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Arthritis is a frequent component of complex disease processes that may involve more than 100 identifiable disorders. It is characterized by inflammation of the cartilage and lining of the body's joints. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints which can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet. Arthritis may be a disabling and occasionally crippling disease; it afflicts almost 40 million Americans. In some forms, it appears to have hereditary tendencies. While the prevalence of arthritis increases with age, all people from infancy to middle age are potential victims. People over 50 are the primary targets. Arthritic feet can result in loss of mobility and independence. But that may be avoided with early diagnosis and proper medical care.
What is Arthritis?
Arthritis, in general terms, is inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints. Arthritis has multiple causes; just as a sore throat may have its origin in a variety of diseases, so joint inflammation and arthritis are associated with many different illnesses.
Besides heredity, arthritic symptoms may have their source in a number of phenomena:
- They can be traumatic, having their origins in injuries, notably in athletes and industrial workers, especially if the injuries have been ignored (which injuries of the feet tend to be).
- Bacterial and viral infections can strike the joints. The same organisms that are present in pneumonia, gonorrhea, staph infections, and Lyme disease cause the inflammations.
- Arthritis can develop in conjunction with bowel disorders such as colitis and ileitis, frequently in the joints of the ankles and toes. Such inflammatory bowel diseases seem distant from arthritis, but their control can relieve arthritic pain.
- Drugs, both prescription drugs and illegal street drugs, can induce arthritis.
- Arthritis can be part of a congenital autoimmune disease syndrome, of undetermined origin. Recent research has suggested, for instance, that a defective gene may play a role in osteoarthritis.
Because arthritis can affect the structure and function of the feet it is important to see our doctors if any of the following symptoms occur in the feet:
- Swelling in one or more joints
- Recurring pain or tenderness in any joint
- Redness or heat in a joint
- Limitation in motion of a joint
- Early morning stiffness
Skin changes, including rashes and growths
Some Forms of Arthritis
Osteoarthritis is the most common form of arthritis. It is frequently called degenerative joint disease or "wear and tear" arthritis. Although it an be brought on suddenly by an injury, its onset is generally gradual; aging brings on a breakdown in cartilage, and pain gets progressively more severe, although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration. Gait patterns – normal walking – may grow erratic. It is a particular problem for the feet when people are overweight, simply because there are so many joints in each foot. The additional weight contributes to the deterioration of cartilage and the development of bone spurs. Rheumatoid arthritis (RA) is a major crippling disorder, and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory system of diseases, often affecting more than a dozen smaller joints during the course of the disease, frequently in a symmetrical pattern – both ankles, or the index fingers of both hands, for example. It is often accompanied by constitutional signs and symptoms – lengthy morning stiffness, fatigue, and weight loss – and it may affect various systems of the body, such as the eyes, lungs, heart, and nervous system. Women are three or four times more likely than men to suffer RA, indicating a linkage to heredity. RA has a much more acute onset than osteoarthritis. It is characterized by alternating periods of remission, during which symptoms disappear, and exacerbation, marked by the return of inflammation, stiffness, and pain. Serious joint deformity, and loss of motion, frequently result from acute rheumatoid arthritis. However, the disease system has been known to be active for months, or years, then abate, sometimes permanently. Gout (gouty arthritis) is a condition caused by a build-up of the salts of uric acid – a normal byproduct of the diet – in the joints. A single big toe joint is commonly the locus, possibly because it is subject to so much pressure in walking; attacks of gouty arthritis are extremely painful, perhaps more so than any other form of arthritis. Men are much more likely to be afflicted than premenstrual women, an indication that heredity may play a role in the disease. While a rich diet that contains lots of red meat, rich sauces, and brandy is popularly associated with gout, there are other protein compounds in such foods as lentils and beans which may play a role.
Different forms of arthritis affect the body in different ways; many have distinct systemic affects that are not common to other forms. Early diagnosis is important to effective treatment of any form. Destruction of cartilage is not reversible, and if the inflammation of arthritic disease isn't treated, both cartilage and bone can be damaged, which makes the joints increasingly difficult to move. Most forms of arthritis cannot be cured, but can be controlled or brought into remission; perhaps only five percent of the most serious cases, usually of rheumatoid arthritis, result in such severe crippling that walking aids or wheelchairs are required.
