Does Rheumatoid Arthritis Cause Foot Pain?

About one in five people with rheumatoid arthritis (RA) will first notice symptoms of this chronic inflammatory disease in their feet and ankles, according to the Arthritis Foundation. Over time, as many as 90% will develop arthritis in these joints, usually on both sides of the body.

“Rheumatoid arthritis is a systemic disease that affects the joints, and typically starts in the periphery of the body, such as the toes,” says Kevin Jeong, D.P.M., the chief of podiatry at Plainview Hospital Northwell Health, in Plainview, NY. “That’s where most people with RA start to see a lot of symptoms such as pain and deformities.”

Why does RA seem to target this area of the body—and what can you do to get back on your feet? We took these and other questions to top RA experts for answers.

Doctors don’t know exactly what causes rheumatoid arthritis in the first place, but suspect that both genetic and environmental factors may be at play. Smoking, an infection, or even stress can trigger RA symptoms, according to the Cleveland Clinic.

What is known is that in the early stages of the disease, RA can impact the feet, particularly the toes. It also can have an effect on the circulatory system, and the areas of the body that are the farthest distance from the heart, such as the toes, are more likely to be impacted, says Dr. Jeong.

“Rheumatoid arthritis in general increases the risk of both coronary artery disease and peripheral artery disease, so you would have increased risk, in general, of having worse circulation,” adds Katherine Yates, M.D., a rheumatologist with The Ohio State University Wexner Medical Center in Columbus, OH.

In RA, your body’s immune system mistakenly attacks the synovium, or the lining of your joints, causing pain, swelling, and stiffness, says Jonathon D. Backus, M.D., a foot and ankle surgeon at the Steadman Clinic in Vail, CO.

If the inflammation isn’t controlled, it can harm the cartilage and lead to bone and joint damage and deformity, according to the Cleveland Clinic. The structure of the feet can also be damaged by changes in the tendons, ligaments, and surrounding soft tissue. “Rheumatoid arthritis can also affect the tendons or ligaments [which can cause] movement of the bones within the foot,” says Dr. Yates.

“Over time, as the tissues start to degrade from the chronic inflammation, deformities can start to occur,” adds Dr. Backus.

While your little piggies may be first in line to fall under attack if you have RA, other parts of your feet and ankles can also be affected. Here’s a closer look at how your feet may be impacted by RA:

Toes

One symptom that doctors may see in people with feet affected by RA is fibular deviation in the toes, a condition in which any of the smaller toes (excluding the big toe) tend to drift outward. “With your right foot, the toes would drift to the right; with the left foot, the toes would drift to the left,” says Dr. Jeong.

In your big toe, you may develop a bunion, where your toe drifts outwards and a bump forms on the inside on the side of your foot. Your toes can also start to curl and form hammer toes or claw toes, where your toes curl and dig down into the floor or the soles of your shoes, creating discomfort and painful callouses.

Balls of Feet

The medical term for pain in the ball of your foot is metatarsalgia, which can be due to a number of causes. “RA involvement in the feet is similar to that of the hands, where you can get pain, swelling, and redness, particularly over the balls of your feet,” says Dr. Yates. RA can affect bursae, which are fluid-filled sacs that develop as a result of excessive rubbing; these can become inflamed and painful, a condition known as bursitis. Some bursae are located under the ball of the foot. You may also develop a thinning out of the normal fat pad that goes across the ball of your foot (known as atrophy).

Dropped Arch

If the tendons and ligaments of your feet are affected by RA, you can develop a drop in your arch and become flat footed, which can lead to pain and discomfort, says Dr. Yates. In other words, damage to the tendons, ligaments, and bones of the feet from RA can cause the arch of your feet to collapse. “That’s not necessarily due to the inflammation of rheumatoid arthritis in the joints, but rather the changes that happen in the tendons and the ligaments because of the inflammation,” she says.

Heel

Pain in the toes or the balls of your feet may cause you to compensate by standing or walking with more of your weight on your heels, with your toes bent upward. This can cause pain in your heel as well as the top of your foot, making it difficult to walk or wear shoes, according to the American Academy of Orthopaedic Surgeons (AAOS).

You may also develop nodules on the heel or other bony spots where your foot rubs against the floor or your shoe as you walk. These rheumatoid nodules are typically benign and don’t require treatment unless they impact your ability to walk or exercise normally.

Ankle

Structural issues like flat arches or other changes in the tendons and ligaments can cause bones to shift out of their normal positions. This can lead to pain and discomfort in the ankles, according to the website CreakyJoints.

As with other RA symptoms, prompt medical attention is important when it comes to treating foot pain. “Early effective treatment can prevent deformities from happening and greatly decrease the risk that you will need surgery in the hands and feet,” says Dr. Backus.

Regardless of which joints are affected by your RA, rheumatoid arthritis is a full-body disease, and as such, your doctor will likely treat you with systemic medications that control the inflammation. “We typically start with methotrexate—that’s our go-to for inflammatory arthritis,” says Dr. Yates. Then, if need be, doctors may switch or add other RA medications, depending on your response and individual needs. Common RA medications include the following:

Disease-Modifying Antirheumatic Drugs (DMARDs)

DMARDs, such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine, slow the progression of RA, tamp down inflammation, and help prevent joint damage. Doctors may combine methotrexate, which is often used first to treat RA, with other DMARDs to increase its effectiveness.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Commonly recommended by doctors to relieve pain and reduce inflammation while waiting for DMARDs to start working, NSAIDs (such as aspirin, ibuprofen, and naproxen) can be an effective way to manage symptoms temporarily. That said, NSAIDs do not reduce the long-term damaging effects of RA on joints—you’ll still need an effective DMARD to do that.

