Arthritis,footcare & footwear

by Dr. Sanjay Sane

Feet are the untiring workhorses of our body. With every mile we walk, 200,000 to 300,000 pounds of stress bears down on our feet, and by the time we're 50, most of us have walked 75,000 miles. That's stupendous task for the two feet. And yet, most of us ignore them.

Structure of the foot

To understand the foot in a better way, it is necessary to know the foot structure and it's functioning in brief. The foot is a complex structure. It contains 26 bones, more than 30 small joints, and more than 100 muscles, tendons, ligaments, nerves and blood vessels. These must all work together so that your foot can do all that you need it to. Feet bear the whole bodyweight and take part in locomotion. They are responsible for distribution of the weight to the ground without causing any harmful effects to, itself and the joints of lower limbs. While babies feet generally all look similar, adult's feet change over time with constant use.

Effects of aging

Feet age as the rest of our body does. Around our mid-40s, joints creak and joint tissues stiffen. Our feet begin to lose their once-plump cushion on the soles. This cushion is made up of fat pads, which are constructed to decrease the stress that walking puts on our bodies. Without those cushions, it can begin to feel like you're walking on pebbles.

Our feet also change size from swelling due to fluid retention, loosening ligaments and the flattening effects of gravity and weight on the foot structure. In a country like India where there is a predisposition to flattened arches, (pronated feet i. e. feet that turn toward the inside of the arch) placing abnormal stress on the foot structure and muscles can substantially add misery in feet with Rheumatoid arthritis.

Years of wearing the wrong or no footwear also take their toll. Problems can crep up like cracks and callosities, bunions, hammertoes or neuromas (an irritated nerve swelling often between the third and fourth toes)

Effects of Arthritis

As age advances, or with neglect, minor looking foot problems soon mutate to osteoarthritis (OA) in our feet. In fact, almost half of people in their 60s and 70s have arthritis affecting the foot or ankle.

Pain-whether it's from arthritis or other foot problems changes the way we walk. And once we deviate from normal pattern of walking, it brings changes in the structural alignment and functioning our feet ankles, knees, hips and lower spine.

As an example, if you pronate and tilt your foot to the inside (simple terms flat foot), cartilage in the medial part of the ankle degenerates, causing you to pronate more, further wearing out the cartilage. This causes ankle to sink down forcing the shin bone to turn inwards putting stress on the knee joint. This leads to non-alignment of the knee, which can degeneration of outside of the knee joint. When the foot isn't aligned, it affects everything - the way the knee, hip, pelvis or lower back is stressed in daily activities. And if stress is abnormal, it leads to problems in those joints, which may result in deterioration of joint surfaces, or arthritis. If you already have disease like Rheumatoid arthritis, joint difficulties are pronounced and can be incapacitating.

Specific Foot Problems :

Inflammatory arthritis

The term 'Inflammatory arthritis' encompasses rheumatoid arthritis (RA), reactive arthritis, psoriasis arthritis and ankylosing spondylitis. The effect on the feet depends on exactly which type of arthritis you have. Rheumatoid arthritis, for instance, tends to affect many of the foot joints, while reactive arthritis usually affects only the ankle. People with inflammatory arthritis can also have inflammation and discomfort in the tendons and the other 'soft tissue' structures in the feet. The part under the heel where the tendons attach to the heel bone is quite often affected in this way.


Gout is a particular type of arthritis caused by the formation of crystals in a joint. Gout often occurs in the foot, and the big toe joint is the most common site, but lesser toes may be affected. Gout causes a lot of inflammation, and the joint can be painful, red and hot while an attack lasts (typically 1-2 weeks) .

Without treatment, the attacks may return and damage the joint and fluid will accumulate, eventually leading o permanent damage and osteoarthritis. Gout is usually controlled well with modern medications.

Problems in the ankles and heels.

Pain in the ankles and heels can arise either from the joints themselves or from the structures around the joint such as muscles and tendons. The joints can be affected by osteoarthritis or by inflammatory arthritis such as RA or reactive arthritis. Osteoarthritis is fairly uncommon in the ankle, unless there has been previous damage from an injury, or damage from long standing inflammatory arthritis.

When inflammatory arthritis affects the ankle, the joint may be especially sore or stiff when you first get out of bed in the morning, or after sitting for a while. With this type of arthritis the heel may drift outwards.

This so-called valgus heel is a common feature of RA. It can be bothersome if the arch also flattens as a result. Research has shown that early treatment may slow the development of a valgus heel in people with RA. Supporting footwear and / or orthoses may help. A valgus heel can also be corrected with surgery.

Plantar fasciitis or heel bone spur

The most common cause of discomfort around the heel is inflammation in the ligaments that attach under the heel bone. You may hear this problem called plantar fasciitis. It used to be know as 'policeman's heel'. This is common with inflammatory arthritis, but can also occur in people without arthritis. If you can lose weight, this may help to ease symptoms in the heel. Treatment with oral medicines and modification in footwear or insoles may also help.

