Arthritis

Arthritis

Despite the fact that there are 26 bones in each foot and over 20 joints, the vast majority of foot pain stems from soft tissue inflammation and injury – caused mostly by overuse. Often, x-rays are not useful.  The most common foot pain that is x-rayed is heel pain. Even when an x-ray shows a “heel spur” it is a misleading diagnosis, since heel pain is almost always caused by soft tissue inflammation of the soft tissue structure known as the plantar fascia, where it inserts into the heel.  My favourite soft tissue disorders are listed below.

Metatarsalgia

Defined as pain in the ball of the foot. There are an infinite number of causes. Generally speaking, pain in the ball of the foot is caused by soft tissue inflammation. It usually affects the 2nd or 3rd ball of the foot joints (MPJ’s) or can be felt on the outside of the foot. People mistakenly think the pain is caused by a dropped metatarsal head. This is almost never true. Metatarsal heads cannot “drop” because they are all connected via ligaments and joint capsule – the 2nd, 3rd and 4th MPJ’s work together as a unit. Unless you have systemic arthritis, metatarsal heads do not and cannot “drop”. This is why the use of metatarsal pads (which are designed to “lift” a dropped metatarsal head) is generally unsuccessful and often counterproductive. Occasionally, pain in the metatarsal head area can be a stress fracture. This condition can be diagnosed easily because of the characteristic swelling and warmth it causes in a localized and specific area of the foot. An x-ray can confirm the diagnosis 10 days after the crack in the surface of the bone occurs. Back to the usual cause of metatarsalgia – soft tissue strain. The most common causes are over-exertion, poor footwear, high arched feet, high impact activities, excess pronation. The classic scenario involves someone who has just returned from a walking holiday in Europe where they wore thin-soled flimsy shoes for miles and miles of walking on cobblestone streets.Treatment usually includes rest, massage, improved footwear, some type of insole or orthotic and time.

Sesamoiditis

This condition is extremely painful and difficult to treat. Under the big toe joint, there are 2 small bones called sesamoids. They act for the foot in a similar way that the patella acts for the knee. They guide tendons to the big toe joint and are responsible for maintaining the stability of the joint. If they become inflamed they result in considerable pain with walking and standing. They burn, ache and make one’s life downright miserable. This condition is common in dancers. The treatment involves unweighting the sesamoids (using padding techniques to lift weight bearing pressure off the bones). Sometimes this can be done with simple padding and other times it has to be done in conjunction with a custom orthotic. 

Tendonitis

There are a number of tendons that can become inflamed – the 3 most common are the peroneal tendon (on the outside of the leg and foot), the posterior tibial tendon (on the inside of the leg and foot) and the Achilles tendon. All of these tendons are responsible for control of foot motion. They become inflamed when faulty biomechanics of the foot or lower extremity changes the function of these tendons. Generally speaking, people with overly pronated feet are more likely to have problems with the posterior tibial tendon or the Achilles’ tendon, while people with overly supinated feet tend to develop problems with the peroneal tendon. Peroneal tendonitis is also commonly associated with chronic foot pain. The tendons can be tender, warm, swollen or may simply ache and interfere with regular activities and walking. Achilles tendonitis is quite common, especially in runners and athletes. Eliminating or modifying one’s running activities is the most effective but least desirable treatment option. There may be underlying factors that predispose someone to developing Achilles tendonitis. These would include a tight Achilles tendon, excess pronation, improper footwear and improper training techniques. Many a sports medicine specialist sees Achilles tendonitis en masse. Physiotherapy is a good place to start. The podiatric approach focuses on proper pronation control and dealing with the faulty biomechanics.

Ligamentous Strains

Suffered by most of us on an ongoing basis because we simply are on our feet too much. The odd ache and pain in the foot is usually a ligamentous strain. It hurts intensely in a localized area – usually for less than a week. Often the problem is related to a specific incident – dancing barefoot for an evening, twisting the foot while walking on a railroad track, wearing heels higher than one is used to – there are many scenarios. Rest and ice and good shoes are the standard treatment suggestions.

Do You Have Arthritis?

The term “arthritis” is difficult to define clearly. If foot pain is not completely understood, and the pain seems to come from a joint it is often called arthritis, especially if there is associated swelling. What appears to be joint pain (and called arthritis) is often soft tissue inflammation around the joint or simply a joint strain. For a definitive diagnosis, positive x-ray findings and blood test evidence are usually required. Arthritis pain can be barely noticeable and not disabling, severe and disruptive to one’s life and activities, or somewhere in between. It can almost always be treated and often the symptoms eliminated. If the arthritis condition is more severe, the symptoms can be minimized. More severe cases may proceed to surgical treatment.

