Rheumatism and the feet: relieving deformities early and protecting joints

The underlying mechanisms

Rheumatoid arthritis is the most common inflammatory rheumatic systemic disease in adulthood. It leads to chronic inflammation of the synovial membrane, known as synovitis. In a healthy foot, the synovial fluid ensures smooth gliding of the cartilage surfaces and supplies them with nutrients. In rheumatic disease, the cells of the synovial membrane proliferate uncontrollably, forming a hyperplastic tissue known as pannus.

This pannus tissue releases aggressive enzymes such as matrix metalloproteinases and inflammatory cytokines. These substances directly attack the articular cartilage and degrade it step by step. As the condition progresses, the inflammatory tissue invades the underlying bone, causing marginal erosions. The smaller joints of the foot are particularly susceptible to this process. The metatarsophalangeal joints, abbreviated as MTP joints, which connect the metatarsal bones to the phalanges, are affected extremely frequently.

Parallel to the osseous destruction, chronic inflammation loosens the capsular and ligamentous structures. The ligaments lose their tension. The interplay of the intrinsic foot muscles loses its equilibrium. The natural plantar pad, a submetatarsal fat pad beneath the metatarsal heads, shifts anteriorly towards the toes. Specialists refer to this as dislocation of the fat pad. As a result, the metatarsal heads lose their protective cushioning, pressing directly against the thinning skin and the sole of the shoe with every step.

As a consequence of these biomechanical shifts, typical deformities occur. These include hallux valgus, in which the great toe deviates laterally, as well as hammer toes and claw toes. In the midfoot, loss of the transverse arch leads to splayfoot (metatarsus latus). In the hindfoot region, involvement of the subtalar joint and insertion tendons often causes a valgus alignment. The foot collapses inwards, resulting in a painful pes planovalgus (flatfoot with valgus alignment). Without corrective interventions, these deformities stiffen over time.

Typical signs

Rheumatic foot changes often begin insidiously. Initially, affected individuals report diffuse morning stiffness in the toe and ankle joints, often lasting longer than 30 minutes. Under weight-bearing conditions, a burning pain occurs beneath the forefoot. Many patients vividly describe this feeling as walking on round pebbles or crumpled socks. At rest, the pain initially subsides, but it returns with increased intensity upon renewed exertion.

As joint changes progress, visible symptoms on the skin and bone structure become apparent. Due to toe deformities, the joints rub against the upper part of the shoe or adjacent toes. The body responds to this mechanical pressure with increased cell division in the epidermis, creating circumscribed hyperkeratotic thickenings. Beneath these hyperkeratotic plaques, localized pressure frequently gives rise to deep-seated corns, medically termed clavi.

The altered weight-bearing conditions manifest through the following characteristic features:

• Subluxation or dislocation of the metatarsophalangeal joints with plantar prominence of the metatarsal heads
• Hallux valgus with medial exostosis formation and bursal irritation
• Claw and hammer toe deviations with dorsal pressure points on the interphalangeal joints
• Planovalgus deformity (flatfoot with valgus alignment) caused by insufficiency of the posterior tibial tendon

These inflammatory changes must be distinguished from classic degeneration, such as osteoarthritis. Osteoarthritis typically presents with pain upon initial movement that depends on strain, without marked signs of resting inflammation such as warmth or swelling. Gout also differs significantly, progressing in acute, extremely painful attacks that usually affect a single joint in isolation, predominantly the first metatarsophalangeal joint. Diabetic polyneuropathies, by contrast, are accompanied by a loss of pain sensation, whereas the rheumatic foot remains extremely sensitive to pain.

Causes in daily life

In daily life, various factors interact to accelerate symptoms in rheumatic conditions. A primary trigger for painful pressure points is unsuitable footwear. Fashion-oriented shoes often feature an overly narrow toe box. They compress the already unstable toes and exacerbate joint subluxation. High heels shift the entire body weight forward onto the compromised forefoot skeleton, multiplying the pressure on the metatarsal heads.

