Monday, 18 Feb 2019

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Multidisciplinary Recommendations for Rheumatoid Foot Problems

Approximately 90% of patients with rheumatoid arthritis (RA) have foot problems. A multidisciplinary panel (including 2 patients, 22 professionals (rheumatologists, rehabilitation physicians, orthopaedic surgeons, specialized nurses, podiatrists, orthopaedic shoe technicians, pedicurists, researchers) in the Netherlands set out to develop recommendations for those who treat RA foot problems. 

Using rules to grade the literature and evidence, they established recommendations that required ≥70% of the expert consensus.  All tolled, 41 recommendations were developed. Two recommendations were for diagnosis and treatment. Thirty-nine recommendations on foot care, seven on diagnosis, 27 on treatment (including corticosteroid injections, foot surgery, therapeutic shoes, foot orthoses, exercise therapy, toe-orthoses and toenail-braces, treatment of toenails and skin), four on communication, and one on coordinated footcare.

These multidisciplinary recommendations for RA foot problems included the following recommendations: 

Recommendations on check-ups of feet and shoes

  • Rheumatologists and nurses specialised in rheumatology should perform regular feet check-ups. These check-ups should include, at least, patient history of foot disease, foot inspection, and palpation of foot joints for the detection of swelling and pain.
  • Over-the-counter shoes should have, at least, sufficient room in the toe box and a stiff sole allowing a heel-to-toe gait. The following additional shoe features may be important, depending on the foot conditions and wishes of the patient: i) light weight; ii) spacious, adjustable, and easy to close in-step/heel girth; iii) strong, raised, and padded heel part; iv) inflection point at the MTP joints; v) adequate length and width, measured in standing position; vi) no seams on the inside; vii) removable insoles so that custom-made foot orthoses can be placed in it.

Recommendations on diagnostic imaging

  • For the detection of joint damage in the feet, a non-weight-bearing X-ray in anterior-posterior (AP) direction is the preferred method.
  • When clinical examination is inconclusive in the diagnosis of inflammation of joints and soft tissue, ultrasonography should be considered. When ultrasonography is inconclusive, additional diagnostic imaging (MRI or CT scan) can be considered.

Recommendations on medical and surgical treatment

  • Corticosteroid injections can be applied in joints and soft tissue of the foot in the treatment of local arthritis and synovitis.Corticosteroid injections may also be applied in the treatment of tendinitis and pain.
  • A corticosteroid injection conducted by ultrasonography (if available) is preferred, because this may result in a more accurate determination of the location of the injection.
  • Early in the treatment process, consultation by an orthopaedic surgeon should be considered. Surgical intervention should be considered when the following foot conditions do not respond to conservative therapy: i) persistent pain and stiffness, ii) > 6 months of synovitis in foot and ankle joints, iii) tenosynovitis or tendon ruptures, iv) malalignment of the foot (e.g., hammer toes) causing mobility limitations and pain or problems finding adequate shoes, v) returning callosity/clavus, vi) wounds/(pre)ulcers, and vii) osteomyelitis/septic arthritis.
  • Resection arthroplasty of the MTP joints can be applied to improve joint mobility and to reduce pain, forefoot plantar pressure, and problems finding well-fitting shoes.* In severe malalignments of the toes or damage to the MTP joints, resection arthroplasty is preferred. Without severe malalignments/damage, a MTP joint-preserving surgical technique can be considered.
  • An arthrodesis of the MTP1 joint can be performed to reduce pain and improve the weight-bearing capacity of the forefoot.
  • When surgical treatment of the hindfoot is necessary, arthrodesis of the subtalar joint is preferred. For flat feet, an additional arthrodesis of the calcaneocuboid joint and talonavicular joint should be considered (triple arthrodesis).
  • In the treatment of severe pain and damage of the tibiotalar joint, an arthrodesis of the tibiotalar joint or an ankle prosthesis can be applied. An arthrodesis is preferred, provided that the Chopart-joint-line is intact and the status of other joints does not form a contraindication. An ankle prosthesis can be considered when preservation of mobility in the tibiotalar joint is important (according to the patient) and the preoperative status of the patient does not form a contra-indication.

