From healthcentral.com
When RA reaches later, more advanced stages, certain changes of the hands and feet become more common. Here’s what you need to know
On top of the joint pain, swelling, tenderness, and stiffness that occurs in rheumatoid arthritis (RA), there’s a potential complication to have on your radar: changes to your joints (previously referred to as joint deformities).
“There are three things to know about rheumatoid arthritis: It’s autoimmune, it’s inflammatory, and it can be very destructive,” says rheumatologist Sana Haseeb, D.O., an assistant professor at Loyola Medicine and internal medicine physician based in Burr Ridge, IL.
Deformities—which is an outdated term that physicians rarely use anymore in reference to RA—can affect the hands and feet, are most common in advanced disease once inflammatory cells have existed in joints for a long time, leading to damage.
Fortunately, severe joint damage is becoming less common in RA, though it can and does still happen. Learn more about the issues that affect hands and feet with RA, along with treatment and prevention measures.
Causes of Joint Changes with RA
Rheumatoid arthritis is an autoimmune disease, which means that the body's own immune system mistakenly attacks its tissues. In the case of rheumatoid arthritis, the joints (often small joints, such as those in the hands and feet) are affected.
How so? Inflammatory cells move into the joints and cause inflammation in synovial fluid, which is a thick liquid in between your joints, says Donald Kimpel, M.D., a rheumatologist at UVA Health in Charlottesville, VA. “These inflammatory cells set up shop, causing swelling. The longer inflammation has settled in, the more likely it is to cause joint damage or damage to the ligaments and tendons around the joint,” he says.
With this damage, the disease can wreak havoc on the connective tissues and eat away at part of the bone, which is called an erosion, says Dr. Haseeb. If left untreated, you may see the physical impact of the disease with joints “swaying” or knuckles or fingers twisting in abnormal ways, she says.
These joint setbacks typically show up in later stages of the disease, says Dr. Haseeb. And fortunately, thanks to advancements in medications to treat rheumatoid arthritis, including biologics, joint destruction is becoming less common, she says.
Common Rheumatoid Arthritis Foot Changes
The feet bear the brunt of your weight, and in RA, that can contribute to pain and tenderness along the base of the toes, middle of feet, heels, and ankles, says Dr. Haseeb. “Patients will start to mention that their toes are curling up or extending in ways that are not comfortable,” she says. Wearing shoes can become difficult. Joint issues that may affect the feet include:
Bunions
A prominent and painful bony bump at the base of the big toe, bunions can cause the big toe to angle toward other toes, says Charis F. Meng, M.D., a rheumatologist with Hospital for Special Surgery in New York City. Although bunions have been shown to be one of the most common foot changes in RA, according to an earlier study, they are also a frequently experienced foot issue among the general population. As such, it’s important to note that having a bunion does not mean you have RA.
Flat Feet
You might also hear this called a fallen arch. In one small study, two out of three people with RA had an arch that was lowered or flattening, making it one of the most common foot problems in RA, per the International Journal of Environmental Research and Public Health in 2021. It occurs when rheumatoid arthritis damages the talonavicular joint, which helps create the “arch” in your foot; once the joint is damaged, the arch can collapse.
Hammertoe
In hammertoe, the joint in the middle of the toe bends down like a hammer, describes Dr. Meng. Hammertoe can also affect people without RA–in fact, wearing improperly fitting footwear is one of the main causes of hammertoe, according to Mayo Clinic.
Claw Toe
A claw toe is similar to a hammertoe. With claw toes, toes are bent upward at the joint at the ball of the foot, they bend downward at the middle toe joint, and the top toe joint may also curl downward, according to the American Academy of Orthopaedic Surgeons.
Treatments for Arthritis Foot Changes
Pain, stiffness, and destruction of foot joints from RA can significantly impact mobility and quality of life. Managing these changes effectively often requires a combination of treatments tailored to the specific needs of the individual. Here are some common approaches to treating arthritis-related foot changes, according to the American Academy of Orthopaedic Surgeons:
Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs like ibuprofen and naproxen can help reduce inflammation and pain in the affected joints.
Corticosteroids: These can be administered orally or through injections directly into the affected joints to reduce severe inflammation.
Disease-modifying antirheumatic drugs (DMARDs): For rheumatoid arthritis, DMARDs can slow the progression of the disease and prevent joint damage.
Custom insoles and orthopaedic shoes: Specially designed insoles and shoes with a wide toe box can provide extra support and cushioning, helping to alleviate pain and redistribute pressure on the foot.
Toe splints or supports: These devices can help correct deformities like bunions or hammertoes and improve alignment.
