Ankle and Foot Arthropathies: Difference between revisions

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'''Original Editors ''' - &lt;a href="User:Ward Willaert"&gt;Ward Willaert&lt;/a&gt;
'''Original Editors ''' - [[User:Ward Willaert|Ward Willaert]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel Evidence-Based Practice Project]]
 
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== Search Strategy ==
== Introduction ==
 
[[File:Foot.jpg|right|frameless|493x493px]]
Search terms: “Arthropathy”, “Haemophilic arthropathy”, “Osteoarthritis”, Rheumatoid arthritis”, Gout”, “psoriatic arthritis”, reactive arthritis”, Diabetic foot arthritis”, “Charcot neuropathic osteoarthropathy”<br>All these terms combined with: … AND “Diagnosis”, … AND “Epidemiology”, … AND “Treatment”, … AND “medical management”, … AND “Physical management”.
Any joint in the [[Ankle and Foot|ankle]], [[Foot Anatomy|foot]] and toes can be affected by an arthropathy (arthropathy is a general term for any disease of the joints).
 
* There are more than 100 forms of [[arthritis]], many of which affect the foot and ankle, causing [[Joint Classification|joint]] [[Pain Behaviours|pain]], swelling and stiffness.  
Used databases: PubMed, Google Scholar, Web of Science, Pedro, VUB library<br>
* Arthritis in the feet can make standing and walking painful and the  feet and/or toes  may change shape, making it harder to fit shoes and [[Activities of Daily Living]] may be affected.
 
* Athropathies of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients’ [[Quality of Life|quality of life]].  
== Definition/Description&nbsp;  ==
* Although arthropathy is less common in the ankle than the [[Hip Anatomy|hip]] and [[knee]], it can be just as disabling.<ref name="Stauffer">Stauffer RN: Intra-articular ankle problems. In Evarts CM (ed): surgery of the musculoskeletal system, vol. 4. New York, Churchill-Livingstone, 1990.</ref>
 
* Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle<ref name=":0">Rao S, Riskowski JL, Hannan MT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414868/ Musculoskeletal conditions of the foot and ankle: assessments and treatment options.] Best Practice & Research Clinical Rheumatology. 2012 Jun 1;26(3):345-68. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414868/ (last accessed 1.7.2020)</ref>.
An arthropathy is a disease of a joint. <br>Although the terms "arthropathy" and arthritis have very similar meanings, the former is traditionally used to describe the following conditions:
Arthropathy is a blanket or global term for a wide range of joint presentations.   
 
*Reactive arthropathy is caused by an infection, but not a direct infection of the synovial space.  
*Enteropathic arthropathy is caused by colitis and related conditions.
*Crystal arthropathy involves the deposition of crystals in the joint.  
**in &lt;a href="Gout"&gt;gout&lt;/a&gt;, the crystal is uric acid.  
**In pseudogout/chondrocalcinosis/calcium pyrophosphate deposition disease, the crystal is calcium pyrophosphate.  
*Diabetic arthropathy is caused by diabetes.
*Neuropathic arthropathy is associated with a loss of sensation
 
Although an arthropathy is distinctly less common in the ankle than in the hip and knee, it is an equally disabling condition<ref>Stauffer RN: Intra-articular ankle problems. In Evarts CM (ed): surgery of the musculoskeletal system, vol. 4. New York, Churchill-Livingstone, 1990, p 3868</ref>  
 
== Clinically Relevant Anatomy  ==
 
The most important relevant anatomy is the bone structures and joints of the foot and ankle.<br>The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint. The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heelbone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side. Just down the foot from the ankle is a set of five bones called tarsal bones that work together as a Group, they excist of 3 cuneiform bones (lateral, intermediate and medial), the navicular bone and the cuboid bone. There are multiple joints between the tarsal bones. The connection between these tarsal bones and the upper bones is called the transverse tarsal joint of the line of Chopart. The tarsal bones are connected to the five long bones of the foot called the metatarsals, this connection is calles the tarsometatasal joint or the line of Lisfranc. Then there are the bones of the toes, the phalanges. The joints between the metatarsals and the first phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern. <ref>http://www.eorthopod.com/content/foot-anatomy</ref><br>
 
== Epidemiology /Etiology  ==
 
add text here <br>
 
== Characteristics/Clinical Presentation  ==
 
The characteristics and clinical presentation of ankle arthropathies such as different forms of arthritis can be described as followed:
 
*Ankle pain
*stiffness
*swelling
*limited range of motion (ROM)
*Pain Mostly gets worse by activities such as standing, walking or running.
 
We can also speak of the so called “Start-up pain” such as when a patient has pain and stiffness in the ankle after sleeping or sitting in one spot for a while is also a common complaint.
 
When this happens/occurs it often takes the patient a few minutes (or longer) to “warm-up” the ankle. The ankle will tend to swell more as the day progresses particularly if there is increasing activity( patient is still doing sport activities, work activities,…).
 
Most of the time Pain is experienced throughout the ankle although it may be more noticeable in the front of the ankle if large bones spurs have formed. When there has been damage to the joint ankle, it’s often seen that arthritis will occur. Cartilage that normally covers the bones of the ankle joint can be lost leading to an ankle arthropathy.  
 
