Impact of midfoot and Hindfoot involvement on functional disability in Korean patients with rheumatoid arthritis

New Insight into the Effects of Different Types of Midfoot and Hindfoot Deformities on the Functional Outcomes of Rheumatoid Arthritis Patients

In advanced stages of rheumatoid arthritis (RA), the pattern of joint involvement leads to varied types of foot deformities such as forefoot, midfoot, and hindfoot deformities. We aim to evaluate midfoot and hindfoot deformities and their effect on functional outcomes in RA patients. In this prospective cross-sectional study clinical and radiological evaluations of 100 adult RA patients were studied for midfoot and hindfoot deformities. The RA disease activity, functional disability level, specific foot and ankle assessments, gait speed, and balance tests were assessed. Radiological examinations of the weight-bearing feet in a standing position were done. We found that the most frequent deformity type was the planovalgus foot (24%). There were statistically significant differences between the types of foot deformities and disease duration, disease activity, falls, Tinetti and Berg balance Test, and health assessment questionnaire-disability index. The multivariate regression analysis of independent correlates of falling detected that patients with equinovarus deformity were 2.5 times more liable for falling with 63.5% predictive power. According to the predictive criteria of deformity type for falling, the equinocavovarus type had accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 91%, 84.5%, 98.5%, 99%, and 84%, respectively. We found in RA patients, midfoot and hindfoot deformities cause a significant reduction of functional ability and quality of life. The early detection of foot deformities requires a good awareness of the clinical and radiographic diagnosis of different types of deformities thus reducing the possible functional disabilities via early management by combined orthotic, physiotherapy, and surgical treatments.

Association of Foot Health and Lower Extremity Function in Older People with Rheumatoid Arthritis: A Cross-Sectional Study

INTRODUCTION

Foot health and lower extremity function are important in older people with rheumatoid arthritis (RA), as they maintain and promote these individuals' independent living and functional health. RA is a long-term inflammatory health condition that alters foot structure and function. Relatively little is known about the association between foot health and lower extremity function in older people with RA. Therefore, the aim of the study was to analyse the levels of foot health and lower extremity function in older people with RA and to explore the associations between these factors.

METHODS

A cross-sectional survey design study was conducted. The data were collected online in April 2023 from a national association of patients with rheumatic conditions in Finland using two instruments: the Self-administered Foot Health Assessment Instrument (S-FHAI) and the Lower Extremity Function Scale (LEFS). The data were analysed using descriptive and inferential statistics.

RESULTS

Older people with RA (n = 270) reported many foot health problems, the most common of which were foot pain, dry skin, and oedema. Lower extremity function in older people with RA was at the mild-to-moderate functional limitation level and respondents reported major difficulties running or hopping, squatting, carrying out their usual hobbies, performing strenuous activities outside their homes or putting on shoes/socks. Poor levels of foot health were correlated with decreased lower extremity function.

CONCLUSION

Foot health is associated with lower extremity function in older people with RA. Therefore, it is essential that older people with RA be provided with systematic foot health assessments, care and rehabilitation to promote their lower extremity health and improve their functional health. Multiprofessional collaboration and seamless care chains at different levels of health care could benefit older people with RA looking to maintain their functional ability and - above all - promote their active ageing.

Assessment of the functional impact of foot involvement in patients with rheumatoid arthritis

AIM OF THE WORK

We aimed to evaluate the impact of foot involvement in patients with rheumatoid arthritis (RA) using the functional foot index (FFI) and to identify predictive factors of the functional impact of foot abnormalities in RA patients.

PATIENTS AND METHODS

This was a cross-sectional study including patients with RA meeting the criteria of the American College of Rheumatology and the European League Against Rheumatism 2010. The main epidemiological data, results of podoscopic and clinical examination of the foot and ankle, biological tests and radiological findings were collected. The presence of foot pain was assessed by a visual analogic scale (0-10), and the functional impact of foot involvement was assessed based on the validated French version of the FFI.