Most of the information in this section is directed towards people who already have a diagnosis of the more progressive arthritis conditions including rheumatoid arthritis, seronegative arthritis, and psoriatic arthritis. These are the 3 most common foot problems that (I see that) seem to plague people with arthritis. Everyone is absolutely unique in the variety and extent of problems and pain they experience. No generalizations can be made. There are typically 3 main areas of pain and they are discussed separately below.

Do You Have Arthritis?

The term “arthritis” is difficult to define clearly. If foot pain is not completely understood, and the pain seems to come from a joint it is often called arthritis, especially if there is associated swelling. What appears to be joint pain (and called arthritis) is often soft tissue inflammation around the joint or simply a joint strain. For a definitive diagnosis, positive x-ray findings and blood test evidence are usually required. Arthritis pain can be barely noticeable and not disabling, severe and disruptive to one’s life and activities, or somewhere in between. It can almost always be treated and often the symptoms eliminated. If the arthritis condition is more severe, the symptoms can be minimized. More severe cases may proceed to surgical treatment.

Most of the information in this section is directed towards people who already have a diagnosis of the more progressive arthritis conditions including rheumatoid arthritis, seronegative arthritis, and psoriatic arthritis. These are the 3 most common foot problems that (I see that) seem to plague people with arthritis. Everyone is absolutely unique in the variety and extent of problems and pain they experience. No generalizations can be made. There are typically 3 main areas of pain and they are discussed separately below.

Problem: Metatarsalgia (pain in the ball of the foot)

This is the most common arthritis complaint I see in my office. It may be mild and annoying or it can be quite debilitating. Imagine if every step you take you feel pain as you come up onto the ball of the foot. It’s not pleasant – and often it’s only possible to minimize, not to eliminate the pain. Pain in the ball of the foot – metatarsalgia – is multifactorial. Most people with arthritis have a combination of problems leading to the pain. The most common would be synovitis (joint inflammation). Synovitis is treated using anti-inflammatory and other medications. After synovitis has been present for some time, the joints that are affected tend to become looser. They can come out of position more easily. This results in dropped metatarsal heads, deformities of the toes and uneven weightbearing in the ball of the foot. Painful callouses usually develop. The callouses can be trimmed, but the pain usually is deeper in the joint. Any soft tissue structures in the ball of the foot can become inflamed including the joint capsule, ligaments, muscles, nerves and even blood vessels. When the ball of the foot hurts consistently and chronically, the gait pattern tends to change. There is less bending of the foot, which results in reduced use of the achilles tendon and its associated muscles. In turn, the achilles tendon can shorten and create other dysfunctional biomechanics in the foot and lower extremity. Also, people with progressive arthritis tend to develop bunions and HAV (hallux abductovalgus deformities). These deformities cause increased pain and further shifting of weight to the smaller metatarsal heads, which are not in a position to accept the extra weight.

Treatment is multi-faceted. The goal is to decrease weight bearing on the painful areas. This can be done using pads, orthotics, shoe modifications and callous trimming. Achilles tendon stretching is important and wearing good quality runners or walkers is almost always helpful. Custom orthotics are probably the best way to redistribute weight bearing and maintain as normal foot function as possible, despite the chronic pain.

Problem: Ankle or Subtalar Joint (below the ankle) Pain

People who have a diagnosis of arthritis may have severe pain and swelling in the ankle and subtalar joint (the top joint of the foot just below the ankle). There can also be associated tendonitis which can further diminish normal function of these joints. It is difficult to treat because these joints must go through a range of motion every step that is taken.

The most effective way to minimize inflammation is to stop walking completely, for a short time. This can be counter-productive to one’s general health. Symptoms can be treated using rocker bottoms on shoes and sometimes orthotics can be helpful. These joints may be fused eventually to eliminate pain. Once fused, the gait pattern is significantly hindered (but the pain is usually gone).

Problem: Heel Pain

The heel pain associated with arthritis can be very similar to a simple plantar fasciitis. The pain with arthritis is usually more severe and more difficult to treat. Also, there tends to be swelling and warmth in other joints of the foot. Tarsal tunnel syndrome is a condition that is more common in people with arthritis and can lead to heel pain, usually with associated numbness and tingling. This condition results from swelling in the ankle and subtalar joints and irritates the nerve going down the inside of the ankle. It can result in localized pain, irritated nerves in the heel and foot, numbness, and weakness in the foot.

Treatment of heel pain in someone with arthritis is similar to treating it in anyone. Custom orthotics are usually essential to relieve weight bearing pressure on the plantar fascia. Cortisone injections (by a professional) can be tried directly into the heel (yes, it hurts). Footwear must be supportive and well-cushioned. The use of a foot roller and localized massage or physiotherapy can also be useful.

Not sure if orthotics are right for you? Get in touch with Dr. Sue Turner at 604.736.1910or click below to book an appointment!