== Differential Diagnosis ==


Intra-articular pathologic lesions must be distinguished from surrounding <u>joint tendinitis </u>and <u>bursitis</u>. This can be achieved with diagnostic testing such as magnetic resonance imaging or with injection of local anesthetic.&nbsp;  
*Noninfectious arthritis eg [[Psoriatic Arthritis|Psoriatic arthritis]]; [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylitis]]; [[Gout]]; [[Rheumatoid Arthritis]]; [[Osteoarthritis]]; Haemophilic Arthropathy (with severe haemophilia causes high levels of impairment) <ref name="Barg">Barg, A., et al. Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series. Haemophilia 2010;16(4):647-655.</ref>; Post traumatic Arthritis.
*[[Reactive Arthritis|Reactive arthropathy]] occurs as a reaction against an infection site elsewhere in the body.<ref name="mayoclinic">Reactive Arthritis (Reiter’s Syndrome). www.mayoclinic.org. Retrieved May 16, 2011.(accessed  3 december 2016)</ref>  
*[[Enteropathic Spondylitis|Enteropathic arthropathy]] Includes a group of rheumatic conditions such as arthritis caused by bacteria, parasitic infections and spondyloarthropathies. Other conditions that are included in this type of arthropathy are intestinal bypass arthritis, Whipple’s disease , collagenous colitis and [[Celiac Disease (Coeliac Disease)|celiac disease.]]<ref name="Björkengren">Björkengren A. G., Resnick D, Sartoris DJ. Enteropathic arthropathies. Radiologic Clinics of North America 1987: 189 </ref><ref name=":1" />
*Crystal arthropathy is characterised by accumulation of tiny crystals in one or more joints.<ref name="McGill">McGill, Neil W. Gout and other crystal-associated arthropathies. Best Practice &amp; Research Clinical Rheumatology 2000: 445-460 </ref>
*[[Charcot-Marie-Tooth Disease: A Case Study|Neuropathic arthropathy]] is gradual joint destruction when there is chronic damage of peripheral nerves and diminished proprioception (also called Charcot arthropathy and prominently affects patients with [[diabetes]])<ref name=":1">Scope heal [https://scopeheal.com/arthropathy/ Arthropathy] Available from:https://scopeheal.com/arthropathy/ (last accessed 1.7.2020)</ref> <ref name="Sanders (2013)">Sanders, L.J., Edmonds, M.E. & Jeffcoate, W.J. Diabetologia (2013) 56: 1873. https://doi.org/10.1007/s00125-013-2961-6 </ref>
*[[The Diabetic Foot|Diabetic arthropathy]] is a neuropathic arthropathy occurring in diabetic patients.&nbsp;<ref name="Medical dic">Medical dictionary. http://medical-dictionary.thefreedictionary.com/diabetic+arthropathy (Accessed 2 december 2016)</ref>
Be sure to look at all the links above for detailed information, this page is a general overview.


<u>Primary osteoarthritis </u>is a diagnosis of exclusion. It has been addressed successfully with low tibial osteotomy<ref>Takakura Y, Tanaka Y, Kumal T, et al: Low tibial osteotomy for osteoarthritis of the ankle. J Bone joint surg Br 1995; 77:50.</ref>
== Relevant Anatomy ==
[[File:Bones of the foot.png|right|frameless|485x485px]]
Each foot has 28 bones and more than 30 joints. The most common foot joints that arthritis affects are:
# The [[Ankle Joint|Ankle joint]]
# The 3 joints of the foot that involve the calcaneus, the navicular , and the cuboid bone.
# The !st MTP joint <ref>Cleveland clinic [https://my.clevelandclinic.org/health/diseases/13900-foot-and-ankle-arthritis Foot and ankle arthritis] Available from:https://my.clevelandclinic.org/health/diseases/13900-foot-and-ankle-arthritis (last accessed 1.7.2020)</ref>
More information about the anatomy of the ankle and foot can be found here: [http://www.physio-pedia.com/Biomechanics_of_Foot_and_Ankle Biomechanics of Foot and Ankle] and [http://www.physio-pedia.com/Ankle_Joint Ankle Joint].


<u>Post traumatic osteoarthritis </u>is the most common form of ankle arthritis. Post-traumatic disease can be present after intra-articular fractures or improper joint biomechanics after extra-articular fractures. Frequently, deformity is present in the joint. The extent of bone loss after trauma and joint space collapse can be assessed with weightbearing radiographs and CT scans.  
== Signs and Symptoms ==
In general the symptoms are pain in the joints, reduction of the functions of the structure of connection or support and inflammation in the tendons, ligaments, joints, muscles and bones.
* Decreased range of motion, effusion, neumarthrosis, bone erosion.
* The symptoms are similar to rheumatic conditions and include pain, swelling and stiffness.
* Skeletal muscle is also affected by pain and inflammation of bones, structure, muscles, and is a type of joint disease<ref name=":1" />.
* Pain usually increases on activities such as standing, walking or running.
* “Start-up pain” is also a common complaint, where the patient experiences pain and stiffness in the ankle on moving after being asleep or sitting for a long period, which takes a few minutes of motion to settle.  
* The affected joints will tend to increasingly swell as the day progresses, particularly with a higher level of activity.
== Assessment ==
[[File:OA_ankle.jpg|right|frameless|200x200px]]A clinical examination of the foot includes ‘traditional’ components such as history, palpation, and assessments of sensation, range of motion and strength, as well as special tests that provoke specific tissues. On observation, toe deformities and skin health (dryness, sweating, perfusion) should be noted.<ref name=":0" />


<u>Avascular necrosis </u>must be considered in cases in which sclerosis of the talar dome is present. Patients may have a history of talar neck fracture, steroid or alcohol usage, or nonspecific injuries. Avascular necrosis of the talus can result in progressive segmental collapse and an increasing amount of particulate matter into the joint.  
Salient Points of Examination include:
# Patients’ self-reported outcomes eg [[Visual Analogue Scale|VAS,]] [[Patient Specific Functional Scale|PSFS]]
# Static Foot Structure and Alignment eg [[Foot Posture Index (FP1-6)|the Foot Posture Index]]
# Joint Range of Motion - Quantified using a [[goniometer]], and note position tested in.
#[[File:Walk.jpg|right|frameless]]Muscle strength - Decreased toe flexor strength and foot pain are independently associated with fall risk. Strength deficits have also been reported in individuals with foot pain secondary to tibialis posterior tendinopathy<ref name=":0" />.
# Footwear assessment - Inspect for fit (length and width) and design features such as the presence of a heel cup, arch support, torsional and toe-break flexibility. Patterns of wear on the sole of the shoe and/or or scuffing should be noted. The Footwear Assessment Form is a simple and well-organized tool with established reliability and face-validity<ref name=":0" />.
# Dynamic Assessment of Foot Motion (including Gait Analysis) - Involves an observational or quantitative assessment of foot and lower extremity mechanics during a weight-bearing task (e.g., walking, running, single limb squat, step down). Particularly relevant in a clinical foot exam because evidence indicates that there is only a weak relationship between static and dynamic measures of arch height and large between-person variability<ref name=":0" />
# Dynamic Assessment of Plantar Load Distribution - When performing a clinical assessment, the plantar aspect of the foot should be inspected for patterns of calluses and weight-bearing.
# Provocational Tests - The final part of the clinical examination comprises provocational tests that provoke specific tissues. The [[Windlass Test]]<nowiki/>tstretcheshe plantar fascia and is considered positive if the patient reports pain when the 1st metatarso-phalanegeal joint is passively dorsiflexed. Limited extensibility in the gastrocnemius-soleus complex or the [[flexor hallucis longus]] can be assessed using passive muscle length testing. Symptoms related to the [[Sesamoiditis|sesamoids]] may manifest as plantar pain and localized tenderness to palpation.<ref name=":0" />


