By Dr. Steven Gershman
"It's just arthritis doc", I hear often in the office from patients in pain. Chances are if you are older or have parents or grandparents who are older, many of them complain about their arthritis. It is believed that in the US about 20% of the population suffers from some type of arthritis.
What is Arthritis?
The word arthritis comes from the terms "arth-" which means joint and "-itis" which means inflammation. Osteoarthritis is by far the most common type of arthritis. It is also known by the initials "DJD" or degenerative joint disease. Basically, it is "wear and tear " arthritis. The joints become worn out over time with resulting pain and disability. Rheumatoid arthritis is truly joint inflammation as it is an autoimmune disease where the body's immune system attacks the joints creating inflammation.
Another common form of "arthritis" is what is known as enthesopathy. This is a disorder or inflammation of a tendon or ligament attachment to bone. Common areas are the achilles tendon to the heel in the back of the heel, the plantar fascia to the heel on the bottom of the foot, and the peroneal tendon to the outside of the foot. Commonly there is a bone spur at the attachment of the tendon from the chronic irritation which causes pain.
Other types of arthritis include psoriatic, gout, ankylosing spondylitis, lupus, and arthritis secondary to inflammatory bowel diseases and fibromyalgia.
Generally, joints are areas in the body where bones come together to allow motion in one or more directions. The bones are covered by cartilage at their ends where they meet and there is a space between the cartilage coatings which is filled with synovial fluid which lubricates the cartilage allowing motion. The joints are enclosed by a flexible tissue called the synovial membrane.
Arthritis damages the cartilage coating the ends of the bones. Over time it wears out the cartilage leaving holes or in severe cases complete destruction of the cartilage leaving bone against bone. When this occurs, there is loss of normal joint space and inflammation and pain. In DJD or wear and tear arthritis this is common. In Rheumatoid arthritis the immune system attacks the synovial membrane enclosing the joints damaging it and the cartilage causing severe inflammation and deformity such as toes and fingers going in abnormal directions.
Arthritis can affect virtually any joint in the body. The most common areas are neck, shoulders, wrists and hands, lower back, hips, knees, ankles and feet. The focus of this article is the lower extremity from the knees down to the toes. As a podiatrist I see a lot of arthritis in these areas and can treat and affect the arthritis with shoes for arthritis along with inserts/orthotics and sometimes medication and injections.
Symptoms of Arthritis
One of the main signs of arthritis is the joint becoming difficult to move and pain. The joint can actually look bigger and have bony protrusions sticking out. In the feet one of the most common areas affected is the big toe joint. I see this every day in practice. Normal big toe joints can allow the big toe to move almost straight up when off the feet. It is a very flexible joint when healthy. In arthritis, I see enlargement of the joint, mainly on the top with limited or in extreme cases no motion. The joint can become virtually fused. This is called "hallux rigidus”. This is the most common type of arthritis I see in practice in the feet. It has a major effect on the patient.
In the normal gait or walking/running cycle we push off the foot through the big toe joint. The joint has to flex at least 20 to 30 degrees for normal mechanics to occur as we walk. When there is loss of motion from arthritis or any reason, it changes everything. The body has to compensate or find another way to propulse or push off. The compensation is where the problems arise. Compensations require the body to move in a manner that it was not designed to do. This stresses the involved areas causing more damage and pain. In the case of the big toe joint we compensate commonly by pushing off the outside of the foot through the lesser toes which can damage these areas often causing neuromas or pinched nerves, deformed toes (claw or hammer toes), and tendinitis. Also, it has been shown that dysfunction of the big toe joint can lead to chronic low back pain.
Causes of Arthritis
There are many reasons as to why arthritis may occur:
- Age is one factor. As we age, we wear out the joints just like a car that has high mileage. It is often genetic. If your parents and/or grandparents have it, you are more likely to have it to.
- Body weight. Being overweight stresses the joints, especially back, knees and feet and can lead to arthritis.
- Structural causes. If you are born with abnormal structure or faulty biomechanics this can affect your gait and can lead to arthritis.
- Injuries that occur in just daily living that damage body parts can cause arthritis directly to the injured part, or damage adjacent parts as you compensate for the injury. Remember all parts are connected and one part affects the other. A lot of lower extremity arthritis from the lower back down can occur due to faulty foot structure or biomechanics as the feet are the foundation to the body.
How to Diagnose Arthritis?
Most arthritis, including Rheumatoid arthritis, lupus, psoriatic arthritis, gout and a few others can be diagnosed by a medical provider.
- Blood tests
- Medical exam
- Family history
Osteoarthritis or DJD (wear and tear) is diagnosed by an exam and x-ray, but not by blood test.