Biologics

This class of medications, which is prescribed for people with moderate to severe RA, is typically used when the disease doesn’t respond to conventional DMARDs such as methotrexate, per NYU Langone. There are several types of biologics, including:

• Tumor necrosis factor (TNF) inhibitors such as Humira (adalimumab), Enbrel (etanercept), and Simponi (golimumab), which work by blocking TNF, a protein that causes inflammation in the joints

• Interleukin-6 (IL-6) receptor antagonists such as Actemra (tocilizumab), Orencia (abatacept), and Rituxan (rituximab)

Janus Kinase (JAK) Inhibitors

JAK inhibitors work by blocking certain enzymes that play a role in the activation of inflammatory and immune responses that occur in rheumatoid arthritis. Three JAK inhibitors currently used to treat RA include Olumiant (baricitinib), Rinvoq (upadacitinib) and Xeljanz (tofacitinib).

Corticosteroids

Corticosteroids, such as prednisone, are typically prescribed to treat severe flareups of RA symptoms in feet. These medications can quickly and effectively help decrease inflammation and relieve pain. However, in the long term (over a period of a few weeks or months), these steroids can cause potentially serious side effects ranging from osteoporosis and high blood sugar to cataracts and obesity, per NYU Langone.

Along with taking medications, there are also several lifestyle strategies that may be helpful in relieving foot pain related to RA.

Stop Smoking

Aside from crucial health benefits such as reduced risk of cancer and cardiovascular disease, quitting smoking can help you better manage and treat problems in your joints, including those in your feet, related to RA. “Smoking can make medications less effective in people who smoke, and it can make the disease itself more active,” says Dr. Yates.

Eat a Healthy Diet

A review of 62 studies found that a staggering one-third of people with RA had metabolic syndrome, which greatly increases your risk of heart disease, stroke, and type 2 diabetes. An anti-inflammatory diet such as the Mediterranean diet can help reduce your risk of health conditions related to RA such as metabolic syndrome, says Dr. Jeong.

Exercise Regularly

While exercise may be the last thing you want to do if you have pain or stiffness in your foot joints or ankles, being physically active is an important lifestyle strategy. “Rheumatoid arthritis patients have arteries that are not as elastic and as flexible, so it can be difficult for the heart to pump blood throughout your entire body,” says Dr. Jeong. Cardiovascular exercise, in particular, is a good way to boost blood flow throughout the body, including the feet.

High-impact activities like running can be difficult if your feet are in pain, so consider low-impact alternatives like swimming or tai chi. You can also find a physical therapist experienced in working with people with RA who can tailor a fitness routine that works best for you.

Check Your Feet Regularly

Examine your feet regularly, checking for any wounds or signs of infection or damage, says Dr. Yates. “Many people with RA have decreased sensitivity in the feet because of poor blood flow,” she says. “They may not know that there’s a wound unless they look for it.”

This is especially the case if you have RA nodules, blisters, or other skin issues, which can easily become infected, adds Dr. Yates. Talk to your doctor if you experience symptoms in the feet that require further medical attention.

Choose the Right Shoes

Even if you haven’t experienced problems with your arches, it’s important to wear shoes with good arch supports, says Dr. Yates. Wearing supportive shoes with a footbed that fits or improves the shape of your foot is essential.

Try a Warm Footbath

For some people, soaking your feet can help relieve pain, especially if they’re experiencing active inflammation in the joints, says Dr. Yates. Use lukewarm water (not too hot or cold) and consider adding Epsom salts or a mild soap like bodywash. Just make sure to keep your soaks to less than 10 minutes and dry your feet well when you’re done, per the Cleveland Clinic.

If all else fails, surgery may be needed to help relieve pain and restore function to the feet, says Dr. Backus. “Surgical options are vast and depend on the joints affected and deformity created from the RA disease process,” he says.

Foot problems such as bunions and hammer and claw toes can be improved with surgery, says Dr. Backus. Arthritic joints that don’t respond to other therapies can be treated with selective joint fusions throughout the foot and ankle—the joint is cut out and squeezed together with plates, staples, and screws that allow the bones to heal together.

For flat feet, surgeons may perform tendon transfers and osteotomies (cutting the bones to reshape the foot or ankle). And ankle arthritis can also be treated with a total ankle replacements for some people, says Dr. Backus.

If you suspect that foot pain is related to RA, or if something seems off, get in touch with your health care provider. “We like patients to come as soon as they start to notice something a little funky, even if it turns out not to be RA,” says Dr. Jeong. “Early recognition and early treatment is key, and it’s most important to prevent these permanent, non-reversible joint damage and ultimately, joint disability,” he says. Even if a treatment isn’t working, or isn’t as effective as it once was, your doctor can find other options to manage your disease.

Good communication can also help your doctor formulate a treatment plan that’s tailored to your needs. “It helps clinicians come up with a better plan if the patient is able to communicate their life goals,” says Dr. Jeong. “If they tell us what they want to achieve, such as wanting to be able to walk half a mile a day, then that’s where we can tailor the treatment.” With the right approach, your feet (and the rest of you) will hopefully start to feel better.