<u>Systematic inflammatory diseases </u>such as <u>rheumatoid arthritis </u>should be excluded prior to considering operative intervention. Ankle arthritis can be effectively treated with a medical regimen prior to considering surgical intervention, particularly during a flare of the disease. The majority of patients with rheumatoid arthritis test positive for rheumatoid factor. In addition, the diagnosis of rheumatoid arthritis requires the presence of certain other symptoms: morning stiffness, multiple joint swelling, rheumatoid nodules, and joint erosion on radiographs<ref>Geppert MJ, Mizel MS: Management of heel pain in inflammatory arthritides. Clin Orthop 1998; 349:93.</ref>  
== Medical Treatment  ==
Management of ankle and foot arthropathies generally commences with conservative interventions, including analgesic or anti-inflammatory medications, therapeutic injections, physical therapy, footwear modifications and foot orthoses. If these treatments are ineffective, surgical options may be considered.<ref name=":2">Roddy E, Menz HB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871064/ Foot osteoarthritis: latest evidence and developments.] Therapeutic advances in musculoskeletal disease. 2018 Apr;10(4):91-103. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871064/ (last accessed 2.7.2020)</ref>


Patients with absence of rheumatoid factor in the serum, but manifestations of inflammatory arthritis are classified as having <u>seronegative arthropathy</u>. The four major disorders include <u>ankylosis spondylitis</u>, <u>psoriatic arthritis</u>, <u>Reiter’s syndrome</u>, and <u>inflammatory bowel arthritides</u>.  
The medications used to treat arthropathies vary depending on the diagnosis. Commonly used medications include:
#[[File:Methotrexate.jpg|right|frameless]][[Pain Medications|Painkillers]] eg paracetamol, For more-severe pain, opioids might be prescribed,
# Oral non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely used first-line pharmacological treatment. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.<ref name=":3">Mayo clinic [https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777 Arthritis] Available from:https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777 (last accessed 2.7.2020)</ref>
# Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
# Disease-modifying antirheumatic drugs ([[DMARDs in the Management of Rheumatoid Arthritis|DMARDs]]). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. eg methotrexate (Trexall, Rasuvo, others) and hydroxychloroquine (Plaquenil).
# [[BDMARDs in the Management of Rheumatoid Arthritis|Biologic response modifiers]]. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. eg Tumor necrosis factor (TNF) inhibitors are commonly prescribed. Other medications target other substances that play a role in inflammation eg interleukin-1 and certain types of white blood cells known as B cells and T cells.
# [[Corticosteroids in the Management of Rheumatoid Arthritis|Corticosteroids]]. This class of drugs, which includes prednisone (Prednisone Intensol, Rayos) and cortisone (Cortef), reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or can be injected directly into the painful joint<ref name=":3" />.
[[Therapeutic Corticosteroid Injection|Therapeutic Injections]]: Provide an effective alternative financially and some evidence exists that they are effective in pain alleviation (current evidence is limited and the benefit described from injection therapy has been short-lived in most cases)<ref>Urits I, Smoots D, Franscioni H, Patel A, Fackler N, Wiley S, Berger AA, Kassem H, Urman RD, Manchikanti L, Abd-Elsayed A. I[https://link.springer.com/article/10.1007/s40122-020-00157-5 njection Techniques for Common Chronic Pain Conditions of the Foot]: A Comprehensive Review. Pain and therapy. 2020 Feb 27:1-6. Available from:https://link.springer.com/article/10.1007/s40122-020-00157-5 (last accessed 2.7.2020)</ref>.
* The most widely used are: corticosteroid injections and Viscosupplementation, the intra-articular injection of a lubricating fluid (hyaluronan) (aim of restoring the viscoelasticity of the synovial fluid).<ref name=":2" />
* Regenerative Injections are another option 1. Platelet-rich plasma (PRP) injections - these injections use your own blood and platelets to promote healing. Platelets contain growth factors and proteins that aid healing in soft tissues. Research shows PRP injections can alter the immune response to help reduce inflammation; 2. Placental tissue matrix (PTM) injections - injections of placental tissue  (obtained after a healthy baby is delivered from a healthy mother), there is a large number of growth factors in placental tissue that promote healing<ref>Clevelandclinic [https://health.clevelandclinic.org/4-injections-that-can-banish-joint-pain-for-months/ 4 Therapeutic injections] Available from:https://health.clevelandclinic.org/4-injections-that-can-banish-joint-pain-for-months/ (last accessed 2.7.2020)</ref>; 3. Mesenchymal Stem Cells (MSC) - Mesenchymal stem cells are usually collected from the patient’s fat tissue, blood, or bone marrow. When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of cartilage damage.When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of damage<ref>arthritis health [https://www.arthritis-health.com/treatment/injections/stem-cell-therapy-arthritis SCT]  Available from: https://www.arthritis-health.com/treatment/injections/stem-cell-therapy-arthritis (last accessed 2.7.2020)</ref>.


