Involvement of the foot in patients with psoriatic arthritis. A review of 26 cases

Foot involvement in psoriatic arthritis: Prevalence, clinical and radiological features

BACKGROUND

The purpose of this study was to evaluate the prevalence of foot involvement in psoriatic arthritis and to describe its different clinical and radiological features.

PATIENTS AND METHODS

We conducted a cross sectional study including 40 patients with psoriatic arthritis over a period of 12 months. Anamnesis, clinical examination of feet, podoscopic examination, X-rays of feet and heels, and ultrasound in B mode and power Doppler mode were done for each patient.

RESULTS

Foot involvement was found in 95% of cases. It was symptomatic in 70% and inaugural of the disease in 20% of cases. The hindfoot and the forefoot were the sites most affected (77.5% and 47.5% respectively). The involvement of the midfoot was rarer (25%). Dactylitis was found in 17.5% and deformities of forefoot were found in 22.5% of cases. Antalgic gait was noted in 17.5% and static disorders of foot at podoscopic examination were identified in 35% of cases. Feet dermatological manifestations were found in 45% of cases. Diagnosis of different rheumatological manifestations was based on clinical findings and caracteristic radiological images on X-rays. We demonstrate he sensitivity of ultrasound in the detection and the diagnosis of different foot lesions including enthesitis, synovitis and tenosynovitis, dactylitis, bone erosions and psoriatic nail dystrophy.

Foot health and quality of life in women with breast cancer undergoing chemotherapy: a cross-sectional study

BACKGROUND

Chemotherapy is one of the most widely used therapies for breast cancer, triggering important repercussions on people's quality of life. However, little research has been undertaken about podiatric adverse effects. This study aimed was to determine the prevalence of podiatric pathology developed in people with breast cancer who receive chemotherapy.

METHODS

Observational, descriptive, and cross-sectional study was conducted in the Oncology service of the A Coruña University Hospital (northwest Spain). People with breast cancer and undergoing chemotherapy treatment of legal age (≥ 18), who signed the informed consent (n = 117) were included. Sociodemographic, comorbidity, disease and foot health variables, as well as two self-administered questionnaires (Foot Health Status Questionnaire and Foot Function Index) were studied. The current ethical-legal aspects were followed.

RESULTS

Foot health problems were highly prevalent, highlighting nail color changes (59.8%), onychocryptosis (39.7%), xerosis (62.4%), plantar fasciitis (12.8%), and neuropathic symptoms (75.2%). Some foot pain was presented in 77.8% of the sample, predominantly at nail level (15.4%) or sole of the foot and nail (14.5%). Most participants described their foot health as fair or poor (56.4%) and felt limited in walking (65.8%). The lowest score for the Foot Health Status Questionnaire was footwear (30.6(33.5)).

CONCLUSIONS

Foot health adverse effects represent worrisome problems in women with breast cancer undergoing chemotherapy, due to their high prevalence and negative implications on quality of life. These problems are critical as they may have implications for stopping or reducing chemotherapy. All these results call for the development of more research to contribute to the care and wellbeing of people with cancer who receive treatments such as chemotherapy. Thus, this line of research is a new path to be developed by the podiatry community.

The role of the multidisciplinary team in the management of psoriatic arthritis

Psoriatic arthritis (PsA) has a heterogenous clinical phenotype with manifestations in a number of different organs and systems. Whilst PsA is typified by enthesitis, synovitis and psoriasis (skin and nail); innate and adaptive immune system dysfunction often results in concomitant conditions. These include inflammatory bowel disease, uveitis, metabolic syndrome, metabolic bone disease and mental health issues. All of which have the potential to impact on quality of life, daily function, employment, family life and social activities. Through a collection of clinical vignettes, we describe the importance of multi-disciplinary and multi-speciality involvement in the care of people with PsA.

