Foot health management

This chapter will provide the reader with current evidence and the clinical strategies to improve the foot health management of patients with rheumatic and musculoskeletal diseases. The education of patients and health professionals will be key to implementing self-management early in the disease, together with the recognition of problems that require clinical intervention to improve the patient’s long-term outcomes. Unfortunately, there is still a lack of evidence to support many specific interventions, particularly for patients with connective tissue diseases. However, we can utilize increased understanding of the effects that these diseases have on the foot, together with clinical expertise, to manage symptoms and prevent damage and deformity.

Soft-tissue disorders

This chapter covers soft-tissue disorders, a common occurrence in rheumatology. There is a brief overview of 10 of the most common soft-tissue disorders of the foot in rheumatology, including Achilles tendinopathy, ankle sprains, retrocalcaneal bursitis, tarsal tunnel syndrome, peroneal tendinopathy, tibialis posterior tendinopathy, plantar heel pain, and more. For each disorder, presentation, signs, and management are discussed.

Normal function and movement

In this chapter, we will begin with a basic overview of the principles of human movement, anatomy, and function, before discussing the foot structure–function relationship. We will then briefly review the principles and techniques of gait analysis, followed by a review of walking and the gait cycle and the response of ankle cartilage during gait. Next, a description of normal movement and foot function, reviewing tissue- and joint-specific function, as well as complex systematic foot function, will be given. Finally, a review of some specialized techniques for studying foot function, including computational modelling, biplane fluoroscopy, and cadaveric gait simulation, will be provided.

Surgery

Surgery plays an important role in treating foot and ankle conditions yet is often poorly understood. This chapter uses the available evidence to provide an overview of common surgical procedures and their outcomes. It is not intended to be instructional but, instead, we hope it will help inform clinicians about surgical options and their outcomes, as well as offering advice on the perioperative management of people undergoing foot and ankle surgery.

Pathomechanics and gait analysis

Gait analysis is the systematic study of human walking. This chapter summarizes currently available gait analysis techniques that are available to the clinician and researcher. Gait analysis can be used alongside clinical history and examination and other special investigations to gain a better understanding of the relationship between joint disease, impairment, and compensatory gait mechanisms. Abnormal pathology leads to abnormal biomechanics, and tools that demonstrate these changes can lead to insights into the effects of the disease on function, in disease progression, and the impact of physical treatments. Plantar pressure measurement techniques yield valuable information on structure and function and are probably the most likely tool to be used in clinical practice. Three-dimensional joint kinematic and kinetic analyses are more difficult to perform and interpret and are likely to remain largely research tools. Gait analysis techniques will drive experimental work to further advance core knowledge and inform future development of customized approaches to conservative therapies such as footwear and orthosis manufacture, as well as foot surgery.

Imaging of arthritis in the foot and ankle

This chapter discusses imaging of the foot and ankle in rheumatological disease, including the advantages and disadvantages of specific techniques by disease. Conventional radiology remains the mainstay for radiological investigation, and a systematic approach to viewing the plain film radiographs is covered. Findings by imaging technique and disease are described. Computerized tomography, nuclear medicine, magnetic resonance imaging, and ultrasound are all analysed.

Juvenile idiopathic arthritis

The impact of foot problems in adults with rheumatic and musculoskeletal diseases is generally well established. However, in contrast, the impact of foot problems in children with rheumatic diseases has received relatively little attention. Therefore this chapter provides an overview of the most common rheumatic disorder of childhood: juvenile idiopathic arthritis (JIA), with a focus on how it affects the foot, how it impacts on foot function, gait, and activities of daily living, and its associated assessment and management strategies. We acknowledge that other rheumatic disorders of childhood such as (but not limited to) juvenile systemic lupus erythematosus and dermatomyositis may occasionally present with foot-related impairments; however, these are less likely to affect the foot and ankle in the same way or to the same extent as JIA, and podiatrists are often less involved in management of these conditions. Therefore this chapter will focus on JIA, which frequently affects the foot and ankle and often requires podiatric contributions to the overall management strategies implemented by a multidisciplinary team.

Spondyloarthropathies

The spondyloarthropathies include ankylosing spondylitis and psoriatic arthritis. The hallmark clinical features are inflammatory spinal disease, dactylitis, and enthesitis, together with an asymmetrical oligoarthritis, often of the lower limbs. Psoriaform skin and nail changes are also frequently seen, and, less commonly, but characteristically, a mutilating arthritis with severe deformity of the toes. These unique features often allow a diagnosis to be made purely on clinical examination of the lower limbs. However, these features also provide challenges for local treatments as skin disease may complicate the use of orthoses and percutaneous steroid injections. However, the importance of mechanical factors in the pathogenesis of these disorders almost mandates a combined mechanical and pharmacological approach to treatment.

Clinical assessment

This chapter provides an overview of the importance and process for clinical assessment of the foot and ankle in rheumatology. A reference guide for obtaining a clinical history is provided, in addition to recommendations about considering psychosocial and footwear history. An overview of common screening techniques is provided, with particular reference to common serological and musculoskeletal assessment approaches. Specific examples of movement assessment are considered and the importance of clinical observation and palpation in rheumatic disease is noted in addition to the importance of understanding the complex and changing presentation of pain. Finally, insight about future research directions is provided. Overall, it is intended that readers of this chapter will find useful guidance and practical tips for use in a clinical environment.

Autoimmune connective tissue diseases

This chapter will briefly cover the epidemiology and pathophysiology of systemic sclerosis and systemic lupus erythematosus, and, to a larger extent, their pathological effect on the lower limb. It will also discuss current evidence for foot pathology management with reference to potential risks and imaging strategies.