Physical examination of the rheumatoid foot and ankle should include a thorough assessment of the entire patient and observation of gait. Medical complications and management, especially the use of anti-TNF and other biological medications, should be noted. Identify disease at other sites which may affect anaesthesia (eg atlanto-axial instability) or rehabilitation (such as upper limb disease which may make it difficult to use crutches or limit weight bearing post-operatively.
Focal examination of the foot and ankle requires a systematic review of the skin, neurovascular status, range of motion, strength, overall alignment and assessment of deformities. Peripheral pulses must be carefully examined to assure adequate perfusion in potential surgical candidates. A vascular consultation should be obtained if there are any signs of arterial insufficiency which may affect surgical intervention.
Assessment of a patient with rheumatoid forefoot problems should always include a review of other joints, the overall limb alignment and examination of the joints and alignment of the ankle and hindfoot. Patients with hindfoot valgus do less well after forefoot reconstruction than those with normal hindfeet (Stockley 1990).
Check skin integrity and look for neuropathy and vasculitis.
Look under the forefoot for exposed metatarsal heads. Check the reducibility of toe deformities. If the MTP joint is reducible, how unstable is it? (draw test) Are the tender areas or calluses over the PIP joints dorsally or at the tips of plantar-flexed toes? If toe deformity is mild and most of the pain comes from the MTP joints, feel for synovitis – if in doubt an ultrasound can be helpful.
RA has traditionally been diagnosed using the American Rheumatology Association’s criteria (McGregor 1995). Recently the ARA and the European League Against Rheumatism (EULAR) agreed revised criteria (Aletaha 2010), which uses number of joints involved, rheumatoid factor/ACPA serology, acute phase protein levels and disease duration to drive a classification algorithm. Disease activity is monitored by the degree of inflammation in index joints, acute phase protein levels and other clinical features as summarized in scores such as the DAS28, SDAI and ACR/EULAR criteria (Felson 2011). However, several of these scores do not assess disease activity in the foot and ankle and there is some evidence that patients who appear to be in remission at other sites still have active foot arthritis (van der Leeden 2010, Wechalekar 2011).
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