Rheumatoid Arthritis (RA) of the Foot and Ankle

Causes

Causes are unknown. There may be a genetic reason, but some experts believe it could be an environmental “trigger” (such as a bacterial or a virus infection) to activate the pathology in patients who inherit RA.

Symptoms

Stiffness, swelling, severe pain and discomfort are the most common symptoms. They tend to come and go in cycles called “flares” and may last from a few days to several weeks, being worse in the morning and after inactivity. Often patients with RA experience other symptoms in their feet and ankles such as nodules in the Achilles tendon or lax tendons and ligaments in the middle foot that may cause collapsing of the arch. In addition to mobility issues, particularly with ramps and stairs, deformities may progress leading to difficulty wearing shoes. ^{1, 2}

RA involving the ankle causes inflammation around the joint, due to the friction between the ankle from the degenerated cartilage. The surrounding tissues that support the ankle may also be damaged, becoming weak and unable to firmly support the joint. The ankle joint structure may also be seriously affected over time, leading to permanent changes in the joint shape.

Besides inflammation symptoms, other signs may be fatigue, low-grade fever and weight loss.

Diagnosis

A doctor will diagnose RA of the ankle with a physical or clinical examination and imaging. The doctor will investigate the medical history of the patient, check the ankles for any sign of inflammation and test the range of motion.

Imaging, including an X-ray, ultrasound, and MRI scans, may be needed to assess the extent and exact location of the joint damage. Blood tests are also used to identify serologic factors associated with RA or an associated condition.

Treatment Options

Treating this condition may involve a combination of different procedures, which include non-surgical options such as orthotic devices, bracing, physiotherapy, ice/rest/offloading, an anti-inflammatory diet, quitting smoking, and medications to reduce inflammation and pain. For those patients who suffer from an advanced form of RA of the ankle, the recommended treatment option is surgery. ^{1, 3}

Based on the patient’s lifestyle, type of RA and extent of the cartilage damage, the surgical technique could be fusion (arthrodesis) of the two bones that form the joint to prevent them from rubbing and provoking inflammation and pain. In some cases, a total ankle replacement may be needed to minimize pain and discomfort in the ankle, improve stability and recover function.

Complications

Over time, RA can deform joints and cause them to shift out of place. RA may also affect many non-joint structures, including skin, lungs, kidneys, eyes, bone marrow, and blood vessels. Osteoporosis and infections are further complications.

Failure for the fusion to heal and increased stress on other joints following an ankle fusion are the most concerning post-surgical complications. ⁴