<u>Metabolic</u> and <u>infectious causes </u>of arthritis must be considered as well. This can include <u>gonococcal disease</u>, <u>Lyme disease</u>, and <u>gouty uricemia</u>. Patients should be questioned about possible exposure to disease sources for sexually transmitted diseases and insect bites.<br><br>H(a)emophilic arthropathy occurs by people who have haemophily, this is a desease which unables the blood from bleeding. When these bleedings occur within the joint it causes multiple defects to the joint, this is the result of a number of mechanisms affecting the synovial lining which becomes progressively fibrotic and the hyaline cartilage which disintegrates and is eventually lost. Mechanical and chemical processes cause degeneration of cells but enzymatic processes appear to be primairily responsible for the degradation of the matrix of the articular cartilage.<ref>J Bone Joint Surg Br. 1981;63B(4):601-9. The pathogenesis of chronic haemophilic arthropathy. Stein H, Duthie RB</ref>
== Physiotherapy ==
[[File:Foot massage.jpg|right|frameless]]
The primary aim of treatment is to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Individualised treatment is paramount taking into account clients diagnosis.  


Charcot osteoarthropathy or pedal neuropathic joint disease is a condition associated with peripheral neuropathy , it is a progressive deterioration of weight-bearing joints, usually in the foot or ankle, and is characterised in its early stages by acute inflammation that leads to bone and joint fracture, dislocation, instability and Gross deformaties. in patients with diabetes, Charcot osteoarthropathy is associated with a longstanding duration of diabetes and peripheral neuropathy. In the early stages of Charcot osteoarthropathy, the patient presents with a warm, erythematous and oedematous foot with or without associated pain or reported previous injury and can clinically mimic cellulitis or gout.<ref>Aust Fam Physician. 2010 Mar;39(3):117-9. Charcot osteoarthropathy of the foot. Perrin BM, Gardner MJ, Suhaimi A, Murphy D</ref>. It can lead to gross structural deformities of the foot and ankle, and subsequent skin ulceration and lower limb amputation from soft tissue or bony infection. The Charcot foot occurs most often in patients with diabetic neuropathy; other predisposing conditions include alcoholic neuropathy, sensory loss caused by cerebral palsy or leprosy, and congenital insensitivity to pain. However, it is often unrecognised, with deleterious consequences..<ref>Am Fam Physician. 2001 Nov 1;64(9):1591-8. Charcot foot: the diagnostic dilemma. Sommer TC, Lee TH.</ref><ref>J Diabetes Complications. 2009 Nov-Dec;23(6):409-26. Epub 2008 Oct 17. Charcot arthropathy of the foot and ankle: modern concepts and management review. Wukich DK, Sung W.</ref><br>
The plan of care should be designed with the goal of targeting impairments noted during assessment. Options include (see links also):
# [[File:ShoeCue insole.jpg|right|frameless]]Lifestyle Modifications
* In the early stages of arthritathies, limiting the amount of force being placed on the foot and ankle may relieve pain. For example, low-impact activities such as swimming and yoga can provide cardiovascular benefits without putting stress on the foot or ankle.
* Losing weight may decrease pressure on the joints. The foot and ankle support the entire body every time we stand and move, and being overweight increases this pressure and may cause arthritis to progress more quickly.
2. [[Introduction to Orthotics|Orthoses]] and [[Foot Orthoses|footwear]]


== Diagnostic Procedures ==
3. [[Manual Therapy|Manual therapy]] examples include
* [[File:Standing Heel Rise.jpg|right|frameless]][[Massage]] – with sufficient pressure through the superficial tissue to reach the deep lying structures (used to increase blood flow, decrease swelling, reduce muscle spasm and promote normal tissue repair).
* Mobilisation –  joint and soft tissues are gently moved to restore normal range, lubricate tissues and relieve pain. eg Talar glides, Maitland mobilisations
4. [[Stretching]] and [[Exercise -Therapeutic|therapeutic exercises]], eg Stretches that target hamstrings, calves, foot arch and heel are particularly effective and complete range of motion exercises. Strengthening exercises like "small foot exercise", attempting to pick up pegs with toes, walking bare feet in sand.  


'''Osteoarthritis'''
5. [[Cryotherapy]] or [[Thermotherapy]]


The diagnosis of osteoarthritic ankle joint starts with clinical assessment, and includes assessment of alignment and stability and measurement of range of motion. Different radiographic modalities may help to recognize and analyse the underlying reasons for ankle OA. Only weight-bearing radiographs of the foot and ankle should be performed. Additional imaging modalities such as MRI and SPECT-CT may help to evaluate the extent of degenerative changes and their biological activities. (29)<br>
6. [[Therapeutic Ultrasound|Ultrasonic Therapy]] – to reduce tissue spasm, accelerates healing and pain relief.


'''Rheumatoid arthritis'''
7. I[[Interferential Therapy]] – used for differing treatment effects. E.g. pain relief, muscle or nerve stimulation, promoting blood flow and reducing inflammation.


Different imaging techniques, e.g. MRI, CT and ultrasonography (US), should help clinicians to detect early or subclinical foot problems, because clinical signs of foot disease in RA are often subtle. (9)(53)
8. [[Gait|Gait re-education]] – assess and treat appropriately with eg gait aides


