Background: Patients with rheumatoid arthritis are recognized as being at risk for osteoporosis as a result of the disease process as well as the medication used to treat it. This study was conducted to consider the use of calcaneal scanning with quantitative ultrasound—contact ultrasound bone analysis (CUBA)—to diagnose osteoporosis in patients with rheumatoid arthritis.
Methods: Forty-six patients (11 men and 35 women) with established rheumatoid arthritis underwent dual-energy x-ray absorptiometry (DEXA) of the nondominant wrist and CUBA of the nondominant heel. Sensitivity, specificity, and positive and negative predictive values were used to determine the correlation between osteoporosis as diagnosed by the CUBA heel scan compared with the DEXA wrist scan given that DEXA is widely seen as the gold standard for the diagnosis of osteoporosis.
Results: The CUBA heel scan revealed a sensitivity of 90% and a specificity of 44% for a diagnosis of osteoporosis compared with DEXA. The positive predictive value of the CUBA scan was 31%, and the negative predictive value was 94%. Therefore, if normal bone density is found using CUBA, there is 94% certainty this is correct. However, if osteoporosis is diagnosed using CUBA, there is only 31% certainty this is correct. In such instances a secondary scan using a different method (eg, DEXA) would be required. Future work should consider the effect of minor alterations to the equipment or scanning protocol, because this may improve diagnosis.
Conclusions: The CUBA unit could be used as a primary screening device. Given the cost and accessibility issues associated with DEXA, quantitative ultrasound may have a role in screening for osteoporosis in the primary-care setting to determine the most appropriate routes of referral for patients requiring further investigations. (J Am Podiatr Med Assoc 97(2): 108–114, 2007)
Osteoid osteoma is a primary benign bone tumor that consists of a central area (nidus), surrounded by sclerotic bone. The most relevant symptom is pain that increases during the night and improves after salicylates or nonsteroidal anti-inflammatory drug administration. Osteoid osteoma is frequently misdiagnosed because it mimics juvenile idiopathic arthritis, bone infection, or malignancy. A 14-year-old girl presented to our department with a history of chronic pain in her left ankle. Juvenile idiopathic arthritis was diagnosed and anti-inflammatory treatment was prescribed. Because of persistence of ankle pain, the patient underwent further examinations, in particular, bone scintigraphy and computed tomography. As a result, osteoid osteoma of the talar neck was diagnosed. The patient underwent surgical treatment and her condition improved. Osteoid osteoma should also be considered in patients with chronic ankle pain to avoid misdiagnosis and start adequate treatment. This condition should be suspected in a patient with chronic bone pain and normal complete blood count and inflammatory parameters.
Gonococcal arthritis is a frequently occurring clinical entity that should be included routinely in a differential diagnosis of pedal joint pain. Unfortunately, the lack of specificity in the presentation makes gonococcal arthritis difficult to diagnose. Indices of suspicion should rise with any sexually active patient, particularly when septic arthritis is suspected without a detectable portal of entry. The authors emphasize again the importance of carefully choosing empiric antibiotic coverage for gonococcal arthritis. Three factors that should be considered are regional epidemiology, the anatomical site of the primary infection, and the possible coexistence of other infectious agents. Understanding the clinical staging of this condition will help to achieve a timely diagnosis and successful treatment.
Juvenile idiopathic arthritis (JIA), a chronic, autoimmune, inflammatory joint disease, is the most common arthritis affecting children younger than 16 years. Children with JIA commonly experience lower-limb dysfunction and disability. We systematically reviewed the effectiveness of physical and mechanical therapies for lower-limb problems in JIA.
Randomized controlled trials of physical and mechanical interventions for lower-limb problems in children with JIA were included. Primary outcome was pain. Secondary outcomes included disability, functional ability, and health-related quality of life. Several databases were searched for eligible studies. Authors of included studies and researchers in the field were contacted to identify additional studies.
Two studies evaluating the effectiveness of customized/custom foot orthoses in treating foot and ankle pain in children with JIA (N = 100) were included. One study also evaluated simple cushioned inserts. Meta-analyses for comparisons between custom/customized foot orthoses and a control intervention after 3 months were not significant for the outcomes of pain (mean difference, –8.97; 95% confidence interval [CI], –18.01 to 0.07), child-rated health-related quality of life (mean difference, 4.38; 95% CI, –3.68 to 12.44), and parent-rated health-related quality of life (mean difference, 1.77; 95% CI, –6.35 to 9.90). Meta-analyses were supported by sensitivity analyses.