The effects of custom-made foot orthoses on foot pain, foot function, gait function, and free-living walking activities in people with psoriatic arthritis (PsA): a pre-experimental trial

Introduction

Foot involvement is a significant concern in psoriatic arthritis (PsA) as it can lead to severe levels of foot pain and disability and reduced mobility and quality of life. Previous studies have shown moderate efficacy for custom-made foot orthoses (CFO) in reducing foot pain and disability in people with rheumatoid arthritis. However, evidence on the efficacy of CFO in people with PsA is lacking.

Objectives

To explore the effects of CFO on foot function, foot and lower limb pain, gait function, and free-living walking activities (FWA) in people with PsA.

Methods

A pre-experimental study including twenty participants with PsA (mean age: 54.10 ± 9.06 years and disease duration: 11.53 ± 10.22 years) was carried out. All the participants received and wore CFO for 7 weeks. Foot and lower limb pain and foot function were measured before and after the intervention using the numerical rating scale (NRS) and the foot function index (FFI). Gait function was assessed by recording spatiotemporal parameters (STPs) during a 10-m walk test using an instrumented gait analysis system (Mobility Lab). Free-living walking activities (step count, free-living cadence, time spent in different ambulatory physical activities (APA)) were recorded over 7 days using an accelerometer-instrumented sock.

Results

The FFI reported scores demonstrated severe baseline levels of foot pain (54.46 ± 14.58 %) and disability (46.65 ± 16.14%). Statistically and clinically significant improvements in foot pain and foot function and large effect sizes (Cohen’s effect size > 1, p < 0.005) were observed after the intervention period. A strong correlation (r = −0.64, p < 0.01) between the CFO wearing time and foot function was demonstrated. However, no significant changes were found for gait STP or free-living walking activities after 7 weeks of CFO use.

Conclusion

Results support the clinical and biomechanical plausibility of using CFO in people with PsA to reduce pain and improve foot function. Large-scale and controlled studies are needed to confirm these findings. Moreover, a multidisciplinary approach including the prescription of exercise therapy and physiotherapy combined with CFO could be required to improve STP and promote APA in people with PsA.

Trial registration

ClinicalTrials.gov, NCT05075343. Retrospectively registered on September 29, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02808-8.

Spatiotemporal parameters and gait variability in people with psoriatic arthritis (PsA): a cross-sectional study

Background

Foot involvement is a major manifestation of psoriatic arthritis (PsA) and can lead to severe levels of foot pain and disability and impaired functional mobility and quality of life. Gait spatiotemporal parameters (STPs) and gait variability, used as a clinical index of gait stability, have been associated with several adverse health outcomes, including risk of falling, functional decline, and mortality in a wide range of populations. Previous studies showed some alterations in STPs in people with PsA. However, gait variability and the relationships between STPs, gait variability and self-reported foot pain and disability have never been studied in these populations. Body-worn inertial measurement units (IMUs) are gaining interest in measuring gait parameters in clinical settings.

Objectives

To assess STPs and gait variability in people with PsA using IMUs, to explore their relationship with self-reported foot pain and function and to investigate the feasibility of using IMUs to discriminate patient groups based on gait speed-critical values.

Methods

Twenty-one participants with PsA (age: 53.9 ± 8.9 yrs.; median disease duration: 6 yrs) and 21 age- and sex-matched healthy participants (age 54.23 ± 9.3 yrs) were recruited. All the participants performed three 10-m walk test trials at their comfortable speed. STPs and gait variability were recorded and calculated using six body-worn IMUs and Mobility Lab software (APDM®). Foot pain and disability were assessed in participants with PsA using the foot function index (FFI).

Results

Cadence, gait speed, stride length, and swing phase were significantly lower, while double support was significantly higher, in the PsA group (p < 0.006). Strong correlations between STPs and the FFI total score were demonstrated (|r| > 0.57, p < 0.006). Gait variability was significantly increased in the PsA group, but it was not correlated with foot pain or function (p < 0.006). Using the IMUs, three subgroups of participants with PsA with clinically meaningful differences in self-reported foot pain and disability were discriminated.

