Hello there Rheumatology Fans;
Feet, what are they and what do they do? An eternal question asked about the leg-hands. In cases of Spondyloarthritis feet are commonly affected in various ways and understanding the nuance is necessary.
In This Article
Spondyloarthritis Overview
Ouchy Feet
What Are The Issues?
Management
Spondyloarthritis
Firstly lets just remind ourselves that Spondyloarthritis is an umbrella term which can be broadly split into predominantly axial symptoms and predominantly peripheral symptoms. In predominantly axial disese the most likely peripheral location to get symptoms is the heel – achilles/plantar fascia insertion and in predominantly peripheral disease the most common location to get enthesitis is the achilles/plantar fascia. Add to this that the MTPJs (metatarsophalangeal joints) are nearly as commonly affected as the MCPJs (metacarpophalangeal joints) with arthritis then the feet can’t be ignored.
Ouchy Feet
As mentioned above, in spondyloarthritis the feet are highly likely to be symptomatic over the course of both axial and peripheral disease - as high as 98% of patients. This will clearly have impacts on function like walking, exercising and so on. Most people are not compelled to go for a run or similar when the heels and/or toes hurt when they wake up in the morning.
Ankylosing Spondylitis/radiographic Axial Spondyloarthritis is famed for causing structural change to the axial skeleton, fusion of the SIJs and bamboo spine (named because it makes the vertebrae fuse and look like bamboo plant segments). The fear then is that this may happen elsewhere in the body affected by the inflammatory process. This study that was published recently attempted to look at this but was flawed in a number of ways and I don’t think it really adds anything to our knowledge base.
What Are The Issues
The main affect to the feet in both axial and peripheral presentations of Spondyloarthritis is to the heel where the insertion of the achilles tendon and platarfasia is. This is an extremely high load enthesis and as such is a very popular target for the auto-inflammatory pathophysiology of these diseases.
Peripheral arthritis is less common but occurs msot commonly in those with Psoriatic Arthritis. Any of the joints of the foot or ankle can be affected by synovitis and in my experience this is usually the ankle or mid-foot but the MTPJs are very often involved in these cases as well.
Another hallmark of Psoriatic Arthritis is Dactylitis (sausage digit) affecting the toes. An insidious swelling, redness and stiffness of one or more toes affects foot function and even footwear choice! I wrote a whole article on that subject HERE.
Management
Surely we know how to manage these feet then right! Well, actually no. The study above hints at managing foot posture as a good idea but I think we are way off that as an evidence-based solution. I spoke to Paul Kirwan at Therapy Live in 2022 about Rheumatological tendons and we don’t have any evidence to load them either. As far as the two of us are aware we haven’t seen any research into loading as a treatment approach.
Optimising medical treatment is a good option but sometimes it can seem like bringing the heavy artillery. It isn’t ideal to leave these people to it either.
I have found the following things useful in different amounts depending on the individual
offloading the heel using a wedge, cushion or insole. I try to use these purely for aggravating activities rather than as a blanket change. Be careful to explain what these are for – short term offloading, they are not really a solution.
loading the achilles/plantarfascia. I have had some success with isometrics, eccentrics, heavy and so on. Try to pay close attention to the way the tendon symptoms react, especially with regards to inflammatory patterns such as night pain, early morning pain/stiffness and worsening after rest. We do not want these to significantly increase
self applied cold/heat. In some people this can help to ease the symptoms a little faster, some trial and error needed
load management. discussing both underloading (extended periods of rest) and over loading activities and moderating these can help quite nicely. Not staying still for too long can often be overlooked. This comes in highly variable amounts with individuals.
graded exposure to increasing activity (or inactivity)
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