Treatment of arthritis varies based on type and what part of the body it has affected.
- Medication. With rheumatoid arthritis and any of the other autoimmune arthritis disorders, there are medications that treat the actual underlying autoimmune syndrome. A Rheumatologist is a doctor who specializes in arthritis treatment and can manage these medications. Acetaminophen and NSAID'S like Ibuprofen are commonly used. NSAID'S can be dangerous as long-term use can damage the kidneys. Unfortunately, the more common wear and tear or DJD arthritis is not treatable with medications. Medications can reduce the pain and swelling but do not improve the damage.
- Joint injections of "cortisone" sometimes help for a while. Treatment is initially palliative which means symptom treatment only which won’t affect the course of the damage.
- Physical therapy can help a lot with everyday movements that are being avoided due to arthritis. The lack of movement in arthritis joints only makes them stiffer and more painful. Therapy can help you learn to move your joints with less pain and discomfort.
- Eventually for severe joint damage, joint replacement surgery is required. The most common joints replaced are the shoulders, hips, knees, and now ankles. For the hands and feet there are only surgeries to reduce deformities, but they cannot help with the cartilage loss and lack of proper movement. Replacement surgery is usually quite successful relieving pain and renewing mobility. However, big toe joint replacement surgery is often unsuccessful.
- Shoes. I am a Podiatrist. I treat feet and ankles. I see a lot of arthritis in feet and ankles along with knees and hips and backs. Proper shoes for arthritis can help manage pain and reduce the compensations that cause further damage. Ill-fitting or improper shoes can contribute to the damage from arthritis and add to the pain and disability. Toes are a common area of deformity with arthritis especially if the big toe joint is damaged and compensation in gait occurs. Often there are hammertoes and toes that deviate sideways. In these cases, the best shoes for this type arthritis deformity have a deep toe box to accommodate the elevation of the toes so there is less rubbing on the top of the toes. Shoes designed with stretch materials in the upper provides extra give so the toes aren't irritated.
With arthritis any abnormality in the biomechanics of the feet can magnify the damage and pain. Shoes for arthritic feet are the starting point in effective treatment. Here are the features that you should look for in shoes best for arthritis.
- Shoes designed with an orthotic insole support the arch of the foot, align the feet with the rest of the body and prevent excessive pronation.
- The shoes need to be deep from the heel to the toe area to accommodate inserts or orthotics that may be recommended for treatment.
- A low heel prevents further damage to the toes, back and knees from elevated heels. Micro trauma to the lower back, flexion in the knees and forefoot damage to the toe joint can occur as a result of elevated heels.
- Wide width arthritis shoes are a must! They need to have enough width to accommodate the wide forefeet often seen with arthritic deformity in order to provide a comfortable and pressure free fit. Some brands such as Orthofeet offer shoes in wide, extra wide and even extra extra wide.
- A tall, wide and round toe box is essential to allow maximum toe movement and protect hammer toes and other deformities in the forefoot.
- The best arthritis shoes need to be stable enough to help create as normal a gait pattern as possible. In cases of big toe joint arthritis, I order rocker bottom shoes which roll the foot through the damaged joint.
- Flexible, soft uppers and foam padded interiors are best to gently cushion and protect arthritic feet. Stretch materials provide a pressure free fit as they shape to the specific contours of the feet.
- Sometimes there is arthritis of the hands which makes putting on shoes difficult. A hook and loop (Velcro) closure or tie-less lace shoes developed by Orthofeet are a big help. The tie-less lace style combines laces and straps on both sides of the shoe, and enables fastening without the need for tying the laces.
Orthofeet has a full line of shoes for arthritis that meet these criteria, and as I have written before I wear them as does my wife for our foot issues. To view the full collection, click here.
- Orthotics. After starting with shoes I often proceed with either a non-custom orthotic insert like the Orthofeet Biosole Gel orthotic or a custom orthotic if warranted. Orthotics stabilize the feet allowing the best possible gait and reduce the damaging compensations that add to the arthritis. I have seen many cases of back pain, hip pain, and knee pain improve with proper shoes and orthotics. Even in severe arthritis I have seen improvement in symptoms.
Finally, arthritis is a very common issue in our society as we live longer, are more active and are heavier. I never say to a patient "it's JUST arthritis. There is not JUST there when someone is in pain from arthritis. Doctors and therapists can make life easier and less painful, so don't hesitate to seek out help for painful joints. If you are younger or lucky enough to have good joints, do all you can now to protect them. Eat well, keep your weight down, exercise safely, don't ignore pain, wear proper well-made shoes and replace them yearly before they wear out. The old saying "an ounce of prevention is worth a pound of cure " is as true today as ever.