Rheumatoid arthritis (RA) symptoms often start in the small joints of the hands and feetespecially the knuckles, first finger joints, wrists and the joints that connect the feet to the toes. Formerly a rheumatoid arthritis diagnosis meant that deformities were likely to follow, especially in these joints, usually due to long-term uncontrolled disease. Today, they are much less likely, according to Mark Figge, MD, chief emeritus of the Surgical Arthritis Service at the Hospital for Special Surgery in New York City.

“Now with significantly improved drug treatmentswe still see gout changes, but they happen later in life and are much less severe. Usually only one or two joints are affected, as opposed to nearly all joints being involved. Patients are healthier with better bone and skin quality as a result of their increased activities and less dependence on [corticosteroids],” he explains.

But as Dr. Figge notes, gouty changes can still occur. When they do, they can change both the appearance and function of affected joints.

Causes of joint deformities
In RA, certain immune system cells—mostly T cells and B cells—migrate to the joint lining (synovium), where they cause inflammation. This can lead to the formation of abnormally thick tissue called pannus, which can damage the cartilage and surrounding ligaments and tendons. As a result, the joints lose their shape and alignment.

Types of deformities
In the early stages of RA, feet can be affected a little more than the hands, partly because they have the extra stress of carrying the body’s weight. Extra pounds can make the problem worse. A small study of 82 people with RA found that ankle pain occurred more often with higher body weight, more severe symptoms, and longer disease duration. Another study involving 230 people with RA found that those with a higher body mass index (BMI) had more foot pain and more limited mobility, but no more deformities.

Common foot deformities

• hallux valgus. A bony lump at the base of the big toe joint, this is one of the most common foot problems in the general population, usually due to an injury or hereditary problem with the anatomy of the foot. Whether tight shoes or high heels cause bunions is controversial. Bunions are also common in people with RA — the result of erosion in the joint that causes the toe to move or dislocate, crowding out the other toes and pushing out the big toe joint. Finding shoes that fit a bunion foot can be a challenge, but roomy, wide, comfortable shoes are key. Over-the-counter shoe inserts or prescription orthotics that help distribute pressure evenly can also help.
• Flat feet (pes planus). The medial longitudinal arch runs the length of the foot. It is braced by thick bands of ligaments and tendons and acts as a support for the rest of the body. It is normally the highest of the three arches of the foot, but in people with flat feet this arch largely disappears, so that the entire bottom of the foot touches or nearly touches the ground. Estimates vary as to how many healthy people in the United States have flat feet, but the number is generally higher in black people and in those who have RA. Flat feet are usually painless, but because they don’t spread shock as they should, they can change the mechanics of the knees, hips and spine. They are also a leading cause of plantar fasciitis. Arch supports, Achilles tendon stretching, and physical therapy can help prevent these problems.
• Hammer toe. This is an unusual bend in the middle joint of one or more toes, usually the second, third or fourth. Mallet toea similar condition affects the joint(s) closest to the toenail. In the later stages, the muscles and tendons may become more rigid, making it more difficult to curl the toes. As with many foot problems, shoe having a wide, deep toe box is essential to keep the pressure off the swollen joint. Toe stretching exercises and off-the-shelf or custom orthotics that help keep the toes in the correct position can also help. It is possible to correct hammertoes and hammertoes; it just takes a little time and patience.
• Claw toe. This is another condition like mallet and hammertoe, except that both the middle and top joints of the toe are bent to resemble a claw. The same advice as for hammertoe and hammertoe applies:
  • Choose shoes with an extra deep toe box and good arch support
  • Use pillows or insoles to support the toe
  • Stretch and strengthen the toes with specific exercises
  • Use a splint or tape to keep the toe in the correct position

Common hand deformities

Arthritic fingers can be more debilitating and affect your life more than bent toes, although these problems are much less common these days, especially when RA is well controlled. Finger deformities may include:

• Boutonniere deformity. In this condition, the middle joint of the finger will not straighten while the upper joint bends upwards. It happens when RA or an injury damages the tendon at the top of the finger that helps straighten the middle joint. This can be reversed with a splint that keeps the middle joint straight. It must be worn continuously for up to eight weeks. Exercises strengthening the joints, especially the joint at the top of the affected finger, are also important.
• Swan neck deformity. This condition also affects the middle joint of a finger, which bends backwards while the tip bends down, mimicking the curve of a swan’s neck. It is the mirror image of a boutonniere deformity. In RA, this can result when inflammation weakens the joint at the tip of the finger and the extensor tendon slips out of place. The most common treatment is to use a ring rail to keep the finger in the correct position, or extension block splints, which can help correct excessive movement of the intervertebral joint.
• Ulnar deviation (ulnar drift). This occurs when chronic inflammation of the knuckle joints causes the fingers to bend towards the outer side of the forearm. Splints can help align joints and relieve pain.

Working with one occupational therapistcan also be of great help. They can design a training program as well as rails. They can also teach you how to make everyday tasks easier and how to make your environment better suit you and your needs.

Surgery
Surgery is rarely necessary for arthritic changes in the hands and is usually a last resort when more conservative methods fail. Although surgical interventions have improved significantly, they are still prone to complications, and many people never achieve a fully functional or aligned joint through surgery.