Another issue lies in altered gait patterns. To avoid pain when rolling off the foot, patients unconsciously adopt an antalgic gait, rolling off primarily over the lateral border of the foot or the hindfoot. This altered loading overburdens adjacent muscle chains, tendons, and joints, producing chronic overuse symptoms that extend far beyond the originally inflamed joint.

Mistakes also occur frequently during routine foot care. Rheumatic patients are often on medication regimes involving glucocorticoids, such as cortisone, or immunomodulators. These medications lead to thinning of the skin structure, often termed parchment skin. The connective tissue loses elasticity, and wound healing is delayed. Anyone attempting to self-remove calluses using sharp blades, planes, or pumice stones risks minor injuries. These microtraumas create entry points for pathogens and can trigger severe infections.

When to seek medical advice

Regular podiatric monitoring is valuable, yet it cannot replace specialist care in rheumatology and orthopaedics. Clear warning signs, known as red flags, require immediate medical investigation. If a joint suddenly swells significantly, turns intensely red, and feels markedly hot, an acute inflammatory flare-up or septic arthritis must be ruled out. This applies especially when systemic symptoms such as fever, chills, or general malaise are present.

Open skin lesions, blisters, deeper fissures, or ulcerating changes on the metatarsal heads and toe tips require immediate medical attention. Due to the use of immunosuppressants, the risk of infection is drastically elevated. A small lesion can quickly penetrate into deeper tissues, potentially resulting in bone infection, known as osteomyelitis.

Likewise, newly occurring numbness, tingling paresthesias, or a sudden loss of strength when lifting the foot demand neurological and orthopaedic diagnostics. Such symptoms may indicate nerve compression caused by massive joint swelling or rheumatic vasculitis. Close coordination between the rheumatologist, general practitioner, and podiatrist is imperative in such situations.

What podiatric treatment can achieve

Medical foot care in rheumatic diseases requires a high degree of tact and sound specialist knowledge. At the beginning of each therapy session, a thorough medical history and visual assessment are conducted. The therapist evaluates skin condition, checks circulation, and localises pressure tenderness as well as bony prominences. All findings are carefully documented to enable follow-up monitoring. You can learn more about structured treatment procedures at /en/services.

During actual treatment, state-of-the-art rotary instruments equipped with specialized diamond burs and carbide cutters are used. To prevent frictional heat, we utilize wet-drilling techniques with a fine spray mist, ensuring continuous cooling of the tissue. Callus thickenings on the stressed metatarsal heads are precisely and painlessly removed layer by layer. Deep-seated corns can also be gently removed in this manner without damaging the surrounding sensitive skin.

A major focus is placed on crafting bespoke pressure and friction relief appliances. For this purpose, we use medical silicone orthoses. These orthoses are mixed from two components directly on the patient's foot and molded for a precise fit. After curing, they possess a defined softness with a Shore hardness of approximately 15 to 25. Such an orthosis can, for instance, separate compressed toes, cover sensitive exostoses, or relieve the dorsal interphalangeal joint in hammer toe deformities. It fits easily into shoes and is hygienically washable.

If toenails come under pressure due to altered toe mechanics and tend towards deformities such as onychauxis or ingrowing, gentle corrective techniques are employed. Where required, we evaluate the overall clinical status within the scope of our qualification as a /en/sectoral-practitioner (sectoral practitioner of podiatry) to coordinate tailored therapeutic concepts.

In addition, targeted cold therapy can support inflammatory swelling. Controlled thermal stimuli cause transient vasoconstriction, slowing down inflammatory metabolic processes and alleviating pain. Further information can be found at /en/cryotherapy. A standard podologische Komplexbehandlung (comprehensive podiatric treatment) typically lasts 45 to 60 minutes. Treatment intervals generally range between four and six weeks, depending on the rate of callus recurrence and inflammatory status.

Self-care and practical measures

Home care forms the daily counterpart to professional management in the practice. Dedicate a few minutes each day to inspecting your feet carefully. Use an unbreakable hand mirror or ask family members for assistance. Look out for redness, small pressure marks, skin fissures, or changes in nail structure. This routine helps identify issues before they develop into painful wounds.

