1. Podiatry and the treatment of Rheumatoid Arthritis
Sue McAusland
Podiatrist,
Blackpool Teaching Hospitals NHS Trust

2. Standards /Guidelines
NICE (2009) guidelines (CG79)
Podiatry Rheumatic Care Association (PRCA)
Arthritis and Musculoskeletal Alliance (ARMA) Standards of Care for people with musculoskeletal conditions
North West Clinical Effectiveness Guidelines for RA- objective to improve foot and ankle assessment an management

3. NICE Guidelines
Rheumatoid Arthritis is an inflammatory disease that largely affects synovial joints which are lined with a specialised tissue called synovium.
It typically affects the small joints of the hands and the feet, usually both sides (symmetrical), although any synovial joint can be affected.

4. Stats 400,000 in UK have RA. 12,000 a year in UK develop RA
2-4 times greater in woman than men
Peak age is 70, but can develop at any age
People who have synovitis of undetermined cause should have hands and feet x-rayed
The foot is affected in nearly all people with RA eventually
In the foot, joint pain and stiffness is the most common initial presentation, but other features eg tenosynovitis, nodule formation and tarsal tunnel syndrome may present, reflecting soft tissue involvement.

5. National Guidelines and Podiatry
All People with RA and foot problems should have access to a podiatrist for assessment and periodic review of their foot health needs (NICE Recommendation 14)
ARMA recommends people with RA should be seen by specialist within 12 weeks to confirm diagnosis and to give access to MDT access including foot health assessment- it does not have to be a podiatrist.
Functional insoles and therapeutic footwear should be available for all people with RA if indicated (NICE Recommendation 15)

6. Basically Doing the right thing To the right patient In the right way
At the right time

7. How can RA affect the feet?
Hallux valgus
Valgus heel deformity
Lesser toe deformities causing hard skin (callus) formation. For some this leads to foot ulceration particularly in those with poor tissue viability
Bacterial and fungal infections
Nail pathologies that increase risk of ulceration and systemic infection

8. What are we attempting to do?
Relieve pain
Maintain foot function
Improve quality of life
Using safe/cost effective treatments such as:
Palliative foot care
Prescribed orthoses
Specialist footwear

9. What do Podiatrists provide
Aiding early recognition of undiagnosed MSK disease as foot may be first site of involvement before any other manifestation of the disease
Education – self management advice including footwear advice. Considered the minimum standard for people with RA. Footwear flyers. British Footwear Assoc for hard to find footwear
General foot care, nail cutting, corn and callus, padding , offloading pressure areas.
Provision of orthoses
Monitoring of risk factors due to RA such as ulcerations, skin conditions
Treatment of ulcers
Referral for surgical opinion when joints become unmanageable

10. Callus on feet Should we remove it? Argument for and against.
Callus removed – does it help pain relief. Needs to be often to be of benefit
Callus removal may be necessary to expose an ulcer.
Argument against suggest that pressure relief is more effective management in the long-term with use of orthoses.

11. Fungal infections At increased risk with immuno-suppressed
Increased risk of ulcer underneath nail if left untreated
Treatment:
Take nail clippings/ positive result treat with oral meds/nail lacquer

12. Ingrowing toenails Mild condition
Conservative + antibiotics (where indicated)
Severe condition
Partial or total nail removal
Biologics – may complication treatment path /consult rheumatologist

13. Orthoses Early intervention for symptomatic pain Advanced problems
To help reduce pain and prevent further deformity
Advanced problems
May prevent tissue breakdown for poor tissue
Types of insoles:
Simple cushioning
Insoles with padding
Contoured padding (custom or off-shelf)

14. Footwear
Where do we start!
Ill fitting footwear

15. What makes a good shoe Stable/firm heel Extended heel counter
Padded topline
No prominent internal seams
Increase toe spring or rocker sole
Low laced for ease of access
Useful website:

16. Can’t find a suitable shoe on the high street?
Refer to surgical appliances
Stock or bespoke shoes
Beware there are cosmetic downsides
Consider surgery- as an alternative

17. Now- does your shoe fit? Optional !!
Measure your foot. See how your shoe fits .

18. I hope you found this useful.
Thank you for listening.
Any question?