Painful arches ache and tired feet

The arches of the feet form a mechanism similar to the arch of old stone bridge, allowing the weight of the body to be spread evenly over many bones and joints and distribute the same to the ground. The arch structure can change with arthritis, and the structures nearby can be strained. In mild cases this feels like tiredness in the arch area, but pain and discomfort may develop if the muscles or tendons are very overworked. Losing some weight can help a lot, although this can be difficult to do if your feet hurt, because exercise becomes more difficult.

Swimming is good alternative form of exercise which you may be able to do instead of walking or other 'weight-bearing' exercises. If you have pain in the arches then non-steroidal anti-inflammatory drugs (NSAIDs), taken as tables may help. Arch supports or orthoses (functional orthoses) are very helpful for arch pain or tiredness.

Bunions and bursae

Bunions are bony lumps that develop on the side of the foot at the base of the big toe. A fluid-filled sac under the skin (a bursa) may develop here too, especially if footwear is pressed against the bunion. The bursa may become inflamed and painful. Sometimes, as the bunion develops, the big toe my be pushed over towards the smaller toes (this condition is know as hallux valgus). This can cause the other toes to become clawed, a condition known as hammer toes (see below). In RA a bunion combined with clawing of the toes is common.

If a bunion forms the symptoms can be controlled. Choosing footwear with a soft upper will reduce pressure and rubbing on the bunion joint. If the bunion or the bursa does flare up then 'bunion pads' can be bought from the chemist. If the joint is continually painful over a long period of time, surgery may be needed.

Claw toes or hammer toes

Hammer toes (also known as claw toes, mallet toes or retracted toes) occur when the toes are permanently bent.

Hammer toes happen either because of problems with the tendons inside the foot, or because the toes are squashed by poorly fitting shoes and/or socks. The most common cause of discomfort from hammer toes is a build-up of hard skin over the raised-up joints.

The only way to correct hammer toes is with surgery, although splints made of rubber, leather or silicone may help control mild cases. Any pain from corns and calluses may be eased by choosing shoes of a more generous fit, or with uppers made from soft materials. A protective pad over the area may also reduce the symptoms.

Painful ball of the foot

Pain can be caused by arthritis actually in the joints of the ball of the foot, especially if you already have arthritis elsewhere in your body. However most pain under the ball of the foot comes from minor damage to the soft tissues - the tendons, bursae, fat pads, nerves and skin.

Bursae are often found under the ball of the foot in people with RA.

They also occur next to large bunions. Treatment for the inflamed bursa starts with reducing pressure on the area.

Rheumatoid Nodules.

In people with RA, rheumatoid nodules (firm,pea-sized lumps) can occur at sites of pressure such as the big toe joints, the back of the heels, or on the toes. Nodules occurring on the soles of the feet can be particularly uncomfortable. Padding can ease discomfort by cushioning the lumps. In some cases, surgical removal of the nodules may be needed.

Callus and corns.

Another common cause of discomfort under the ball of the foot is a build-up of hard skin (called callus) and/or corns. Callus forms at areas of high pressure or friction. If pressures are extremely high, small areas of skin within the callused area produce an abnormal type of skin tissue leading to the formation of a corn.

Treatment : Self help

If you are overweight, losing some weight can help ease the pressure on painful feet. Exercise is important in keeping joints moving, and the rest of the body healthy, but it may be necessary to change the type of exercise you take if your feet hurt. For example, swimming might be an alternative. If your ankles feel stiff in the morning, allowing some time for the joints to 'loosen up' will usually help. During the day, alternating sitting and standing activities helps to take the pressure off the feet.

Tips to help you keep your feet in good shape :

Role of surgery

Joint replacements for the ankle and foot are not yet as successful as replacement of knees and hips.Most foot surgery is corrective surgery and is aimed at correcting the positions of the joints by resetting the bones or fusing the joint in the corrected position, or claw toe correction.

Pairing off calluses, excision of corns, and excision of warts may be required in some cases.If you are considering surgery, do discuss all of the available options with the surgeon before deciding whether to go ahead.

Steroid injections

If just one or two joints are inflamed and painful, a steroid injection may be recommended and given by the doctor, usually under a local anesthetic.


Comfort and not fashion is the best pointer to the suitability of footwear. If the footwear protects your feet against injuries and keeps them warm, dry and comfortable, then it is doing its job. It also must protect and support the arch, or relieve high pressure areas from excessive walking strains. In patients with advanced deformities and pain, customized orthotic supports are necessary. A test called as Foot Pressure measurement or a foot scan is very helpful for the treating doctor and the footwear consultant to diagnosis the problem and design the footwear in a proper way.


Toe box :-

Sole :-

Heel :-

Shoe Fastenings :-

Care while buying footwear