The following measures have proven effective in daily life:

• Daily inspection of the soles and interdigital spaces using an unbreakable hand mirror
• Selection of footwear featuring soft upper leather, a wide toe box, and removable footbeds
• Daily care of atrophic skin with fragrance-free, moisturizing, urea-containing emulsions
• Gentle toe mobilization exercises without exceeding the pain threshold

When purchasing shoes, strictly observe biomechanical criteria. Preferably buy shoes in the afternoon, as feet swell slightly as the day progresses. Choose models with soft, pliable uppers such as elk leather or flexible stretch inserts. The sole should feature an integrated rocker bottom. Such a curved sole construction relieves the forefoot of flexion during gait and substantially reduces peak pressure on the MTP joints. Furthermore, the shoe must offer sufficient depth to accommodate custom soft-cushioned insoles without causing compression.

Skincare requires products tailored specifically to thin, fragile skin. Creams with a urea content of 5 to a maximum of 10 percent provide intense moisture and keep the stratum corneum pliable. Higher concentrations should be avoided, as they can burn on irritated skin. Apply the emulsion thinly, avoiding the interdigital spaces. Moisture between the toes promotes fungal infections and skin maceration.

Common errors

In clinical practice, we regularly encounter mistakes made out of unawareness that significantly aggravate the condition of the feet. The most dangerous error is the application of over-the-counter corn plasters from pharmacies or chemist shops. These plasters contain salicylic acid. While acid may dissolve hyperkeratotic tissue on healthy skin, in rheumatic patients with glucocorticoid-thinned skin, the acid eats uncontrollably into deeper tissue layers. This leads to chemical burns and deep tissue necrosis.

Another misconception is the belief that firm, tight shoes provide stability to an unstable foot. The opposite is true. External pressure squeezes altered joints together, accelerating cartilage destruction. Extensive, hot foot baths should likewise be avoided. Prolonged soaking severely softens the skin, rendering it prone to fissures and stripping away essential lipids. A brief, lukewarm foot bath lasting no longer than three minutes is entirely sufficient.

Many individuals delay visiting a podiatrist because they accept pain as an inevitable symptom of their underlying condition. Do not wait until walking becomes almost impossible or wounds have formed. The earlier pressure relief is initiated, the better the progression of rigid deformities can be delayed.

Clinical evidence and context

Medical evidence regarding podiatric and orthopaedic care in rheumatoid arthritis is unambiguous. Epidemiological studies show that up to 90 percent of all patients with rheumatoid arthritis develop significant foot problems over the course of their disease [1]. The joints of the forefoot are frequently affected within the first two years after initial diagnosis, even when pharmacological management successfully controls hand pain.

Clinical studies demonstrate the efficacy of customized pressure relief devices and fitted insoles. A randomized controlled trial showed that early intervention with soft-cushioned foot orthoses can reduce peak pressure under the metatarsal heads by more than 30 percent [2]. Patients reported a statistically significant reduction in walking pain and an improvement in overall daily function.

Systematic reviews also highlight that a combination of professional podiatric skin and nail care, individually crafted silicone orthoses, and adapted footwear drastically reduces the risk of ulceration [3]. Guidelines from the German Society for Rheumatology (DGRh) explicitly recommend incorporating qualified podiatrists into the interdisciplinary treatment team [4]. Interdisciplinary collaboration among rheumatologists, podiatrists, and orthopaedic shoe technicians secures long-term patient mobility.

Treatment in Memmingen

At our practice FREITAG® Podologie GmbH in Memmingen, we offer individuals with rheumatic diseases nuanced and compassionate care. Led by owner Helga Maria Freitag, state-recognized podiatrist and sectoral practitioner of podiatry (sektorale Heilpraktikerin für Podologie), we rely on state-of-the-art hygiene standards and gentle treatment procedures. We understand the specific characteristics of rheumatic parchment skin and tailor every procedure precisely to your current state of health.

Our catchment area extends beyond Memmingen across the entire Unterallgäu, the Allgäu, and the adjacent region of Upper Swabia. We collaborate closely with treating rheumatologists, general practitioners, and local medical supply stores to ensure seamless care for you. Detailed insights into our premises can be found at /en/practice. If you have questions or would like to schedule an appointment, please feel free to reach out via our contact options at /en/contact.