for potential confounders, hindfoot involvement was associated with a higher degree of functional disability. However, walking difficulty was more associated with midfoot involvement rather than with involvement in other regions.
CONCLUSIONS:
In Korean patients with RA, hindfoot involvement is associated with functional disability and midfoot involvement affects walking.
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NewsBot · Sep 11, 2017

Gastrocnemius Contracture in Patients With Rheumatoid Arthritis
James R. Jastifer MD, Adam Green, BS
Foot & Ankle International September 9, 2017

Background:
Rheumatoid arthritis is a chronic disease affecting multiple joints of the body. More than 90% of patients affected by rheumatoid arthritis develop foot or ankle pain over the course of their disease. The purpose of the current study was to report ankle dorsiflexion in rheumatoid arthritis patients as well as a control group utilizing a validated measurement instrument.

Methods:
Using a previously validated device, 70 patients presenting with rheumatoid arthritis and 70 controls were measured for ankle range motion and isolated gastrocnemius contractures. Clinical and goniometer measurement of ankle range of motion was also performed.

Results:
The rheumatoid arthritis group had a mean dorsiflexion of 12.3 degrees compared to a mean of 17.3 degrees in the control group (P < .05). The difference in dorsiflexion was significantly less utilizing a goniometer than using the validated device, which may be due to measurement technique and external landmarks (P < .05).

Conclusion:
Patients with rheumatoid arthritis had less ankle dorsiflexion than the control group. The clinical significance of this study is that it provides evidence that patients with rheumatoid arthritis have decreased ankle dorsiflexion even despite a lack of foot and ankle pain. In light of the high lifetime incidence of foot and ankle pain in these patients, this study provides some evidence that the decreased ankle dorsiflexion may be a contributing factor in foot and ankle pain, but further studies are needed.
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NewsBot · Oct 27, 2017

Prevalence, impact and care of foot problems in people with rheumatoid arthritis: results from a United Kingdom based cross-sectional survey
Oonagh WilsonEmail author, Sarah Hewlett, James Woodburn, Jon Pollock and John Kirwan
Journal of Foot and Ankle Research 2017 10:46

Background
Foot symptoms in rheumatoid arthritis (RA) derive from a combination of inflammation, altered foot mechanics, deformity and secondary skin lesions. Guidelines recommend regular review of patients’ feet, but the extent to which the general population of RA patients report foot symptoms and access foot care has not been established. The aims of this study were to determine the prevalence, impact and care of foot problems in all patients with RA in one geographical area and identify factors associated with accessing foot care.

Methods
Cross-sectional survey of a random sample of patients with RA, who resided within a single community-based National Health Service (NHS) podiatry service. The questionnaire collected demographic data (age, gender, local deprivation score), clinical data (disease duration, arthritis medications, disability (Health Assessment Questionnaire (HAQ)), current foot problems, foot care accessed (podiatry, orthotics and/or orthopaedics) and care received, measures of impact (Foot Impact Scale) and ability to work.

Results
Of 1003 total eligible patients in the target population, 739 were posted survey packs. Of these 413 (56%) replied. Responders and non-responders had similar age (63.5 yr. vs.61.5 yr), gender (74.1%F vs. 75.2%F), and highest deprivation category (13.3% vs.15.9%). Of the responders 92.1% reported current foot problems: articular 73.8%, cutaneous lesions 65.4%, structural 57.6%, extra-articular 42.6%. Responders’ median (IQR) disease duration 10 (5–20) years, HAQ 1.5 (0.75–2.0), FISIF 10 (6–14) and FISAP 16 (7–23) and 37.8% reported impacts on work. While 69.5% had accessed foot care there were differences in the route of access (by gender and whether independent or NHS provision) and were older (64.9 yr. vs 60.4 yr. p = 0.001), had longer disease duration (12 yr. vs 7 yr. p < 0.001) and had a greater proportion of females (72.2% vs 61.7% p = 0.04) than those who had not accessed care.

Conclusions
Current foot problems were reported by 92.1% of the study sample and substantially impacted on life and work. While overall access to foot care was higher than anticipated, routes of access differed and extent of current problems suggests the provision of effective, timely and targeted care is a pressing need.
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NewsBot · Sep 15, 2019

Prevalence of feet and ankle arthritis and their impact on clinical indices in patients with rheumatoid arthritis: a cross-sectional study.
Lee SW et al
BMCMusculoskeletDisord. 2019 Sep 11;20(1):420.