The objectives in the treatment of arthritis are controlling inflammation, preserving joint function (or restoring it if it has been lost), and curing the disease if that is possible.
Athlete’s foot is a skin disease caused by a fungus, usually occurring between the toes. The fungus most commonly attacks the feet because shoes create a warm, dark, and humid environment which encourages fungus growth. The warmth and dampness of areas around swimming pools, showers, and locker rooms, are also breeding grounds for fungi. Because the infection was common among athletes who used these facilities frequently, the term "athlete's foot” became popular. Not all fungus conditions are athlete’s foot. Other conditions, such as disturbances of the sweat mechanism, reaction to dyes or adhesives in shoes, eczema, and psoriasis, also may mimic athlete's foot.
The signs of athlete's foot, singly or combined, are drying skin, itching, scaling, inflammation, and blisters. Blisters often lead to cracking of the skin. When blisters break, small raw areas of tissue are exposed, causing pain and swelling. Itching and burning may increase as the infection spreads. Athlete's foot may spread to the soles of the feet and to the toenails. It can be spread to other parts of the body, notably the groin and underarms, by those who scratch the infection and then touch themselves elsewhere. The organisms causing athlete's foot may persist for long periods. Consequently, the infection may be spread by contaminated bed sheets or clothing to other parts of the body.
It is not easy to prevent athlete's foot because it is usually contracted in dressing rooms, showers, and swimming pool locker rooms where bare feet come in contact with the fungus. However, you can do much to prevent infection by practicing good foot hygiene. Daily washing of the feet with soap and water; drying carefully, especially between the toes; and changing shoes and hose regularly to decrease moisture, help prevent the fungus from infecting the feet. Also helpful is daily use of a quality foot powder.
- Avoid walking barefoot; use shower shoes.
- Reduce perspiration by using talcum powder.
- Wear light and airy shoes.
- Wear socks that keep your feet dry, and change them frequently if you perspire heavily.
Fungicidal and fungistatic chemicals, used for athlete's foot treatment, frequently fail to contact the fungi in the horny layers of the skin. Topical or oral antifungal drugs are prescribed with growing frequency. In mild cases of the infection it is important to keep the feet dry by dusting foot powder in shoes and hose. The feet should be bathed frequently and all areas around the toes dried thoroughly. If an apparent fungus condition does not respond to proper foot hygiene and self care, and there is no improvement within two weeks, consult one of our doctors. We will determine if a fungus is the cause of the problem. If it is, a specific treatment plan, including the prescription of antifungal medication, applied topically or taken by mouth, will usually be suggested. Such a treatment appears to provide better resolution of the problem when the patient observes the course of treatment prescribed by the podiatrist; if it’s shortened, failure of the treatment is common. If the infection is caused by bacteria, antibiotics, such as penicillin, that are effective against a broad spectrum of bacteria may be prescribed.
Diabetes mellitus is a chronic disease which afflicts about 16 million people in the United States, half of whom are unaware they have the disease. It is a metabolic disease characterized by elevated glucose (blood sugar), resulting from defects in secretion of the hormone insulin, defects which cause tissue to resist absorption of insulin, or both. Chronic elevation of blood sugar (hyperglycemia) is associated with long-term damage to the eyes, heart, kidneys, feet, nerves, and blood vessels. Symptoms of hyperglycemia may include frequent urination, excessive thirst, extreme hunger, unexplained weight loss, tingling or numbness of the feet or hands, blurred vision, slow-to-heal wounds, and susceptibility to certain infections. Those who have any of these symptoms and have not been tested for the disease should see a physician without delay. Inpiduals with diabetes are prone to many complications, both acute and chronic. About 15 percent of those with diabetes will develop an open wound (ulceration) on a foot during their lifetimes, and 20 percent of these ulcerations will lead to amputations. The annual incidence of nontraumatic lower extremity amputations among people with diabetes is about 54,000, according to the American Diabetes Association. Among African-Americans, the amputation rate is 1 1/2 to 2 1/2 times that of whites, and Native Americans have even higher rates, three or four times that of whites.