RESULTS

Fifty RA patients with an average age of 59.3 ± 9.9 years [39-79] were included, and 80% of them had foot involvement. Foot pain was present in 32 patients (64%), most frequently situated in the forefoot (56%). The average FFI score was 33.67 ± 30.53 [0-92.67]. The following factors had a significant association with the FFI score: an occupation soliciting the feet (p = 0.001), disease duration (p = 0.033, r = 0,302), the Health Assessment Questionnaire (p = 0.0001, r = 0,480), body mass index (p = 0.0001, r = 0,654), the presence of podiatric abnormalities (p = 0.0001) and Visual Analog Scale foot pain (p = 0.0001, r = 0,854). A significant association was also found between the FFI score and the presence of a hallux valgus (p = 0.004), a spread of the forefoot (p = 0.029), a claw of the toes (p = 0.002), a triangular forefoot (p = 0.0001), a quintus varus (p = 0.002), flat feet (p = 0.0001) and a valgus of the hindfoot (p = 0.001).

CONCLUSION

Due to the high frequency of foot involvement and its significant functional impact, meticulous examination of the feet and assessment of their functional impact must be one of the parameters for monitoring the disease. Its impact on one's quality of life can be important.

LEVEL OF CLINICAL EVIDENCE

4 (cohort studies, non experimental, observational studies).

Ankle and foot pathologies in early rheumatoid arthritis, what can ultrasound tell us?

BACKGROUND

Rheumatoid arthritis (RA) is a systemic autoimmune polyarticular disease. Despite being commonly affected in RA, the ankle and foot do not receive much attention, particularly in early disease. The precise diagnosis of their involvement and its impact on health is a clinical challenge that requires accurate assessment.

AIM

To determine the role of ultrasound in evaluation of ankle and foot pathologies and assess its impact on functional activity in newly diagnosed RA patients.

METHODS

The study was conducted on 152 RA patients and 52 healthy controls. Patients were subjected to history taking, clinical examination, and ultrasound scan. Impact on health was measured by health assessment questionnaire, as well as foot function index.

RESULTS

In a cohort of patients with early RA with median duration of 1 month, tibialis posterior (TP) tenosynovitis (45.4%) was the most common pathology, followed by tibiotalar (TTJ) synovitis (39.8%), and peroneal tenosynovitis (39.1%). In terms of disease duration, TTJ (P = .001) foot pathologies were less common in early RA and tended to worsen over time, whereas TP (P = .048) and peroneal tenosynovitis (P = .011) were more common in early RA. In multivariate analysis TTJ, subtalar synovitis, forefoot pathologies, TP tenosynovitis, and Achilles enthesitis were found to be significant predictors of functional disability. The most important predictors of ankle pain were TTJ synovitis, TP tenosynovitis, peroneal tenosynovitis, and plantar fasciitis.

CONCLUSION

Ankle and foot involvement is a common issue of early RA, and it has a significant impact on quality of life. Ultrasound is a reliable tool for evaluating various abnormalities in this complex area, allowing for better management.

The Structural Index Score and its relation to foot function, disability and physical performance tests in rheumatoid arthritis (RA) - A cross-sectional study

OBJECTIVES

To evaluate the Structural Index Score (SIS) - a clinical foot deformity assessment index developed for RA, and to compare its results with foot function, disability and physical performance tests.

METHODS

In this cross-sectional study, 104 patients with foot pain were evaluated according to SIS score, subscales (Forefoot SIS and Rearfoot SIS) and items. Results were compared with the Foot Function Index (FFI), the Health Assessment Questionnaire Disability Index (using lower limbs items: LL-HAQ), and physical performance tests: Berg Balance Scale (BBS), the Timed Up and Go test (TUG) and the 5-Time Sit down-to-Stand up Test (SST5).

RESULTS

There was a weak correlation of SIS score with FFI and LL-HAQ. Rearfoot SIS was correlated with FFI, LL-HAQ and worse performance in BBS, TUG and SST5. Regarding Rearfoot SIS items, the ankle ROM was correlated to all studied outcomes, the calcaneus varus/valgus was correlated with FFI (total, pain and disability subscales) and the planus/cavus deformity with FFI-pain, HAQ-DI and LL-HAQ. Forefoot SIS did not correlate with any outcome measures. In relation to Forefoot SIS items, hallux valgus was associated with foot function (FFI-total, pain and disability subscales), the MTPs joints subluxation was correlated with FFI-disability subscale, and the 5th MTP exostosis was associated with FFI-pain.