BACKGROUND:
We aimed to evaluate the prevalence of foot and/or ankle arthritis (FAA) and its impact on clinical indices in patients with rheumatoid arthritis (RA).

METHODS:
This cross-sectional study used data from the Korean College of Rheumatology Biologics & Targeted therapy registry to observe clinical outcomes of patients undergoing biologics therapy and conventional therapy. FAA was defined as ≥1 tender or swollen joint in the ankle and/or 1st-5th metatarsophalangeal (MTP) joints. Disease Activity Score 28 (DAS28), Routine Assessment of Patient Index Data 3 (RAPID3), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) were assessed.

RESULTS:
Among 2046 patients, 598 had FAA. The ankle joint was the most commonly involved joint in FAA (tender joint, 71.4%; swollen joint, 59.5%), followed by the third and second MTP joints. Patients with FAA showed higher DAS28, RAPID3, SDAI, and CDAI scores. FAA presence was significantly associated with non-remission as per DAS28-ESR (odds ratio, 3.4; 95% confidence interval, 2.0-5.8), DAS28-CRP (3.6, 2.4-5.3), SDAI (6.3, 2.8-14.6), CDAI (7.6, 2.4-24.3), and RAPID3 (5.6, 2.7-11.5) indices on adjusting for age, sex, disease duration, presence of rheumatoid factor, presence of anti-cyclic citrullinated peptide antibody, lung disease, use of methotrexate, and previous use of biological disease-modifying anti-rheumatic drugs. Patients with FAA were less likely to achieve remission of SDAI (n = 6, 1.0%) and CDAI (n = 3, 0.5%) than that of DAS28-ESR (n = 21, 3.5%), DAS28-CRP (n = 38, 6.4%), and RAPID3 (n = 12, 2.0%).

CONCLUSIONS:
FAA represents a severe disease activity and is an independent risk factor for non-remission in patients with RA.
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NewsBot · Jun 28, 2020

Do ankle, hindfoot, and heel ultrasound findings predict
the symptomatology and quality of life in rheumatoid
arthritis patients?
Oana Șerban et al
J Ultrason 2020; 20: e70–e82. doi: 10.15557/JoU.2020.0012

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the
findings with healthy subjects, and to analyze if these findings are associated with ankle pain
and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and
35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the
evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for
the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of
feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less
subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The
body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid
arthritis patients compared to healthy controls, but when subtalar synovitis was present, the
pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot
valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes,
calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of
life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology
(inflammatory modifications, but also degenerative findings and deformities). Ultrasound
scanning is an important tool in the evaluation of inflammatory and degenerative lesions in
these regions, and their early detection might contribute to a better therapeutic management
in these patients.
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NewsBot · Jan 6, 2024

Foot static disturbances and clinical features in overweight patients with rheumatoid arthritis
Anna Kuryliszyn-Moskal et al
Arch Med Sci. 2020 May 28;19(6):1774-1780

Introduction: Rheumatoid arthritis (RA) is a chronic, inflammatory, connective tissue disease, leading to foot deformities, impairment of locomotive functions, and reducing patients' quality of life. Obesity prevalence is rising in early RA and is associated with worse disease activity, function and health-related quality of life, with a significant negative impact on achieving a low Disease Activity Score in 28 joints (DAS28). The aim of the study was to evaluate foot deformities in overweight RA patients according to the severity of the disease.

Material and methods: The study was performed on 50 overweight women with RA. The control group consisted of 50 overweight women free of any disorders. Plantography examination was carried out by means of a CQ ST 2K podoscope. Rheumatoid arthritis disease activity was assessed by DAS28. Activity limitation was assessed using the Health Assessment Questionnaire (HAQ) and foot posture by the Foot Posture Index (FPI-6). Body composition analysis was performed using In Body 220.

Results: Hallux valgus was the most frequent deformation in RA patients with overweight. Longitudinal flat foot was much more frequent in RA patients than transverse flat foot. A relationship between fat tissue mass and presence of transverse flat foot in RA patients with overweight was found. In this group DAS28, VAS, and Clarke's angle were correlated with increased value of HAQ.

Conclusions: Plantar contourography showed a trend of an increase of α angle values and the Sztriter-Godunow index (KY) in overweight RA patients with increasing severity of radiological changes and DAS28, requiring use of proper prevention and therapeutic strategies of destructive changes.
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