An Unwelcome Lifetime Companion
Diabetes, once diagnosed, is present for life. Considerable research is focused on finding a cure, and much progress has been made in treatment and control of the disease. The majority of people with diabetes have type II diabetes. Type I, insulin-dependent diabetes mellitus, once referred to as juvenile, or juvenile-onset diabetes, afflicts five to 10 percent of people with diabetes. Type II, non-insulin-dependent diabetes mellitus, once known as adult-onset diabetes, afflicts the other 90-95 percent, many of whom use oral medication or injectable insulin. The vast majority of those people (80 percent or more) are overweight, many of them obese. Obesity itself can cause insulin resistance. The socioeconomic costs of diabetes are enormous. The dollar costs have been estimated at 592 billion annually, about equally split between direct medical costs and indirect costs. Diabetes is the fourth leading cause of death by disease in the United States. Inpiduals with diabetes are two to four times as likely to experience heart disease and stroke. It is the leading cause of end-stage kidney disease and new cases of blindness among adults under 75. The trauma of amputation is particularly debilitating. It often ends working careers, and restricts social life and the independence which mobility affords. For more than 50 percent of those who experience an amputation of one limb, the loss of another will occur within three to five years. The key to amputation prevention is early recognition and foot screening, at least annually, of at-risk inpiduals. Those inpiduals considered to be at high risk are those who exhibit one or more of six characteristics: (1) peripheral neuropathy, a nerve disorder generally characterized by loss of protective sensation and/or tingling and numbness in the feet; (2) vascular insufficiency, a circulatory disorder which inhibits blood flow to the extremities; (3) foot deformities, such as hammertoes; (4) stiff joints; (5} calluses on the soles of the feet; and (6) a history of open sores on the feet (ulcerations) or a previous lower extremity amputation.
Your Doctor's Role
Our doctors are a foot care specialists with skills in recognition and treatment of diabetic foot conditions. Because diabetes is a systemic disease, affecting many organs of the body, ideal case management requires a team approach, involving one of our doctors as well as the family physician, several medical specialists, and a dietitian. Our foot and ankle specialists, as an integral part of the treatment team, have documented success in the prevention of amputations. It is one of the most serious conditions treated by our physicians, whose training stresses salvage of the foot rather than amputation. A comprehensive approach to prevention of complications must include good glucose control, adherence to diet, an exercise program, proper medication and hygiene, and regular foot care. Those who follow the medical team's advice have a good chance of preventing or delaying the complications of the disease, and living normal lives. Furthermore, with such a regimen as groundwork, it is estimated that more than half of the lower extremity amputations among people with diabetes could be prevented.
For the person with diabetes who has not yet developed foot complications, there are warning signs which should be recognized and called to the attention of the family physician or one of our doctors.
- color changes of the skin
- elevation of skin temperature
- swelling of the foot or ankle
- pain in the legs, either at rest or while walking
- open sores, with or without drainage, that are slow to heal
- ingrown and fungus-infected toenails
- corns or calluses with bleeding within the skin
- dry fissures (cracks) in the skin, especially around the heel
- Ulceration is a common occurrence of the diabetic foot. Poorly fitted shoes, or something as seemingly trivial as a stocking seam, can create a wound that cannot be felt and may not immediately be seen by someone whose level of skin sensation has been minimized. Left unattended, such an ulcer can quickly become infected and lead to serious consequences.
Visit Your Foot and Ankle Specialist Regularly
For the person with diabetes a number of practices and precautions should be employed. Regular visits to your foot and ankle specialist for foot inspections, no less than annually and preferably more often, are recommended. The doctor may conduct specific diagnostic tests to assess the presence or progression of diabetes complications. Such tests may include assessments of circulation, using an instrument known as the Doppler for measurement of blood flow; vibration sense, using a tuning fork; sensation (light touch and deep pressure), using a plastic monofilament slightly thicker than a toothbrush bristle in what is called the Semmes-Weinstein test; and foot structure, using X-rays. We will probably also reinforce self foot care, reminding patients of previously dispensed advice. There is a sizable list of “do's and don’ts.” Shoes are at the top of the list Poorly fitted shoes are involved in as many as half of the problems that lead to amputations. Foot shape and size may change over the years; peripheral neuropathy contributes to change. Everyone, particularly those with diabetes, should be fitted by experienced shoe fitters for every new pair of shoes. New shoes should be comfortable at the time they're purchased – they should not require a break-in period – but it is a good idea to wear them for only short periods of time at first. Shoes should have leather or canvas uppers, fit both the length and width of the foot, leaving room for the toes to wiggle freely, and be cushioned and sturdy. Athletic footwear may fit the bill nicely. It’s a good idea to change shoes during the day, to relieve pressure areas. Avoid high heels and shoes with pointed toes. Never wear shoes with open toes or heels, including sandals, especially those with straps between the first two toes. Shake shoes out and feel inside them for rough stitching or foreign objects, such as small pebbles. Never go without socks. Diabetics who have difficulty finding shoes that fit should ask one of our doctors to prescribe corrective shoes, or refer them to a shoe specialist, the pedorthist. For those eligible, Medicare provides coverage for extra depth shoes or specially molded shoes, and inserts, for those with advanced cases of diabetes. The medical or osteopathic doctor treating an individual for diabetes can certify the need for therapeutic shoes which one of our physicians can prescribe.