When detecting joint inflammation ultrasonography and MRI have shown to be superior the clinical examination. (54) Sonography is being used more and more and has been found effective for the detection of erosions in patients with RA. Ultrasonography detected 6.5-fold more erosions in early disease than radiography. (53) Because US is easily available and less expensive than MRI it can be recommended as the first imaging method after plain radiography. (54)  
9. [[Taping]]
== Epidemiology /Etiology ==
*[[File:Ligaments_of_the_ankle_lateral_aspect_Primal.png|right|frameless]]Osteoarthritis - Approximately 1% of the world’s adult population is affected by ankle OA <ref name="Barg" />
* Rheumatoid Arthritis - The prevalence of foot pain in patients with RA has been reported at ranges from 60 to 94 % at some stage of the disease. <ref name="Lohkamp">Lohkamp M. et al. The prevalence of disabling foot pain in patients with early rheumatoid arthritis. The Foot  2006;16(4):201-207.</ref><ref name="Brenton">Brenton-Rule, Angela, et al. Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study.BMC musculoskeletal disorders 2016;17(1):1.</ref>
* Diabetic Foot Arthropathy -  Charcot neuropathic osteoarthropathy are detected in up to 29% of diabetics, whereas under MRI the detection rate rises to 75%.<ref name="Kucera">Kucera, Tomas, Haroun Hassan Shaikh, and Pavel Sponer. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. Journal of Diabetes Research 2016</ref>
* Gout - The global prevalence of gout is substantial and is increasing in many parts of the world over the past 50 years. The distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher prevalence of gout than that of developing countries and incidence of the disease appears to be on the increase. <ref name="Kuo">Kuo CF, et al. Global epidemiology of gout: prevalence, incidence and risk factors. Nature Reviews Rheumatology 2015;11(11):649-662.</ref>
*  Psoriatic Arthritis - Prevalence of Psoriatic arthritis in psoriasis patients is between 6% and 39%. It is possible that the condition remains generally underdiagnosed, related to lack of awareness by both the patient and physician. <ref name="Mease">Mease P. Psoriatic arthritis update." BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK 64.1/2 (2006): 25.</ref><u></u>
== ''<u></u><sub></sub><sup></sup>''<u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup>Clinical Bottom Line ==
<u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup>''<u></u><sub></sub><sup></sup>''<u></u><sub></sub><sup></sup>'''<u></u><sub></sub><sup></sup>'''<u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup><u></u><sub></sub><sup></sup>
*[[File:Ankle pumps.gif|right|frameless]]Ankle and foot arthropathies covers all joint disease types of the foot and ankle. 
* Physical therapy can be effective in all cases of ankle and foot arthropathies
* Accurate differential diagnosis is important so that the most appropriate  management protocol is implemented for the specific disease.
* Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance.
* A comprehensive assessment of the foot and ankle should include patients’ self-reported outcomes and measures of alignment, motion, strength and provocative tests.
* Increasing evidence highlights the importance of evaluating dynamic function and regional interdependence (advances in motion capture and plantar load distribution offer exciting opportunities to obtain precise, clinically relevant measures).
Non-surgical interventions are important factors to ease foot pain and slow the disease-related progression of foot and ankle conditions often seen with the rheumatic diseases. Increasingly, studies are showing that orthoses, footwear and other rehabilitation interventions may play an important role in rheumatology-related foot treatment<ref name=":0" />.


'''Haemophilic arthropathy'''
== References ==
 
<references />  
Radiography remains the workforce horse in the diagnosis and follow-up of haemophilic arthropathy. The radiographical findings in arthropathy follow an expected sequence of events and are overall similar in different joints. Magnetic resonance imaging (MRI) has advantages over radiography based on its capability of visualizing soft tissue and cartilage changes in haemophilic joints. The recent development and standardization of MRI scoring systems for measuring soft tissue and cartilage abnormalities may enable the comparison of pathological joint findings in clinical trials conducted at different institutions across the world (55)
 
'''Diabetic foot arthropathy'''
 
The diagnosis is based on patient’s history, clinical examination, and imaging methods. As a result of their lowered perception of pain, patients are quite often not aware of any injury. (20)(31) Local inflammation is the main symptom which can lead to the diagnosis being suspected. (18)
 
In Charcot feet arthropathies it is very important that the disease is diagnosed quickly, because a delay can lead to worsening structural damage or even limb loss. (16)(56)(57)(58) Unfortunately the diagnosis is often missed at first presentation. A possible reason for the missed diagnosis is that Charcot feet are not emphasized in medical training. The result is that it is difficult to advocate the right choice of approach due to low evidence based information. (16)
 
Acute Charcot activity can be diagnosed if the temperature of the affected foot is 2°C or more than the contralateral unaffected foot. (58)(20)
 
'''Gout'''
 
Gout is ideally diagnosed through identification of characteristic negatively birefringent crystals under polarized light microscopy in fluid aspirated from end-organ deposits, typically from a joint (59). However, fewer than 10% of patients with gout see a rheumatologist, and most cases of gout are diagnosed in the primary care setting based on signs, symptoms, and serum uric acid level (60).
 
'''Psoriatic arthritis'''
 
A diagnostic test for psoriatic arthritis does not exist unlike in RA which is cyclic citrullinated peptide and rheumatoid factor positive. As in other inflammatory conditions, markers such as erythrocyte sedimentation rate and C-reactive protein can be raised in psoriatic arthritis. (22)
 
Scoring systems have been developed to try and identify psoriatic arthritis at an early stage and criteria have been developed to aid in classification of the disease from the other SPAs and inflammatory arthritides. Not only are they useful for identifying psoriatic arthritis earlier, they can also help identify cases of psoriatic arthritis which do not present in the typical manner. Some criteria include psoriatic arthritis with the SPA group. The classification for psoriatic arthritis (CASPAR) criteria was developed specifically for psoriatic arthritis. It has good sensitivity and specificity for those presenting with disease of &lt;2 years’ duration. Although primarily used for classification, it can be used for diagnostic purposes. (22)
 
Further imaging such as magnetic resonance imaging (MRI) can help to identify soft tissue involvement in further detail, particularly when a patient is suffering from enthesitis. Ultrasound has also become a useful tool in the investigation of arthritis; it can help to identify bony erosions in those patients where synovitis or dactylitis is not always evident clinically. Studies have shown that ultrasound scan and MRI are more sensitive for detecting inflammation than plain radiographs <br>in psoriatic arthritis. (22)<br>
 
== Outcome Measures  ==
 
(also see &lt;a href="Outcome Measures"&gt;Outcome Measures Database&lt;/a&gt;)
 
'''Osteoarthritis'''
 
The Ankle Osteoarthritis Scale (two subscales: pain and disability) (103) is a reliable and valid self-assessment instrument that specifically measures patient symptoms and disabilities related to ankle arthritis. (109)
 
More outcome measures of ankle osteoarthritis can be found on the physiopedia page “&lt;a href="http://www.physio-pedia.com/Ankle_Osteoarthritis#Outcome_Measures"&gt;Ankle Osteoarthritis Arthritis&lt;/a&gt;”
 
'''Rheumatoid arthritis'''
 