CONCLUSION

SIS score was correlated to impaired foot function (FFI) and disability (LL-HAQ). Rearfoot SIS was correlated to worse performance on FFI, LL-HAQ, BBS, TUG and SST5. SIS score index can be a useful tool to evaluate the rheumatoid foot deformities, but a better graduation of foot deformities should add sensitivity to this method.

Pedobarographic Measurements of Rheumatoid Feet Compared with Clinical Parameters

Objective:

This study aimed to investigate the relationship between plantar pressure pedobarographic measurements and disease activity, radiological abnormalities, and foot indexes in patients with rheumatoid arthritis (RA).

Methods:

Sociodemographics, foot symptoms, anatomical distribution, pain intensity and duration, and podiatry services access data were collected. Disease activity scale of 28 joints (DAS28) was used for the disease activity, and Health Assessment Questionnaire (HAQ) was used for the functional status. Foot function index (FFI) was used to measure the impact of foot pathology on its function. The Modified Larsen scoring was used to assess radiological abnormalities. Pedobarographic measurements were used to analyze foot loading characteristics.

Results:

A total of 104 feet of 52 patients with RA was evaluated. DAS28 scores did not correlate with the plantar pressure values (p>0.05). A significant correlation was found between HAQ scores and right medial midfoot loading pressure (r=0.355; p<0.01). FFI scores were positively correlated with right lateral midfoot loading pressure (r=0.302; p<0.05). No relationship was found between Manchester Foot Pain and Disability Index and plantar loading characteristics. The radiological scores were correlated with left lateral hindfoot plantar pressure (r=0.286; p<0.05).

Conclusions:

Pedobarographic measurements can be considered as a follow-up evaluation tool for the evaluation of all foot parts (forefoot, midfoot, and hindfoot). Rheumatoid feet investigation showed that foot involvement is independent of the disease duration, whereas midfoot plantar pressures are associated with the body mass index. Additionally, DAS28 may fall short as a marker of disease activity because it neglects foot problems.

Region specificity of rheumatoid foot symptoms associated with ultrasound-detected synovitis and joint destruction

OBJECTIVES

We aimed to clarify the clinical implication of ultrasound (US)-detected foot joint inflammation in tightly controlled patients with rheumatoid arthritis (RA).

METHODS

We evaluated bilateral foot joints (second to fifth metatarsophalangeal joints of forefoot; tarsometatarsal, cuneonavicular and midtarsal joints of midfoot) of 430 RA patients for synovitis using Power Doppler (PD) imaging by US. We made a cross-sectional and a 3-year longitudinal analysis about the associations of US-detected synovitis with clinical, laboratory and radiographic data as well as foot-specific outcomes using a self-administered foot evaluation questionnaire (SAFE-Q).

RESULTS

The US-detected foot synovitis was seen in 28% of patients. The US-detected synovitis was closely related to 28 joint-disease activity score (DAS28) more in the forefoot than in the midfoot, while related to joint destruction in both. Multiple regression analyses showed significant associations between midfoot PD positivity and SAFE-Q in the remission group. SAFE-Q was worsened after the 3-year interval, but PD positivity at baseline did not contribute to the changes. On the other hand, destruction of the joints with US-detected synovitis significantly progressed in 3 years than with not.

CONCLUSIONS

US-detected synovitis on foot joints were related to systemic inflammation, clinical symptoms, and future joint destruction with region specificity.

The role of NK cells in rheumatoid arthritis

OBJECTIVE

Natural killer (NK) cells are part of the innate immune system which not only provides a primary response to pathogenic conditions but can also play an important regulatory role in immune responses. Furthermore, these cells can influence immune responses by affecting other involved cells. Human NK cells can be classified as CD56^dim and CD56^bright; the former demonstrates mostly cytotoxic effects, while the latter comprises mostly tolerant or regulatory NK cells. These cells participate in the immunopathogenesis of rheumatoid arthritis (RA) and their role remains still unclear.