Physical therapy: Targeted exercises and stretches can help strengthen the muscles around the foot and ankle, providing better support and reducing pain.
People with RA often describe their hand symptoms as a lack of grip strength, with difficulty holding their coffee mug, gripping a steering wheel, or holding a pen for an extended amount of time, says Dr. Haseeb. Joint damage can make these issues worse. Here are three hand changes that may affect those with RA:
Swan-Neck Joints
With swan-neck fingers, the joint at the base of the finger bends, the middle joint is straight, and the joint at the tip of the finger bends. RA is the most common cause of this deformity.
Boutonnière Joints
If you have boutonnière fingers, the middle joint is bent toward the palm and the tip of the finger joint bends away from the palm. Without treatment, stiffness, swelling, and range of motion problems can become worse, according to StatPearls.
Ulnar Deviation
With this kind of joint damage, “fingers drift toward the pinky side of your hand,” says Dr. Meng. Overtime, your wrist can also move toward that direction, too. This is also called “ulnar drift.”
Treatments for Arthritis Hand Changes
Living with arthritis in the hands requires a proactive and multifaceted approach. By combining medical treatments with physical therapy, lifestyle adjustments, and possibly surgery, individuals can manage symptoms, maintain hand function, and improve their quality of life. There are several options to manage hand issues with RA, many of which are the same as those for managing RA in the feet, according to Dr. Kimpel, such as:
Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications, such as ibuprofen and naproxen, are often used to reduce pain and inflammation in the joints of the hands.
Corticosteroids: Administered either orally or through injections directly into the joints, corticosteroids can provide significant relief from severe inflammation.
Disease-modifying antirheumatic drugs (DMARDs): For those with rheumatoid arthritis, DMARDs can help slow the progression of the disease and prevent further joint damage.
Biologics: These newer medications target specific parts of the immune system to reduce inflammation and prevent joint damage in conditions like rheumatoid arthritis.
Hand exercises: Strengthening and stretching exercises can help maintain mobility and reduce stiffness in the hands.
Splinting: Wearing splints can help stabilize and protect the joints, particularly during activities that put stress on the hands. Splints can also reduce pain by limiting motion in inflamed joints.
Adaptive devices: Occupational therapists can recommend tools and devices that make daily tasks easier and less painful, such as jar openers, thick-handled utensils, and button hooks.
The treatment options above may make a big difference in your ability to do daily tasks comfortably, making surgery unnecessary. However, if they are not successful, “we might refer more advanced cases to a surgeon, but this is often an end-of-the-road option because surgery can be very invasive,” says Dr. Haseeb. Sometimes, surgery may help reduce pain and improve strength, especially if joint issues are severely limiting your function, but they won’t make hands look like they did before, she says. Ultimately, this will involve a conversation between you and the surgeon to discuss the amount of damage to a joint and weigh the risks and benefits of surgery.
Sometimes, your doctor may recommend a procedure called a synovectomy, which removes inflamed tissue in the joint, says Dr. Meng. “It’s not as common as before, but it’s still done,” she says. Synovectomy can lessen swelling and pain and take some pressure off the joints.
Other surgeries that may be used include joint replacement (where a damaged joint is replaced with an artificial one) and joint fusion (which is when two joints are fused together to improve stability of the joint.) Joint replacement surgery is often more successful in bigger joints (like knees) rather than smaller joints of hands, for instance, says Dr. Kimpel.
How to Prevent Joint Changes in RA
One of the best things that you can do–even if you haven’t been diagnosed with rheumatoid arthritis—is to talk to your doctor (such as a primary care physician or rheumatologist) about the joint symptoms you are experiencing, including pain, swelling, and redness, along with fatigue and low-grade fever. In addition to a physical and medical history, your doctor may recommend lab testing to confirm RA.
If you have been diagnosed with RA, it’s important to closely follow the treatment plan recommended by your rheumatologist. With more advanced therapeutic options (such as biologics) available, medication can help slow some of this damage down, and potentially prevent it, says Dr. Haseeb.
Takeaways
The terms joint “deformities” is rarely used today in rheumatoid arthritis. Instead, doctors talk about the joint damage or changes that can occur with RA, which are caused by long-term inflammation that damages bone and connective tissue to cause small joints in the hands or feet to bend and twist in ways that they otherwise normally would not. This can lead to a visual change, such as hammertoe, bunions, and swan-neck syndrome, among others. Thankfully, joint damage is becoming less common with the use of more advanced medications to control the disease. Early diagnosis and treatment can help prevent or limit joint damage in RA.
https://www.healthcentral.com/condition/rheumatoid-arthritis/joint-deformities
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