American College of Rheumatology (ACR) response criteria for RA. (104)<br>The ACR20 response criteria require a 20% improvement in both tender and swollen joint counts, and a 20% improvement in 3 of 5 items: patient global assessment (visual analog scale, VAS), physician global assessment (VAS), patient pain score (VAS), Health Assessment Questionnaire (HAQ), and either erythrocyte sedimentation rate or C-reactive protein (CRP). For some PsAstudies the joint count was increased to 78 to include distal interphalangeal (DIP) joints of the feet. To achieve an ACR50 or ACR70 response, the same guidelines apply but the level of response is 50% or 70% improvement, respectively. (104)
 
'''Haemophilic arthropathy'''
 
Visualization of bone or cartilage damage in index joints on MRI can be used as outcome measure<br>Tentative haemophilic arthropathy scales based on MRI findings have been developed in the last decade. In 2005, the International Prophylaxis Study Group (IPSG) presented a preliminary comprehensive scoring scheme that combined the pioneer Denver and European MRI scores. The use of such scales should result in a more consistent assessment of haemophilic joints and should facilitate the development of more targeted treatment to prevent or delay further destructive osteoarticular changes. (105)
 
'''Diabetic foot arthropathy'''
 
No research found.
 
'''Gout'''
 
Many different instruments can be used to assess the acute gout core domains. Pain VAS and 5-point Likert scales, 4-point Likert scales of index joint swelling and tenderness and 5-point PGART instruments meet the criteria for the OMERACT filter. (106)
 
'''Psoriatic arthritis'''
 
The Psoriatic Arthritis Response Criteria (PsARC) is recommended in the assessment and monitoring of PsA. It consists of four components: assessment of joint tenderness and swelling utilizing 68/66 joint counts respectively, the patient’s opinion of their global health and the physician’s global assessment. (104)(107)
 
'''Reactive arthritis'''
 
The outcome measures of reactive arthritis can be found on the physiopedia page “&lt;a href="http://www.physio-pedia.com/Reactive_Arthritis#Outcome_Measures"&gt;Reactive Arthritis&lt;/a&gt;”<br>  
 
== Examination  ==
 
'''Osteoarthritis'''
 
The examination of osteoarthritis can be found on the physiopedia page “&lt;a href="http://www.physio-pedia.com/Ankle_Osteoarthritis"&gt;Ankle Osteoarthritis&lt;/a&gt;”
 
'''Rheumatoid arthritis'''
 
The examination of rheumatoid arthritis can be found on the Physiopedia page “&lt;a href="http://www.physio-pedia.com/Rheumatoid_Arthritis"&gt;Rheumatoid Arthritis&lt;/a&gt;”<br><br>
 
== Medical Management <br>  ==
 
'''Osteoarthritis'''
 
There is no cure of osteoarthritis. There are several treatments we can subdivide in pharmacologically, non- pharmacologically and surgical. The choice of treatment of ankle and foot osteoarthritis(OA) depends on the severity of the disease. (61) The goal of managing OA in foot and ankle includes the control of pain, improvement in function and quality of life. A number of different aspects like discomfort, comorbidity and radiologic damage need to be considered. (62-1A)
 
<br>
 
== Physical Therapy Management <br>  ==
 
add text here <br>
 
== Key Research  ==
 
add links and reviews of high quality evidence here (case studies should be added on new pages using the &lt;a href="Template:Case Study"&gt;case study template&lt;/a&gt;)<br>
 
== Resources  ==
 
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== Clinical Bottom Line  ==


<br>  
<br>  


== Recent Related Research (from [https://www.ncbi.nlm.nih.gov/pubmed/ PubMed])  ==
[[Category:Foot]]  
 
[[Category:Ankle]]
see tutorial on "[http://www.physio-pedia.com/Adding_PubMed_Feed Adding PubMed Feed]"
[[Category:Foot - Conditions]]  
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[[Category:Ankle - Conditions]]
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== References  ==
[[Category:Osteoarthritis]]
 
&lt;span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" /&gt;
 
&lt;a href="Category:Musculoskeletal/Orthopaedics"&gt;Orthopaedics&lt;/a&gt; &lt;a _fcknotitle="true" href="Category:Ankle"&gt;Ankle&lt;/a&gt; &lt;a _fcknotitle="true" href="Category:Rheumatology"&gt;Rheumatology&lt;/a&gt; &lt;a _fcknotitle="true" href="Category:Foot"&gt;Foot&lt;/a&gt;

Latest revision as of 16:47, 17 January 2023

Original Editors - Ward Willaert as part of the Vrije Universiteit Brussel Evidence-Based Practice Project Top Contributors - Anouck Leo, Admin, Arturo Quiroz Marnef, Evelien De Wolf, Scott Cornish, Kim Jackson, Lucinda hampton, Rachael Lowe, Ward Willaert, Gayatri Jadav Upadhyay, Yuli Borremans, 127.0.0.1, Mariam Hashem, Cath Young, Maxim de Clippele, Veekhoven Laura, Jan De Backer, Sai Kripa, Aminat Abolade and Fitim Cami  

Introduction[edit | edit source]

Foot.jpg

Any joint in the ankle, foot and toes can be affected by an arthropathy (arthropathy is a general term for any disease of the joints).

  • There are more than 100 forms of arthritis, many of which affect the foot and ankle, causing joint pain, swelling and stiffness.
  • Arthritis in the feet can make standing and walking painful and the feet and/or toes may change shape, making it harder to fit shoes and Activities of Daily Living may be affected.
  • Athropathies of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients’ quality of life.
  • Although arthropathy is less common in the ankle than the hip and knee, it can be just as disabling.[1]
  • Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle[2].

Arthropathy is a blanket or global term for a wide range of joint presentations.

Be sure to look at all the links above for detailed information, this page is a general overview.

Relevant Anatomy[edit | edit source]

Bones of the foot.png

Each foot has 28 bones and more than 30 joints. The most common foot joints that arthritis affects are:

  1. The Ankle joint
  2. The 3 joints of the foot that involve the calcaneus, the navicular , and the cuboid bone.
  3. The !st MTP joint [10]

More information about the anatomy of the ankle and foot can be found here: Biomechanics of Foot and Ankle and Ankle Joint.