METHODS

We searched PubMed/MEDLINE and Scopus databases to review and analyze relevant literature on the impact of NK cells in the pathogenesis of RA.

RESULTS

Although the percentage of NK cells increases in peripheral blood of RA patients compared to healthy individuals, the cytotoxic function of these cells is impaired. It is demonstrated by reduced "perforin⁺ NK cells" and decreased per-cell lytic function. These cytotoxic NK cells may control the pathogenic bone absorptive function of osteoclasts by directly targeting these cells.

CONCLUSION

Collectively, the evidence collected in the current review emphasizes the possible protective role of CD56^dim NK cells in the pathogenesis of RA.

Three-Dimensional Finite Element Analysis and Biomechanical Analysis of Midfoot von Mises Stress Levels in Flatfoot, Clubfoot, and Lisfranc Joint Injury

Background

Midfoot deformity and injury can affect the internal pressure distribution of the foot. This study aimed to use 3D finite element and biomechanical analyses of midfoot von Mises stress levels in flatfoot, clubfoot, and Lisfranc joint injury.

Material/Methods

Normal feet, flatfeet, clubfeet (30 individuals each), and Lisfranc injuries (50 individuals) were reconstructed by CT, and 3D finite element models were established by ABAQUS. Spring element was used to simulate the plantar fascia and ligaments and set hyperelastic coefficients in encapsulated bone and ligaments. The stance phase was simulated by applying 350 N on the top of the talus. The von Mises stress of the feet and ankle was visualized and analyzed.

Results

The von Mises stress on healthy feet was higher in the lateral metatarsal and ankle bones than in the medial metatarsal bone. Among the flatfoot group, the stress on the metatarsals, talus, and navicular bones was significantly increased compared with that on healthy feet. Among patients with clubfeet, stress was mainly concentrated on the talus, and stress on the lateral metatarsal and navicular bones was significantly lower. The von Mises stress on the fractured bone was decreased, and the stress on the bone adjacent to the fractured bone was higher in Lisfranc injury. During bone dislocation alone or fracture accompanied by dislocation, the von Mises stress of the dislocated bone tended to be constant or increased.

Conclusions

Prediction of von Mises stress distribution may be used clinically to evaluate the effects of deformity and injury on changes in structure and internal pressure distribution on the midfoot.

Functional Disability and Its Determinants in Ecuadorian Patients with Rheumatoid Arthritis

INTRODUCTION

Disability in RA is associated with loss of workdays, greater use of health resources and a higher prevalence of depression. The purpose of this study was to determine the prevalence of functional disability and the factors associated with it.

METHODS

A cross-sectional study was carried out during January-June 2019 at a rheumatology clinic in the city of Guayaquil. Patients with pre-established RA were included. Functional disability was measured using the HAQ-DI. Data were analyzed using the statistical program SPSS v22. We compared characteristics between patients with and without disability using Student's t-test and chi-square. A multiple logistic regression model for functional disability was made.

RESULTS

We included 395 patients, 87.8% female and 12.2% male with a mean age of 51.4±12 years and mean duration of disease 13.8±7 years. Most patients had extra-articular manifestations (80.8%) and comorbidities (81.3%). The mean HAQ-DI was 0.8±0.9, with a prevalence of disability of 26.6%. We found a statistically significant relationship between disability and female sex (p=0.018), age (p=0.020), presence of extra-articular manifestations (p=0.008), myalgia (p<0.001) and fatigue (p<0.001). In addition, patients with disabilities had a lower employment rate (26.7%) compared to those without disability (45.5%, p=0.001). In the multivariate logistic analysis, only depression (p=0.029), diabetes (p=0.003), SJC (p=0.001) and VAS of pain (p=0.004) were significantly related to functional disability.

