"It has been acknowledged that professionals specializing in rheumatology receive little training in foot problems in RA and, as a result, lack the appropriate knowledge and skills to assess and manage foot problems effectively."—Jill Firth, PhD.
"It has been acknowledged that professionals specializing in rheumatology receive little training in foot problems in RA and, as a result, lack the appropriate knowledge and skills to assess and manage foot problems effectively," conclude researchers led by Jill Firth, PhD, of the University of Leeds in the UK.Foot ulcers common in RA
The researchers surveyed by mail 1130 RA patients under the care of rheumatologists in Bradford, West Yorkshire, UK. The point prevalence of foot ulceration in these RA patients was 3.39% and the overall prevalence was 9.73%, the study showed. The false-positive rate was initially high at 21.21%, but use of a diagrammatic questionnaire data to exclude leg ulceration reduced this rate to 10.76%. The false-negative rate was 11.76%.
The most common sites for ulceration were the dorsal aspect of hammer toes, the metatarsal heads, and the metatarsophalangeal joint in patients with hallux abducto valgus. Moreover, 33% of RA patients reported multiple sites of ulceration. Almost 50% of RA patients reported recurrent ulceration, the study showed.
Patients with open- and healed-foot ulceration had significantly longer RA disease duration, reported significantly greater use of special footwear, and had a higher prevalence of foot surgery than ulcer-free patients.
Special considerations with RA foot ulcers
Unlike as in diabetes, foot ulceration in RA does not result in lower limb amputation. However, it "may cause increased pain, restricted choice of footwear, reduced mobility, and reduced participation in social activities, all of which may lead to a negative impact on quality of life," Dr. Firth and colleagues write.
Many of these RA patients are taking biologic drugs, which are known to increase risk of infection. In this environment, foot ulcers could potentially progress to life-threatening sepsis, the study authors point out.
Referral paradigm needed
There are not the same "clear care pathways" for the management of foot ulcers in RA as there are in diabetes. Most patients in the study had their wounds dressed by nurses, not podiatrists. Whether this is appropriate is unclear, but better referral patterns can help RA patients get the best care for foot ulcers.
"Podiatrists and orthotists need to be involved as appropriate in order to protect the tissue viability in the [patient’s] foot, which may include callus debridement, the provision of insoles, and appropriate footwear," they write.
The team is conducting a follow-up study looking at predictors of foot ulceration in RA, which will hopefully lead to a multicenter case-control study. "This research is the first step towards amassing an evidence base that will inform the development of referral guidelines and care pathways for the effective management and prevention of recurrence of ulceration in RA," the study authors write.
Understanding and treating the rheumatoid foot from a podiatrist's point of view
"Rheumatoid arthritis presents in the foot much like it does in the rest of the body—with either pain and/or deformity in the joints," explained Cary M. Golub, DPM, FACFAS, podiatrist in private practice in Long Beach, New York. "Deformities can range from a mild contracture of the toe to complex subluxation of a major joint of the foot or ankle."
"The subtle deformities, often not noticed by the patient, can cause friction in footwear and pressure from a displaced metatarsal, resulting in callous formation," he told MSKreport.com. "If identified early, the deformity of the rheumatoid foot may be addressed by either an orthotic or a modification of footwear to reduce the pressure or to disperse the weight in the deformed area."
Untreated, the callous may become a source for breakdown over time, which can lead to ulceration. "With the presentation of a rheumatoid foot, the patient’s vascular status must be assessed. It will determine the healing capabilities of a pretrophic area or an ulcer," Dr. Golub said.
Reference
1. Firth J, Hale C, Helliwell P, et al. The prevalence of foot ulceration in patients with rheumatoid Arthritis. Arthritis Care Res. 2008;59:200-205.
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