Signs and Symptoms[edit | edit source]

In general the symptoms are pain in the joints, reduction of the functions of the structure of connection or support and inflammation in the tendons, ligaments, joints, muscles and bones.

  • Decreased range of motion, effusion, neumarthrosis, bone erosion.
  • The symptoms are similar to rheumatic conditions and include pain, swelling and stiffness.
  • Skeletal muscle is also affected by pain and inflammation of bones, structure, muscles, and is a type of joint disease[6].
  • Pain usually increases on activities such as standing, walking or running.
  • “Start-up pain” is also a common complaint, where the patient experiences pain and stiffness in the ankle on moving after being asleep or sitting for a long period, which takes a few minutes of motion to settle.
  • The affected joints will tend to increasingly swell as the day progresses, particularly with a higher level of activity.

Assessment[edit | edit source]

OA ankle.jpg

A clinical examination of the foot includes ‘traditional’ components such as history, palpation, and assessments of sensation, range of motion and strength, as well as special tests that provoke specific tissues. On observation, toe deformities and skin health (dryness, sweating, perfusion) should be noted.[2]

Salient Points of Examination include:

  1. Patients’ self-reported outcomes eg VAS, PSFS
  2. Static Foot Structure and Alignment eg the Foot Posture Index
  3. Joint Range of Motion - Quantified using a goniometer, and note position tested in.
  4. Walk.jpg
    Muscle strength - Decreased toe flexor strength and foot pain are independently associated with fall risk. Strength deficits have also been reported in individuals with foot pain secondary to tibialis posterior tendinopathy[2].
  5. Footwear assessment - Inspect for fit (length and width) and design features such as the presence of a heel cup, arch support, torsional and toe-break flexibility. Patterns of wear on the sole of the shoe and/or or scuffing should be noted. The Footwear Assessment Form is a simple and well-organized tool with established reliability and face-validity[2].
  6. Dynamic Assessment of Foot Motion (including Gait Analysis) - Involves an observational or quantitative assessment of foot and lower extremity mechanics during a weight-bearing task (e.g., walking, running, single limb squat, step down). Particularly relevant in a clinical foot exam because evidence indicates that there is only a weak relationship between static and dynamic measures of arch height and large between-person variability[2]
  7. Dynamic Assessment of Plantar Load Distribution - When performing a clinical assessment, the plantar aspect of the foot should be inspected for patterns of calluses and weight-bearing.
  8. Provocational Tests - The final part of the clinical examination comprises provocational tests that provoke specific tissues. The Windlass Testtstretcheshe plantar fascia and is considered positive if the patient reports pain when the 1st metatarso-phalanegeal joint is passively dorsiflexed. Limited extensibility in the gastrocnemius-soleus complex or the flexor hallucis longus can be assessed using passive muscle length testing. Symptoms related to the sesamoids may manifest as plantar pain and localized tenderness to palpation.[2]

Medical Treatment[edit | edit source]

Management of ankle and foot arthropathies generally commences with conservative interventions, including analgesic or anti-inflammatory medications, therapeutic injections, physical therapy, footwear modifications and foot orthoses. If these treatments are ineffective, surgical options may be considered.[11]

The medications used to treat arthropathies vary depending on the diagnosis. Commonly used medications include:

  1. Methotrexate.jpg
    Painkillers eg paracetamol, For more-severe pain, opioids might be prescribed,
  2. Oral non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely used first-line pharmacological treatment. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.[12]
  3. Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
  4. Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. eg methotrexate (Trexall, Rasuvo, others) and hydroxychloroquine (Plaquenil).
  5. Biologic response modifiers. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. eg Tumor necrosis factor (TNF) inhibitors are commonly prescribed. Other medications target other substances that play a role in inflammation eg interleukin-1 and certain types of white blood cells known as B cells and T cells.
  6. Corticosteroids. This class of drugs, which includes prednisone (Prednisone Intensol, Rayos) and cortisone (Cortef), reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or can be injected directly into the painful joint[12].

Therapeutic Injections: Provide an effective alternative financially and some evidence exists that they are effective in pain alleviation (current evidence is limited and the benefit described from injection therapy has been short-lived in most cases)[13].

  • The most widely used are: corticosteroid injections and Viscosupplementation, the intra-articular injection of a lubricating fluid (hyaluronan) (aim of restoring the viscoelasticity of the synovial fluid).[11]
  • Regenerative Injections are another option 1. Platelet-rich plasma (PRP) injections - these injections use your own blood and platelets to promote healing. Platelets contain growth factors and proteins that aid healing in soft tissues. Research shows PRP injections can alter the immune response to help reduce inflammation; 2. Placental tissue matrix (PTM) injections - injections of placental tissue (obtained after a healthy baby is delivered from a healthy mother), there is a large number of growth factors in placental tissue that promote healing[14]; 3. Mesenchymal Stem Cells (MSC) - Mesenchymal stem cells are usually collected from the patient’s fat tissue, blood, or bone marrow. When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of cartilage damage.When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of damage[15].

Physiotherapy[edit | edit source]

Foot massage.jpg

The primary aim of treatment is to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Individualised treatment is paramount taking into account clients diagnosis.

The plan of care should be designed with the goal of targeting impairments noted during assessment. Options include (see links also):

  1. ShoeCue insole.jpg
    Lifestyle Modifications
  • In the early stages of arthritathies, limiting the amount of force being placed on the foot and ankle may relieve pain. For example, low-impact activities such as swimming and yoga can provide cardiovascular benefits without putting stress on the foot or ankle.
  • Losing weight may decrease pressure on the joints. The foot and ankle support the entire body every time we stand and move, and being overweight increases this pressure and may cause arthritis to progress more quickly.

2. Orthoses and footwear

3. Manual therapy examples include

  • Standing Heel Rise.jpg
    Massage – with sufficient pressure through the superficial tissue to reach the deep lying structures (used to increase blood flow, decrease swelling, reduce muscle spasm and promote normal tissue repair).
  • Mobilisation – joint and soft tissues are gently moved to restore normal range, lubricate tissues and relieve pain. eg Talar glides, Maitland mobilisations

4. Stretching and therapeutic exercises, eg Stretches that target hamstrings, calves, foot arch and heel are particularly effective and complete range of motion exercises. Strengthening exercises like "small foot exercise", attempting to pick up pegs with toes, walking bare feet in sand.