Conclusion

STPs were significantly altered in participants with PsA, which could be associated with self-reported foot pain and disability. Future studies are required to confirm the increased gait variability highlighted in this study and its potential underlying causes. Using IMUs has been useful to objectively assess foot function in people with PsA.

Trial registration

ClinicalTrials.gov, NCT05075343, Retrospectively registered on 29 September 2021.

Spondyloarthritis in North Africa: an update

Spondyloarthritis (SpA) has been less well studied than rheumatoid arthritis in North Africa, due to a belief that it is rare and benign in certain populations. The main genetic trait of SpA is its association with human leukocyte antigen (HLA)-B27. The distribution of this allele largely explains the prevalence and severity of SpA. The prevalence of HLA-B27 in the general population of North Africa is estimated at about 4%, and rises to about 60% among people affected with SpA. Coxitis is one of the main features of North African SpA, but the response to treatment is comparable to the literature from the West. The major challenge in North Africa remains accessibility to specialized care and means of early diagnosis. Prevalent infections in North Africa do not seem to be a major obstacle to optimal treatment strategies.

Psoriatic arthritis - new perspectives

Psoriatic arthritis (PsA) is a seronegative arthropathy with many clinical manifestations, and it may affect nearly a half of patients with psoriasis. PsA should be diagnosed as early as possible to slow down joint damage and progression of disability. To improve the diagnosis of PsA, physicians should look for peripheral inflammatory pain, axial inflammatory pain, dactylitis, and buttock and sciatic pain. In most patients with PsA, pharmacologic treatment with non-steroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and biologic agents is effective. However, when pharmacological treatment fails, patients with PsA may benefit from orthopedic surgery, which can improve both joint function and quality of life. Total hip arthroplasty, total knee arthroplasty, and arthroscopic synovectomy of the knee are the most common surgical procedures offered to patients with PsA. The management of PsA requires the care of a multidisciplinary team, which should include dermatologists, rheumatologists, physiotherapists, and orthopedic surgeons.

Involvement of foot in patients with spondyloarthritis: Prevalence and clinical features

BACKGROUND

The purpose of this study was to evaluate the foot involvement in a group of patients with spondyloarthritis in regard to symptoms, type and frequency of deformities, location and radiological changes.

METHODS

We conducted a cross sectional study including 60 patients with spondyloarthritis over a period of six months. Anamnesis, clinical examination, podoscopic examination, biological tests and X-rays of feet were done for each patient.

RESULTS

Foot involvement was found in 31 patients (52%). It was symptomatic in 35% of cases and inaugural in 42% of cases. The most frequent site was the hindfoot (22 patients/31). Radiological findings were: erosion (17%), reconstruction (33%), erosion and reconstruction (50%). Forefoot involvement was found in 18/31 patients. Forefoot deformities were found in 9 patients. Two patients had sausage toe and feet skin abnormalities were observed in 12 patients. At podoscopic examination, 23 patients had abnormal footprints. Foot involvement was more frequent in peripheral spondyloarthritis (p=0.008). Patients with foot involvement had an advanced age of disease onset (p=0.05), a shorter disease duration (p=0.038) and more comorbidities (p=0.039). Foot involvement was correlated with C Reactive protein (p=0.043).

CONCLUSION

In our study, foot involvement and foot symptoms were seen frequently in spondyloarthritis and it is associated with late onset of the disease and with higher inflammation in blood tests.