- Wash feet daily, using mild soap and lukewarm water. Those with diabetes should always test bath water temperature with a thermometer or the elbow, since the feet may be unable to detect scalding temperatures.
- Dry feet carefully with a soft towel, especially between the toes, and dust them with talcum powder. If the skin is dry, use a good moisturizing cream daily, but avoid getting it between the toes.
- Feet and toes should be inspected daily for cuts, bruises, and sores, or other changes that are less obvious. If self-inspection is hampered by age or other factors, use a mirror or get the assistance of another person.
- Wear thick, soft socks; avoid mended socks or those with seams, which could cause blisters or other skin injuries. Never go barefoot, even inside your own home, and especially out of doors on unfamiliar terrain such as the beach or grassy areas.
- Smokers should give up the habit The consumption of alcohol should be moderated. Tobacco can contribute to circulatory problems, and alcohol to neuropathy.
- Smokers should give up the habit The consumption of alcohol should be moderated. Tobacco can contribute to circulatory problems, and alcohol to neuropathy.
- Exercise is important Walk as frequently as possible; it’s the best overall conditioner for the feet.
- People with diabetes are commonly overweight. That approximately doubles the risk of complications; close observance of good dietary habits is important.
- For cold feet at night, wear loose socks (don’t use heating pads or hot water bottles, or other external heat sources).
- Don't use garters or elastics to hold up stockings, and don't use panty girdles that are too tight around the legs.
- Cut toenails straight across, then use an emery board to gently file away sharp corners. Don’t cut into the corners.
- Never try to cut calluses with a razor blade, or anything else, without professional guidance, and never use commercial preparations to remove corns or warts; they contain chemicals that can burn the skin.
High Blood Pressure
As a member of the health care team, your foot and ankle specialist is vitally concerned about hypertension (high blood pressure) and vascular disease (heart and circulatory problems). There are several reasons for this concern. First, because you are a patient, we are interested in all aspects of your health and your treatment program. Second, we support the goals of high blood pressure detection, treatment, and control. Let your doctor know if you have any of the following cardiovascular or related conditions:
- Hypertension and/or cardiovascular disease-Hypertension sometimes causes decreased circulation. A careful examination is required to determine if there is lower than normal temperature in any of the extremities, or absence of normal skin coloration, or diminished pulse in the feet. The concern here is that these are signs of arterial insufficiency (reduced blood flow). Increased or periodic swelling in the lower extremities is important because it may mean that hypertension has contributed to heart disease.
- Rheumatic heart disease – Persons who have had rheumatic heart disease must be protected with prophylactic antibiotics prior to any surgical intervention. If you take medication for this condition, tell your podiatrist. Any medication you may be taking for high blood pressure, a heart condition, or any other reason should he reported to the podiatrist to ensure that it does not conflict with medications that may be prescribed in the treatment of your feet.
- Diabetes- This condition frequently affects the smaller arteries, resulting in diminished circulation and decreased sensation in the extremities. Let your doctor know if you have ever been told that you have diabetes, particularly if you are taking medication or insulin for this condition.
- Ulceration-Open sores that do not heal or heal very slowly may be symptoms of certain anemias, including sickle cell disease. Or they may be due to hypertension or certain inflammatory conditions of the blood vessels. We are on the alert for such conditions, but be sure to mention if you have ever had this problem.
- Swollen Feet – Persistent swelling of one or both feet may be due to kidney, heart, or circulatory problems.
- Burning Feet-Although it can have a number of causes, a burning sensation of the feet is frequently caused by diminished circulation.