What is Arthritis?
Arthritis, in general terms, is inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints. Arthritis has multiple causes; just as a sore throat may have its origin in a variety of diseases, so joint inflammation and arthritis are associated with many different illnesses.
Arthritis and the Feet
Arthritis is a frequent component of complex diseases that may involve more than 100 identifiable disorders. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints that can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet.
Arthritis is a disabling and occasionally crippling disease; it afflicts almost 40 million Americans. In some forms, it appears to have hereditary tendencies. While the prevalence of arthritis increases with age, all people from infancy to middle age are potential victims. People over 50 are the primary targets.
Arthritic feet can result in loss of mobility and independence, but that may be avoided with early diagnosis and proper medical care.
Some Causes
Besides heredity, arthritic symptoms may arise in a number of ways:
- Through injuries, notably in athletes and industrial workers, especially if the injuries have been ignored (which injuries of the feet tend to be).
- Through bacterial and viral infections that strike the joints. The same organisms that are present in pneumonia, gonorrhea, staph infections, and Lyme disease cause the inflammations.
- In conjunction with bowel disorders such as colitis and ileitis, frequently resulting in arthritic conditions in the joints of the ankles and toes. Such inflammatory bowel diseases seem distant from arthritis, but treating them can relieve arthritic pain.
- Using drugs, both prescription drugs and illegal street drugs, can induce arthritis.
- As part of a congenital autoimmune disease syndrome of undetermined origin. Recent research has suggested, for instance, that a defective gene may play a role in osteoarthritis.
Symptoms
Because arthritis can affect the structure and function of the feet it is important to see a doctor of podiatric medicine if any of the following symptoms occur in the feet:
- Swelling in one or more joints
- Recurring pain or tenderness in any joint
- Redness or heat in a joint
- Limitation in motion of joint
- Early morning stiffness
- Skin changes, including rashes and growths
Some Forms of Arthritis
Osteoarthritis is the most common form of arthritis. It is frequently called degenerative joint disease or "wear and tear" arthritis. Although it can be brought on suddenly by an injury, its onset is generally gradual; aging brings on a breakdown in cartilage, and pain gets progressively more severe, although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration. Walking may become erratic.
It is a particular problem for the feet when people are overweight, simply because there are so many joints in each foot. The additional weight contributes to the deterioration of cartilage and the development of bone spurs.
Rheumatoid arthritis (RA) is a major crippling disorder, and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory system of diseases, often affecting more than a dozen smaller joints during the course of the disease, frequently in a symmetrical pattern -- both ankles, or the index fingers of both hands, for example. It is often accompanied by signs and symptoms -- lengthy morning stiffness, fatigue, and weight loss -- and it may affect various systems of the body, such as the eyes, lungs, heart, and nervous system. Women are three or four times more likely than men to suffer RA.
RA has a much more acute onset than osteoarthritis. It is characterized by alternating periods of remission, during which symptoms disappear, and exacerbation, marked by the return of inflammation, stiffness, and pain. Serious joint deformity and loss of motion frequently result from acute rheumatoid arthritis. However, the disease system has been known to be active for months, or years, then abate, sometimes permanently.
Gout (gouty arthritis) is a condition caused by a buildup of the salts of uric acid -- a normal byproduct of the diet -- in the joints. A single big toe joint is commonly the affected area, possibly because it is subject to so much pressure in walking; attacks of gouty arthritis are extremely painful, perhaps more so than any other form of arthritis. Men are much more likely to be afflicted than women, an indication that heredity may play a role in the disease. While a rich diet that contains lots of red meat, rich sauces, shellfish, and brandy is popularly associated with gout, there are other protein compounds in foods such as lentils and beans that may play a role.
Diagnosis
Different forms of arthritis affect the body in different ways; many have distinct systemic affects that are not common to other forms. Early diagnosis is important to effective treatment of any form. Destruction of cartilage is not reversible, and if the inflammation of arthritic disease isn't treated, both cartilage and bone can be damaged, which makes the joints increasingly difficult to move. Most forms of arthritis cannot be cured, but can be controlled or brought into remission; perhaps only five percent of the most serious cases, usually of rheumatoid arthritis, result in such severe crippling that walking aids or wheelchairs are required.
Treatment
The objectives in the treatment of arthritis are controlling inflammation, preserving joint function (or restoring it if it has been lost), and curing the disease if that is possible.
Because the foot is such a frequent target, the doctor of podiatric medicine is often the first physician to encounter some of the complaints -- inflammation, pain, stiffness, excessive warmth, injuries. Even bunions can be manifestations of arthritis.
Arthritis may be treated in many ways. Patient education is important. Physical therapy and exercise may be indicated, accompanied by medication. In such a complex disease system, it is no wonder that a wide variety of drugs have been used effectively to treat it; likewise, a given treatment may be very effective in one patient and almost no help at all to another. Aspirin is still the first-line drug of choice for most forms of arthritis, and the benchmark against which other therapies are measured.
The control of foot functions with shoe inserts called orthoses, or with braces or specially prescribed shoes, may be recommended. Surgical intervention is a last resort in arthritis, as it is with most disease conditions; the replacement of damaged joints with artificial joints is a possible surgical procedure.
Surgery When Joint Problems are Severe
Surgery to reconstruct the joint may be needed if arthritis causes chronic problems that cannot be controlled by medications, orthotics or physical therapy, especially if:
- pain is constant
- toe motion is limited, causing a change in natural stance or walk
- deformities (such as bunions and hammertoes) restrict normal activities
In the vast majority of cases, reconstructive surgery can bring improvement. Pain relief is a common benefit. Other benefits may include an improved ability to move the joint, or an improved appearance. Goals of surgery are different for each individual, and should be discussed with the podiatric surgeon.
