Foot pain

The feet and ankles can be affected by several types of arthritis:

• Osteoarthritis often affects the big toe but is also quite common in the arch area. Osteoarthritis can also develop in the ankle – usually following on from a previous injury or long-standing inflammatory arthritis.
• Rheumatoid arthritis can affect many of the joints in the foot.
• Reactive arthritis usually affects only the ankle or around the heel.
• Psoriatic arthritis often affects the toe joints.
• Gout, which is caused by the formation of crystals in a joint, often occurs in the foot and especially the big toe joint.
• Ankylosing spondylitis, which mainly affects the spine, can also cause pain or discomfort around the heels.

Apart from problems in the joints themselves, people with inflammatory arthritis may have inflammation and discomfort in the tendons and the other soft tissues in the feet. The part under or behind the heel where the tendons attach to the heel bone is quite often affected in this way.

Problems in the ankles and heels

Pain in the ankles and heels can arise either from the joints themselves or from the muscles and tendons. Osteoarthritis isn't common in the ankle, unless there has been previous damage from an injury, or inflammatory arthritis. When inflammatory arthritis affects the ankle, the joint may be especially sore or stiff first thing in the morning, or after sitting for a while.

• Valgus heel – With rheumatoid arthritis it is fairly common for the heel to drift outwards. This may not cause any problems if it doesn't drift too far, but it can be troublesome if the arch also flattens as a result. Research has shown that early treatment of rheumatoid arthritis may slow the development of valgus heel.

• Plantar fasciitis – The most common cause of discomfort around the heel is inflammation where tendons and fascia attach under the heel bone (plantar fasciitis or enthesopathy). This used to be known as policeman's heel. Plantar fasciitis is common with inflammatory arthritis, and can also occur in people who don't have arthritis.

Arch pain and tiredness

The arches of the feet allow the weight of the body to be spread over many bones and joints. 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 it can become more painful if the muscles or tendons are very overworked.

Pain in the ball of the foot

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

The most 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.

Other problems that occur in the ball of the foot include:

• Bursae – People with rheumatoid arthritis often develop fluid-filled sacs (bursae) under the ball of the foot. Bursae can grow and shrink as the level of inflammation varies. Bursae also occur next to large bunions.

• Neuroma – Sometimes a neuroma can develop in the forefoot, most often between the 3^rd and 4^th toes. This is a thickening of the nerve, caused by rubbing against other internal tissues. It's most common at the base of the toes. The symptoms are pain or tingling in the toes.
• Rheumatoid nodules – In rheumatoid arthritis, firm, pea-sized lumps can occur at pressure points such as the big toe joints, the back of the heels, or on the toes. Nodules on the soles of the feet can be particularly uncomfortable.

Bunions

Bunions are bony lumps that develop on the side of the foot at the base of the big toe. The big toe joint becomes stiff, and its range of movement is reduced. A bursa may develop here too, especially if shoes press against the bunion. The bursa may become inflamed and painful.

Sometimes, as the bunion develops, the big toe may be pushed over towards the smaller toes (this condition is known as hallux valgus). This can cause the other toes to become clawed or permanently bent. This is quite common in rheumatoid arthritis.

Hammer toes

Hammer toes (also known as claw toes, mallet toes or retracted toes) are toes that 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.

Hammer toes are most common in people who have bunions and/or high-arched feet. Discomfort from hammer toes is usually due to a build-up of hard skin over the raised joints, resulting in corns and calluses. There's also a risk of ulceration though this isn't common.

• Non-steroidal anti-inflammatory drugs (NSAIDs) can help to relieve painful inflammation.
• Special shoes or insoles (orthoses) can relieve arch pain or tiredness and help to correct less severe cases of valgus heel.
• A steroid injection may be recommended if just one or two joints are inflamed and painful, and may also help inflamed tendons or bursae, neuromas and plantar fasciitis. You will need to rest the foot for up to 48 hours after the injection.

Surgery

Surgery is sometimes recommended to improve the structure of your feet. If other treatments haven't helped, surgery may be suggested to:

• correct valgus heel or hammer toes
• remove a neuroma or rheumatoid nodules
• remove part of the bone from a bunion.

You will normally be referred to an orthopaedic surgeon if surgery is suggested. However, some state-registered podiatrists can also perform foot surgery.

Joint replacements for the ankle and foot are not yet as successful as replacement knees and hips. Most foot surgery is aimed at correcting the positions of the joints by resetting the bones or fusing the joint in the corrected position. Your surgeon will discuss the potential pros and cons of all the available options before you decide to go ahead with surgery.

Exercise

Losing weight can help ease the pressure on painful feet. Exercise is important in keeping joints moving. Swimming and other non-weight-bearing exercises are best if your feet are painful. If your ankles feel stiff in the morning, allowing some time for the joints to loosen up will usually help. During the day, alternate between sitting and standing activities to take the pressure off the feet.

Read more general advice and specific exercises that will help you keep active.

Foot care

A good, regular foot care routine will usually keep problems to a minimum. Corns and calluses can usually be scraped away using a pumice stone or abrasive board, though they will come back unless the cause of the pressure or friction is dealt with. Pads and cushions available from the chemist may help with painful pressure points.

You may need to take special care if you have arthritis – either because of the disease itself or because of the medications you take. If you have rheumatoid arthritis, NICE recommends that you should have your feet checked by a professional every year (this can be done by your GP, rheumatologist or nurse), and if you have problems you should be referred to an HPC podiatrist.

• If you are on steroids or have had vasculitis it's best to seek professional advice about looking after your feet and toenails – especially before using skin files or scrapers on corns and calluses. You should also avoid over-the-counter creams or medicated corn plasters, as there may be a risk of tissue damage.
• Athlete's foot is a skin infection that quite commonly occurs along with hammer toes. It causes itching, and sometimes a rash. Thorough washing and drying between the toes will help, but a cream or powder from the chemist will speed things along.

If you can't manage your feet yourself then your GP or hospital consultant can refer you for professional care within the NHS. Most podiatry services accept patients on a self-referral basis. An HPC registered podiatrist/chiropodist will help with troublesome nails, corns and calluses, and will also be able to provide advice and help with obtaining special shoes or orthoses.

Footwear

Comfort should be the main consideration when choosing shoes. Your feet may well change shape as you get older, especially if you have arthritis, so you may need to change to a different size or width fitting.

Leather uppers are usually the most comfortable if you have foot problems. Look for a flexible sole unless you've been advised by a doctor or podiatrist that rigid soles are better for your particular foot problem. If you have hammer toes or prominent joints look for a smooth lining without seams. And if you need special insoles or orthoses, make sure the shoes are roomy enough to take them – especially in the toe area.

Around the house, slippers may feel the most comfortable for hammer toes and prominent joints, but make sure the soles provide adequate cushioning.

Complementary therapies

Therapeutic massage can be helpful in reducing pain or tiredness in the feet. Massage can be combined with a relaxing warm-water footbath, and either of these is fine as long as you don't have any open wounds or sores on your feet. The effectiveness of treatments such as acupressure sandals and magnetic insoles isn't supported by medical evidence.