5. Cryotherapy or Thermotherapy

6. Ultrasonic Therapy – to reduce tissue spasm, accelerates healing and pain relief.

7. IInterferential Therapy – used for differing treatment effects. E.g. pain relief, muscle or nerve stimulation, promoting blood flow and reducing inflammation.

8. Gait re-education – assess and treat appropriately with eg gait aides

9. Taping

Epidemiology /Etiology[edit | edit source]

  • Ligaments of the ankle lateral aspect Primal.png
    Osteoarthritis - Approximately 1% of the world’s adult population is affected by ankle OA [3]
  • Rheumatoid Arthritis - The prevalence of foot pain in patients with RA has been reported at ranges from 60 to 94 % at some stage of the disease. [16][17]
  • Diabetic Foot Arthropathy - Charcot neuropathic osteoarthropathy are detected in up to 29% of diabetics, whereas under MRI the detection rate rises to 75%.[18]
  • Gout - The global prevalence of gout is substantial and is increasing in many parts of the world over the past 50 years. The distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher prevalence of gout than that of developing countries and incidence of the disease appears to be on the increase. [19]
  • Psoriatic Arthritis - Prevalence of Psoriatic arthritis in psoriasis patients is between 6% and 39%. It is possible that the condition remains generally underdiagnosed, related to lack of awareness by both the patient and physician. [20]

Clinical Bottom Line[edit | edit source]

  • Ankle pumps.gif
    Ankle and foot arthropathies covers all joint disease types of the foot and ankle.
  • Physical therapy can be effective in all cases of ankle and foot arthropathies
  • Accurate differential diagnosis is important so that the most appropriate management protocol is implemented for the specific disease.
  • Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance.
  • A comprehensive assessment of the foot and ankle should include patients’ self-reported outcomes and measures of alignment, motion, strength and provocative tests.
  • Increasing evidence highlights the importance of evaluating dynamic function and regional interdependence (advances in motion capture and plantar load distribution offer exciting opportunities to obtain precise, clinically relevant measures).

Non-surgical interventions are important factors to ease foot pain and slow the disease-related progression of foot and ankle conditions often seen with the rheumatic diseases. Increasingly, studies are showing that orthoses, footwear and other rehabilitation interventions may play an important role in rheumatology-related foot treatment[2].

References[edit | edit source]

  1. ↑ Stauffer RN: Intra-articular ankle problems. In Evarts CM (ed): surgery of the musculoskeletal system, vol. 4. New York, Churchill-Livingstone, 1990.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Rao S, Riskowski JL, Hannan MT. Musculoskeletal conditions of the foot and ankle: assessments and treatment options. Best Practice & Research Clinical Rheumatology. 2012 Jun 1;26(3):345-68. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414868/ (last accessed 1.7.2020)
  3. ↑ 3.0 3.1 Barg, A., et al. Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series. Haemophilia 2010;16(4):647-655.
  4. ↑ Reactive Arthritis (Reiter’s Syndrome). www.mayoclinic.org. Retrieved May 16, 2011.(accessed 3 december 2016)
  5. ↑ Björkengren A. G., Resnick D, Sartoris DJ. Enteropathic arthropathies. Radiologic Clinics of North America 1987: 189
  6. ↑ 6.0 6.1 6.2 Scope heal Arthropathy Available from:https://scopeheal.com/arthropathy/ (last accessed 1.7.2020)
  7. ↑ McGill, Neil W. Gout and other crystal-associated arthropathies. Best Practice & Research Clinical Rheumatology 2000: 445-460
  8. ↑ Sanders, L.J., Edmonds, M.E. & Jeffcoate, W.J. Diabetologia (2013) 56: 1873. https://doi.org/10.1007/s00125-013-2961-6
  9. ↑ Medical dictionary. http://medical-dictionary.thefreedictionary.com/diabetic+arthropathy (Accessed 2 december 2016)
  10. ↑ Cleveland clinic Foot and ankle arthritis Available from:https://my.clevelandclinic.org/health/diseases/13900-foot-and-ankle-arthritis (last accessed 1.7.2020)
  11. ↑ 11.0 11.1 Roddy E, Menz HB. Foot osteoarthritis: latest evidence and developments. Therapeutic advances in musculoskeletal disease. 2018 Apr;10(4):91-103. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871064/ (last accessed 2.7.2020)
  12. ↑ 12.0 12.1 Mayo clinic Arthritis Available from:https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777 (last accessed 2.7.2020)
  13. ↑ Urits I, Smoots D, Franscioni H, Patel A, Fackler N, Wiley S, Berger AA, Kassem H, Urman RD, Manchikanti L, Abd-Elsayed A. Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review. Pain and therapy. 2020 Feb 27:1-6. Available from:https://link.springer.com/article/10.1007/s40122-020-00157-5 (last accessed 2.7.2020)
  14. ↑ Clevelandclinic 4 Therapeutic injections Available from:https://health.clevelandclinic.org/4-injections-that-can-banish-joint-pain-for-months/ (last accessed 2.7.2020)
  15. ↑ arthritis health SCT Available from: https://www.arthritis-health.com/treatment/injections/stem-cell-therapy-arthritis (last accessed 2.7.2020)
  16. ↑ Lohkamp M. et al. The prevalence of disabling foot pain in patients with early rheumatoid arthritis. The Foot 2006;16(4):201-207.
  17. ↑ Brenton-Rule, Angela, et al. Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study.BMC musculoskeletal disorders 2016;17(1):1.
  18. ↑ Kucera, Tomas, Haroun Hassan Shaikh, and Pavel Sponer. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. Journal of Diabetes Research 2016
  19. ↑ Kuo CF, et al. Global epidemiology of gout: prevalence, incidence and risk factors. Nature Reviews Rheumatology 2015;11(11):649-662.
  20. ↑ Mease P. Psoriatic arthritis update." BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK 64.1/2 (2006): 25.


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