While surgical care will not cure arthritis or completely restore the joint to its natural health, it will ease pain and make daily activities more manageable.
Surgical Treatments
If bone on both sides of the joint is damaged, the podiatric surgeon may remove a small portion of cartilage and bone, then reconstruct the synovium, ligaments and tendons. This is called a resection.
Fusion or arthrodesis relieves pain by uniting the bones of the joint into a permanent, yet useful position, preventing any motion at the site.
The joint may require a complete reconstruction or resection arthroplasty. Here, the podiatric surgeon removes the bone ends at the joint, corrects tendons and ligaments that may have stretched as a result of arthritis, and replaces the joint with an implant (prosthetic joint).
Two of these surgeries, fusion and implant reconstruction, are described in greater detail in "About Your Foot Surgery."
Implants and Foot Surgery
The choice to use an implant is made carefully, only after the podiatric surgeon has decided that another type of surgery would not provide as many benefits.
Implants made from silicone rubber, polyethylene (a form of plastic), or titanium (see "implant Types and Materials") are quite safe. Like other artificial body parts, implants used in the foot have been evaluated by the Food and Drug Administration (FDA).
Implants for Pain Relief and Support
The narrow space separating the two bones of the joint permits movement. An implant's primary purpose is to maintain this joint space and support the toe. Because the implant replaces damaged or diseased bone and the bone's cartilage, it keeps the toe at an appropriate length. Without an implant, the toe may appear shorter.
The implant helps eliminate pain, and provides stability to the previously weakened joint. A secondary purpose of an implant is to permit the toe to bend and function more freely.
As the joint heals, new tissue forms around the implant, making the joint stable and the reconstruction more durable.
About Your Foot Surgery
Surgery usually requires only one to two hours. It is often completed on an outpatient basis, but a short hospital stay of one or two days is not unusual.
Implant Reconstruction
The podiatric surgeon will expose the damaged joint and carefully remove any inflamed tissue. A small portion of damaged bone also will be removed, and the bone ends smoothed.
The next step is enlargement of the natural canals within the bones. The sterilized implant (double-or single-stem) is then inserted and is supported by the bones. Finally, the tendons, ligaments and joint capsule are reconstructed around the implant.
Antibiotics may be administered both before and after surgery.
Fusion
A small portion of the bone ends at the joint are removed. The bones are then compressed together, so that the two bones unite. In some cases, a bone graft may be necessary.
The fused joint will be held in position with a stainless steel or dissolvable pin, or small bone screws and plates, to allow for healing.
Care After Surgery
Immediately after surgery, the entire foot will be carefully wrapped in a bulky dressing or cast as protection for the first few days. Keeping the foot elevated during this time will help minimize swelling.
Some swelling and stiffness can be expected following surgery, for as long as eight to twelve weeks. Crutches may be needed for walking or standing as the foot heals.
Special Shoes and Splints
After surgery, the foot will be placed in a special shoe that relieves pressure from the ball of the foot and keeps the toe aligned as it heals.
A splint may be worn for the first few weeks after surgery, and possibly for an additional three to six weeks.
Although each person is different, it is likely that most activities can be resumed within three months after surgery. The podiatric surgeon will provide specific instructions as healing progresses.
Activity Restrictions
The podiatric surgeon may restrict any activity for at least 24 hours. Depending on which joint was fused, a cast and crutches may be necessary for as long as six weeks.
Implant Types and Materials
Most implants used in the foot are made from silicone rubber, a synthetic compound that is both flexible and strong.
When a less flexible implant is needed, podiatric surgeons choose implants made from metals such as titanium, a durable, lightweight material. Some implants combine a metal with a plastic such as polyethylene. All implant designs and materials are carefully evaluated and tested by the FDA.
Double-stemmed implants replace damaged bone at the base joint of any of the toes. They are widely used when cartilage is lost, the toe is painful, and to treat deformities such as bunions or bone spurs. Stems on either side of the midsection support the implant within the bones.
Hammertoe implants, used to correct painful hammertoe deformities, also have two stems that fit into either the base or middle joints of the toe.
Implants with a single stem, made from either silicone rubber or titanium, may be used in the base joint of the big toe to treat a bunion, bone spur or toe stiffness and pain. This implant is most effective when only one side of the joint is damaged.
Two-piece ankle implants made of metal and plastic are used in less active individuals with severe arthritis, most often rheumatoid disease. The implant replaces the natural bones of the joint, permitting the ankle to retain a limited amount of movement.
Answers to Questions About Implant Reconstructions
How Long Will the Implant Last? Although every individual is different, most implant recipients can expect the benefits of surgery to last for at least 10 to 20 years. Several thousand people have had these implants for more than 15 years, and remain pain-free and without complications.
Implants are designed specifically for durability and the ability to withstand the pressures of joint movement. No implant, however, is indestructible. With use, especially in young or active people, it is possible that the implant will wear down. Another surgery may become necessary. Your podiatric surgeon can advise you about other patients' experiences with implant durability.
While these are some of the most common treatments for arthritic disorders, others may be used. Your podiatric surgeon will determine which treatment is likely to be most successful in each case.
Arthritis Tips
- Wear comfortable shoes that conform to the shape of your foot.
- Wear shoes with a wide and deep toe box.
- Always fit the larger foot and have your feet sized each time you purchase shoes.
- Avoid high-heeled shoes over two inches tall.
- Seek professional podiatric evaluation and assistance if your feet are uncomfortable or painful.
The information above is provided by the American Podiatric Medical Association.