CONCLUSION

Disability affects a quarter of patients with RA. Among the determinants of disability, we found female sex, older age, grade of pain, inflammatory markers and the level of disease activity.

Do ankle, hindfoot, and heel ultrasound findings predict the symptomatology and quality of life in rheumatoid arthritis patients?

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the findings with healthy subjects, and to analyze if these findings are associated with ankle pain and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and 35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid arthritis patients compared to healthy controls, but when subtalar synovitis was present, the pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes, calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology (inflammatory modifications, but also degenerative findings and deformities). Ultrasound scanning is an important tool in the evaluation of inflammatory and degenerative lesions in these regions, and their early detection might contribute to a better therapeutic management in these patients.

Objectives: To evaluate the ankle, hindfoot, and heel changes (determined by physical examination, ultrasound and baropodometry) in patients with rheumatoid arthritis, to compare the findings with healthy subjects, and to analyze if these findings are associated with ankle pain and could affect the quality of life. Methods: We enrolled 35 rheumatoid arthritis patients and 35 healthy controls, and evaluated their ankles (tibiotalar joints, tendons), hindfeet (talonavicular, subtalar joints) and heels using clinical examination, DAS28-CRP, RAPID3 for the evaluation of functional status, quality of life in rheumatoid arthritis questionnaire, ultrasound, and baropodometry. Results: The ultrasound inter-observer agreement was good for the subtalar joint, and very good for the other structures. Flat foot was identified in 50% of feet in rheumatoid arthritis patients, with 83.8% having concomitant hindfoot valgus and less subtalar joint synovitis visible from the lateral approach (32.4% vs 55.6%, p = 0.041). The body mass index, RAPID3 and subtalar synovitis were independent predictors for the symptomatic ankle (all p <0.05). Midfoot and heel plantar pressures were higher in rheumatoid arthritis patients compared to healthy controls, but when subtalar synovitis was present, the pressures decreased (avoidance of heel support). Poor quality of life in rheumatoid arthritis patients was independently predicted by DAS28-CRP, RAPID3, disease stage, hindfoot valgus, tibiotalar and subtalar synovitis, tendon pathology, Achilles tendon enthesophytes, calcaneal erosions, plantar fasciitis, and perifasciitis (all p <0.05). Conclusion: The quality of life of rheumatoid arthritis patients is significantly affected by ankle and hindfoot pathology (inflammatory modifications, but also degenerative findings and deformities). Ultrasound scanning is an important tool in the evaluation of inflammatory and degenerative lesions in these regions, and their early detection might contribute to a better therapeutic management in these patients.

Foot function in rheumatoid arthritis patients: a cross-sectional study

Rheumatoid arthritis (RA) is a chronic disease that affects mainly small joints from hands and feet. The aims of this study were to analyze the prevalence of foot involvement in a sample of Brazilian RA patients and to explore the influence of disease variables such as inflammatory activity, serological, and epidemiological profile in this type of involvement. One hundred RA patients and 100 healthy controls paired for gender, age, and body mass index answered the FFI-BR (Foot Functional Index-Brazilian version) that evaluates foot function. RA patients had epidemiological and clinical data collection upon direct questioning and chart review. C-reactive protein (CRP), ESR (erythrocyte sedimentation rate), and DAS28-ESR were used to measure disease activity. In the RA sample, 98% had foot pain versus 76% in the controls (p < 0.0001; OR = 15.4; 95% CI = 3.4-67.5); 96% had some difficulty in function versus 66% of controls (p < 0.0001; OR = 12.3; 95% CI = 4.1-36.5); and 73% had some incapacity versus 20% of controls (p < 0.0001; OR = 10.8; 95% CI = 5.5-20.9). Values of FFI-BR showed correlation with ESR (p = 0.006), CRP (p = 0.01), and DAS28-ESR (p < 0.0001). No association between FFI-BR total score and gender, ethnic background, positive rheumatoid factor, tobacco exposure, and any of used medications was found (all p = ns). The majority of RA patients suffers from foot problems and was associated with inflammatory biomarkers. The control of inflammatory activity may help in the treatment of this problem.