Recommendations on conservative treatment

  • Technical adaptations to over-the-counter shoes can reduce pain and improve physical functioning. These adaptations can be prescribed in patients with abnormal foot function, foot joint damage/deformity, or malalignment of the feet, provided that the feet fit in over-the-counter shoes.
  • Ready-made therapeutic shoes with extra depth, support, incorporated inlays, and optional technical adaptation can reduce forefoot plantar pressure and foot pain and improve gait characteristics, physical functioning, and health-related quality of life. These ready-made shoes can be prescribed in patients with i) abnormal foot function, foot joint damage/deformity, or malalignment of the feet, and ii) feet that do not fit in over-the-counter shoes, but for whom custom-made shoes are not indicated.
  • Custom-made therapeutic shoes can reduce pain and improve physical functioning. These custom-made shoes can be prescribed in patients with i) abnormal foot function, foot joint damage/deformity, or malalignment of the feet, and ii) feet that do not fit in over-the-counter shoes or ready-made therapeutic shoes.
  • Custom-made therapeutic shoes should be worn all day, after a habituation period.
  • Foot orthoses are recommended in patients with abnormal foot function, when adequate over-the-counter shoes are insufficient in reducing foot symptoms.
  • Foot orthoses in adequate shoes can reduce forefoot plantar pressure and pain.
  • The function of foot orthoses should be assessed in relation to the patient’s footwear, due to the interaction between the two.
  • Rigid foot orthoses are recommended in feet with correctable malalignment, to control the position of the feet during weight-bearing.
  • Total contact foot orthoses are recommended in feet with uncorrectable malalignment or fragile skin. The material used for the production of total contact foot orthoses depends on the required characteristics of the foot orthoses.
  • General exercise therapy is recommended according to the Dutch KNGF Guideline for Physical Therapy in Patients with Rheumatoid Arthritis.
  • Exercise therapy specific to the foot and ankle can include i) strengthening exercises for the intrinsic foot muscles and M. tibialis posterior; ii) active stretch exercises for the plantar fascia, achilles-tendon, and peroneal muscles; and iii) active exercises to improve joint mobility.
  • A silicone toe orthosis can be used in the treatment of malalignment of toes and secondary pain or high pressure.
  • In the prescription of a silicone toe orthosis, the following factors should be considered: i) a sensibility disorder or peripheral artery disease; ii) a skin defect on the foot of interest; and iii) sufficient room in the shoe for wearing the toe orthosis.
  • A toenail brace can be used in the treatment of an ingrowing or ingrown toenail.
  • In the prescription of a toenail brace, the following factors should be considered: i) a sensibility disorder or peripheral artery disease; ii) a skin defect, inflammation, or onycholysis on the toe of interest; and iii) the use of biologicals.
  • When a fungal nail or mycosis of the skin is detected, treatment should be started to prevent ulcers and secondary bacterial infections.
  • Pressure and shearing forces should be normalised in feet with hyperkeratotic lesions. For normalisation of pressure and shearing forces, i) an individual shoe- and sock advice can be given; or ii) foot orthoses, silicone toe orthosis, technical adaptations to over-the-counter shoes, ready- or custom-made therapeutic shoes, or a provisional therapy (e.g., felt padding or taping) can be prescribed.
  • Excessive hyperkeratotic lesions should be treated. During the treatment the following factors should be considered: i) a sensibility disorder or peripheral artery disease, and ii) fragile skin, plantar bursa, and prominent metatarsal heads on the foot of interest.
  • When an (pre-)ulcer or infection is detected, the treating physician should be consulted.
  • In wound-care, a provisional therapy (e.g., felt padding) can be applied to reduce pressure. When material with an adhesive layer is used, fragile skin should be taken into consideration.

Recommendations on coordination of RA-related footcare

  • Regular consultation and shared decision-making between the patient and healthcare professional should be included in RA-related footcare and should be customised to the individual patient.
  • Footcare in patients with RA should include patient education.
  • Patient education on preventive care for RA-related foot problems should contain information about i) the cause and course of RA and RA-related foot disease; ii) recognition of infection and increased disease activity (systemic and local); iii) footcare and hygiene; iv) recognition and use of adequate footwear (for indoors and outdoors); v) timely consultation by a healthcare professional in the case of foot infection, symptoms of increased disease activity, pain, problems finding adequate footwear, and skin and nail conditions; and vi) the healthcare professional who may be consulted for a specific indication.
  • Patient education on curative care for RA-related foot problems should contain information about i) the treatment strategy (short and long term); ii) the importance of treatment adherence and compliance; iii) the expected treatment results according to pain, physical functioning, activities, and participation; iv) the possible adverse events; and v) costs and reimbursement of the treatment.
  • A multidisciplinary approach in management of RA-related foot problems is recommended. The diagnosis and treatment of RA-related foot disease consists of different aspects, which require the expertise of several disciplines.
Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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