The evaluation of the static and dynamic balance disorders in patients with psoriatic arthritis

To evaluate the static and dynamic balances in psoriatic arthritis (PsA) and to investigate their relationship with clinical and functional parameters. Patients diagnosed with PsA and healthy controls were recruited consecutively into the study. The demographic variables such as age, sex, body mass index of the subjects were noted. Radiographic images were examined for the detection of foot deformities. 'Foot and Ankle Outcome Score' (FAOS) was used to assess foot function. The dynamic and static balance of the patients was evaluated by 'Berg Balance Scale' (BBS) and 'Neurocom Balance Master' device. The fatigue (Multidimensional Assessment of Fatigue: MAF), depression (Beck Depression Inventory: BDI) and sleep disorders (Pittsburgh Sleep Quality Index: PSQI) of all patients were evaluated. This study included 50 PsA patients and 50 healthy controls with mean ages of 45.02 (SD 12.81) and 45.12 (SD 10.56), respectively. Demographic data of both groups were similar. Concerning the balance tests, there were significant differences (p < 0.05) between patient and control groups about the all tests of sway velocity (except on foam surface eyes closed test), end sway of tandem walk test, movement time of bilateral step up over test and lift up index of left step up over test. There was no significant correlation between static and dynamic balance parameters with MAF, BDI, PSQI, foot deformities and FAOS. The static and dynamic balance impairments are seen in PsA. As the balance parameters had no significant correlation with functional and clinical data, they are acceptable as independent parameters during the course of the disease.

Deficiencies in provision of integrated multidisciplinary podiatry care for patients with inflammatory arthritis: a UK district general hospital experience

BACKGROUND

Foot problems are highly prevalent in inflammatory arthritis (IA), especially rheumatoid arthritis (RA). Chronic inflammation can lead to permanent structural changes, deformity and disability. Early podiatry intervention in RA improves long term outcomes. National guidelines recommend that patients should be treated by a multidisciplinary team with dedicated podiatry services. In clinical practice funding constraints limit availability of these services.

OBJECTIVES

To assess prevalence of foot problems and quality and availability of foot care services at a UK district general hospital.

METHOD

1200 IA patients in Swindon (Wiltshire, UK) were invited to complete an anonymised questionnaire regarding access to foot care services and education/information on foot problems.

RESULTS

448 patients. Prevalence of foot problems: 68%. Only 31% of patients had access to appropriate foot specialist. 24% had received foot assessment within 3 months of diagnosis of IA and 17% yearly review thereafter.

CONCLUSIONS

Despite high prevalence of foot problems in our population we identified significant deficiencies in provision of integrated multidisciplinary podiatry care. The data we present could be used by others to support business cases to obtain funding to improve the links between rheumatology and podiatry services.

A reliability study of biomechanical foot function in psoriatic arthritis based on a novel multi-segmented foot model

The objective of this study was to determine the within-and between-day reliability of spatio-temporal, plantar pressure, kinematic and kinetic measurements based on a novel, seven segment foot model applied in patients with Psoriatic Arthritis (PsA). Nine PsA patients and matched healthy adult controls underwent three-dimensional gait analysis on two occasions, one week apart using a seven segment foot model. A core-set of functional variables including inter-segment kinematics, kinetics, spatio-temporal and plantar pressure distribution were analysed using the coefficient of multiple correlation (CMC), Bland-Altman plots, intraclass correlation coefficients (ICC) and the standard error of measurement (SEM). Results showed excellent within- and between-day reliability for intersegment kinematic and kinetic data patterns with CMC values typically greater than 0.950 in a clinically stable cohort of PsA patients. Between-day reliability ranged from poor to excellent for absolute CMC values. Corrected CMC values were consistently higher across all variables ranging from fair-to-good to excellent. ICC values indicated excellent reliability for discrete spatio-temporal, plantar pressure, and ankle moment and power variables for both groups. Reliability for ground reaction forces and kinematic discrete variables ranged from fair-to-good to excellent. Standard error of measurement values ranged from 0.7° to 3.0° for discrete kinematic variables across both groups with greater variability in the PsA patients. In conclusion, intersegment kinematics and kinetics as well as spatio-temporal and plantar pressure can be reliably measured in PsA patients using a novel seven segment foot model. Some discrete kinematic variables have poor reliability and should not be used in prospective cohort and intervention studies.

