The Role of the Podiatrist (aka Chiropodist)

in the Management of Rheumatoid Arthritis

Introduction

Podiatry is part of the healthcare team that works together to care for people with inflammatory arthritis(1). Most people will be familiar with the term ‘chiropody’ but this is being superseded by the term ‘podiatry’, this being the profession's preferred title. In essence, these are interchangeable protected titles. All chiropodists / podiatrists must be Health Professions Council (HPC) registered if they are to use this title. The HPC role is to protect the public whether they receive care through the NHS or via private practitioners, ensuring practitioners update and develop knowledge and skills relevant to clinical practice.

The foot and rheumatoid arthritis (RA)

Rheumatoid arthritis (RA) is the commonest type of inflammatory arthritis. Up to 90% of people with this condition will report associated foot problems. For some people, the foot is the first area of the body to present with signs and symptoms of RA. For others, it may be months, years or maybe never that the foot is a problem for them. The difficulties people can experience vary from soreness, warmth and swelling (a flare) of one or more foot joints that lasts a few days or longer, through to joint erosions, with joint instability, pain and associated changing foot shape. These changes can alter the individual's walking ability. RA and some medications can also have an effect on the skin and underlying tissues, making them more vulnerable to damage and infection. RA can cause bursae and nodules to form that may be susceptible to rubbing. Shape changes in the front of the foot can create pressure sites that develop corns and calluses (hard skin). These may develop into areas of ulceration if not treated appropriately, and so it is advisable to request podiatry guidance if hard skin or corns are present on your feet. Some people can experience decreased blood supply to feet and legs associated with atherosclerosis and vaso-spastic disorders such as Raynauds. These are less common.

The podiatrist's role

The podiatrist role is to identify, diagnose and treat disorders, diseases and deformities of the feet and legs and implement appropriate and timely care. This may be provided directly by a podiatrist or in association with other healthcare team members as required by the individual’s foot problems. The goal of the podiatry element of rheumatology care is to reduce foot-related pain, maintain / improve foot function and so mobility, while protecting skin and other tissues from damage. This and the need for timely access to podiatry services for people with rheumatology conditions is recognised within nationally published guidelines (2,3).

Range of treatments used by podiatry

Podiatry advice and treatments are based on information gained from the history and assessment of a person's foot problem. An assessment of the lower limbs may include the skin, vascular and neurological systems, the musculo-skeletal structures and walking, as well as footwear.

The types of treatments used will be dependent on the individual's particular assessed problem/s with reference to wider health and social matters and wishes. Where appropriate, people are encouraged and enabled to manage their foot and ankle aspects of their condition. However, treatments may include:

• Palliative foot care. This may include assistance with general nail care, which may be made difficult due to hand-related problems or by the nails being distorted or altered in some way; treatment for areas of hard skin/ callus and corns. (Professional guidance should always be sought - you are advised not to use pedicure blades, corn plasters and paints on these area.
• Specialist assessment and management of wounds / ulcers that can occur on the foot
• Prescribing specialist orthoses for the feet e.g. insoles, splints. These vary from soft devices that cushion tender areas under the foot to firmer devices that realign the foot, encouraging it to function better. Often these principles are combined in a device.
• Assessment and advice about appropriate footwear choices, footwear adaptations and accessing specialist footwear services. Some NHS Podiatrist departments have footwear clinics, either independently or in association with an orthotist or shoefitter.
• Advice related to the lower limb including joint protection, management of acute and chronic inflamed joints, appropriate exercise, surgical options.
• Education groups in conjunction with the rheumatology education sessions. These help people to understand the workings of the foot, how RA can affect it and strategies that can be of help. The issues discussed in a foot and leg care program may include:

Foot & leg anatomy related to walking, outlining the effect RA may have on this part of the body.

RA & Foot Structures.

Common signs & symptoms of RA in foot / leg.

What can you do to self-help, including use of hot & cold, joint protection. When to get help. 

Footwear advice.

Role of foot orthoses.

Safe, appropriate self care.

Prevention guidance & minor wounds etc.

Exercise guidance.

Service access - what are the local arrangements for annual foot checks and access to podiatry if you have a problem.

Accessing locally chiropody/ podiatry practitioners

People with rheumarology conditions may require access to differing levels and types of Foot Health Service depended on how active their RA is, how long they have had RA, and impact it has had on their feet, legs and mobility. Your needs may include:

• Prompt access to a podiatry assessment and the initiation of appropriate management/ treatment if indicated (see above), with access to specialist podiatry as necessary.
• Timely periodic review of care needs as indicated.
• Processes in place to ensure that an annual foor check by a health professional (not necessarily a podiatrist) is carried out when appropriate.
• Timely and appropriate guidance to enable self management.
• Access to a range of skill mix within a team of health professions to meet the individual's needs, including foot surgery.

If you receive your rheumatology care at a rheumatology department, you can expect that as part of rheumatology team there will be a podiatrist specialising in musculo-skeletal/ rheumatology foot conditions, either within the department or available via a referral by the rheumatology team. Similarly GPs can refer you to community based services. People can also access podiatry care via private practice. The Yellow pages (looking under ‘chiropody’) and word of mouth are the best way to find someone. If you have access to the internet, the Society of Chiropodists and Podiatrists web site has a 'find a podiatrist' facility http://www.feetforlife.org/ Some employers, department stores and leisure centres also provide podiatry, although the latter is more likely to be sports related.

Conclusion

As mentioned earlier, managing people's foot and leg problems that are associated with RA often will involve the podiatrist working closely with other members of the multi-disciplinary team. As such the rheumatology team will try to ensure that problems are addressed in a timely and appropriate manner, reflecting the needs and wishes of the individual who has RA.

1. ARMA Standards of Care for people with inflammatory arthritis 2004. pp17

2. Standards of care for people with muskuloskeletal foot health problems PRCA 2008 www.prcassoc.org.uk/standards-project

3. NICE Guidelines - RHEUMATOID ARTHRITIS - National clinical guideline for management and treatment in adults 2009 (www.nice.org.uk/CG79)

As part of the work that has been done on foot standards a patient leaflet has been produced called 'Feet First' and this can be obtained by opening the link below or by called the National Rheumatoid Arthritis Society office on 0800 298 7650 to request a copy.

Click here for PDF

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