Systemic causes of heel pain

The clinical course of heel pain can be frustrating to the clinician and the patient. Most heel pain responds to conservative care in a short period of time. However, other causes should be considered, especially if the heel pain is recalcitrant to treatment. A detailed history and physical examination, along with appropriate laboratory tests and radiological studies, can direct the physician toward the correct diagnosis. There are many systemic causes of heel pain, some common and others uncommon. Regardless of the incidence, a strong index of suspicion is raised whenever the heel pain fails to respond as routine plantar fasciitis should.

MRI of enthesitis of the appendicular skeleton in spondyloarthritis

Entheses are sites where tendons, ligaments, joint capsules or fascia attach to bone. Inflammation of the entheses (enthesitis) is a well-known hallmark of spondyloarthritis (SpA). As entheses are associated with adjacent, functionally related structures, the concepts of an enthesis organ and functional entheses have been proposed. This is important in interpreting imaging findings in entheseal-related diseases. Conventional radiographs and CT are able to depict the chronic changes associated with enthesitis but are of very limited use in early disease. In contrast, MRI is sensitive for detecting early signs of enthesitis and can evaluate both soft-tissue changes and intraosseous abnormalities of active enthesitis. It is therefore useful for the early diagnosis of enthesitis-related arthropathies and monitoring therapy. Current knowledge and typical MRI features of the most commonly involved entheses of the appendicular skeleton in patients with SpA are reviewed. The MRI appearances of inflammatory and degenerative enthesopathy are described. New options for imaging enthesitis, including whole-body MRI and high-resolution microscopy MRI, are briefly discussed.

MR imaging features of foot involvement in patients with psoriasis

OBJECTIVE

To determine alterations of the soft tissues, tendons, cartilage, joint spaces, and bones of the foot using magnetic resonance (MR) imaging in patients with psoriasis.

MATERIALS AND METHODS

Clinical and MR examination of the foot was performed in 26 consecutive patients (52 ft) with psoriasis. As a control group, 10 healthy volunteers (20 ft) were also studied. Joint effusion/synovitis, retrocalcaneal bursitis, retroachilles bursitis, Achilles tendonitis, soft-tissue edema, para-articular enthesophytes, bone marrow edema, sinus tarsi syndrome, enthesopathy at the Achilles attachment and at the plantar fascia attachment, plantar fasciitis, tenosynovitis, subchondral cysts, and bone erosions, joint space narrowing, subchondral signal changes, osteolysis, luxation, and sub-luxation were examined.

RESULTS

Clinical signs and symptoms (pain and swelling) due to foot involvement were present in none of the patients while frequency of involvement was 92% (24/26) by MR imaging. The most common MR imaging findings were Achilles tendonitis (acute and peritendinitis) (57%), retrocalcaneal bursitis (50%), joint effusion/synovitis (46%), soft-tissue edema (46%), and para-articular enthesophytes (38%). The most commonly involved anatomical region was the hindfoot (73%).

CONCLUSION

Our data showed that the incidence of foot involvement was very high in asymptomatic patients with psoriasis on MR imaging. Further MR studies are needed to confirm these data. We conclude that MR imaging may be of importance especially in early diagnosis and treatment of inflammatory changes in the foot.

Biological therapy and nail psoriasis

Nail psoriasis affects 50% of psoriasis patients and in many cases causes impairment of manual dexterity, pain, and psychologic stress. Despite the fact that about 80% of psoriatic arthritis patients have nail involvement, patients rarely receive treatment for nail disease. Because of great difficulty in drug delivery to site of action and significant toxicities of most conventional systemic therapies, treatment of nail psoriasis can be very challenging. Biological therapy for psoriasis and psoriatic arthritis is now widely used, and early evidence indicates it may have significant benefit for some patients with psoriatic nail disease. This article reviews the clinical manifestations of nail psoriasis and discusses how to use specific biologic therapies that may provide significant new treatment options for this challenging disease.