There is a paucity of research evaluating physical and mechanical therapies for lower-limb problems in JIA. No physical therapy has been evaluated in randomized controlled trials, and mechanical therapy evaluation is limited to foot orthoses and shoe inserts for foot and ankle pain. The existing research is hampered by small sample sizes. Until further research is conducted, the effectiveness of mechanical and physical therapies for lower-limb problems in JIA remains unclear.
This report presents the results of analyses of statistical data from 1,114 members of the American Podiatric Medical Association (APMA) who responded to the 1999 Arthritis Survey, conducted from July through August 1999. The purpose of the survey was to determine the extent and methods of treatment of patients with arthritis of the foot or ankle by doctors of podiatric medicine.
Abnormal foot posture and deformities are identified as important features in rheumatoid arthritis. There is still no consensus regarding the optimum technique(s) for quantifying these features; hence, a foot digitizer might be used as an objective measurement tool. We sought to assess the validity and reliability of the INFOOT digitizer.
To investigate the validity of the INFOOT digitizer compared with clinical measurements, we calculated Pearson correlation coefficients. To investigate the reliability of the INFOOT digitizer, we calculated intraclass correlation coefficients, SEMs, smallest detectable differences, and smallest detectable difference percentages.
Most of the 38 parameters showed good intraclass correlation coefficients, with values greater than 0.9 for 30 parameters and greater than 0.8 for seven parameters. The left heel bone angle expressed a moderate correlation, with a value of 0.609. The SEM values varied between 0.31 and 3.51 mm for the length and width measures, between 0.74 and 5.58 mm for the height data, between 0.75 and 5.9 mm for the circumferences, and between 0.78° and 2.98° for the angles. The smallest detectable difference values ranged from 0.86 to 16.36 mm for length, width, height, and circumference measures and from 2.17° to 8.26° for the angle measures. For the validity of the INFOOT three-dimensional foot digitizer, Pearson correlation coefficients varied between 0.750 and 0.997.
In this rheumatoid arthritis population, good validity was demonstrated compared with clinical measurements, and most of the obtained parameters proved to be reliable. (J Am Podiatr Med Assoc 101(3): 198–207, 2011)
This work attempts to determine the influence of vitamin C on locally induced inflammation and arthritis in rat paws, as measured by rat paw swelling, polymorphonuclear leukocyte infiltration, pain, and surface skin temperature. Daily subcutaneous administration of 150 mg/kg of vitamin C over 20 days reduced arthritic swelling, increased pain tolerance, and decreased polymorphonuclear leukocyte infiltration, with no significant change in surface temperature. Vitamin C may provide podiatrists with a supplemental or alternative treatment for patients with rheumatoid arthritis.
Low arch alignment and metatarsus primus elevatus (MPE) have been postulated to increase dorsal compressive stresses in the joints of the medial column of the foot and to contribute to the development of degenerative changes. The primary purposes of this study were 1) to examine the relationship between radiographic measures of arch alignment and MPE and 2) to assess arch alignment and MPE in individuals with midfoot arthritis and in asymptomatic controls. The secondary aim was to examine the reliability of radiographic measures of arch alignment and MPE.
Radiographic measures of arch height and MPE were quantified on 28 individuals with midfoot arthritis and 22 individuals in a control group. Reliability was assessed using the intraclass correlation coefficient (ICC). The Pearson product moment correlation (r) was used to assess the relationship between arch alignment and MPE. Between-group differences were assessed using a two-sample t test (α = 0.05).
Good to excellent reliability was noted for measures of arch height (ICC[2,3] = 0.919–0.994) as well as MPE (ICC[2,3] = 0.891–0.882). A modest positive association was noted between normalized cortical elevation and normalized navicular height (r = 0.274, P = .030) and calcaneal inclination angle (r = 0.263, P = .035). Individuals with midfoot arthritis demonstrated lower arch alignment, reflected in a significantly higher calcaneal–first metatarsal angle (P = .002), lower calcaneal inclination angle (P = .004), and lower normalized navicular height (P < .001) compared with controls. No evidence was found to support between-group differences in lateral intermetatarsal angle (P = .495) and normalized cortical elevation (P = .146).
These findings provide objective data establishing the reliability of measures of MPE and arch alignment and their potential clinical significance. (J Am Podiatr Med Assoc 103(5): 347–354, 2013)
The causes of late-onset pain after total ankle replacement (TAR) are various, and include infection, subsidence, polyethylene spacer failure, osteolysis, and wear. There are few reports of late-onset pain caused by gouty attacks after total knee and hip arthroplasty. In addition, no research has reported gouty attacks after total ankle arthroplasty. Therefore, we report a case of a gouty attack after total ankle replacement. A 43-year-old man presented with pain after total ankle arthroplasty performed 5 years previously. We found a white-yellow crystalline deposit within the synovial tissue during ankle arthroscopy, confirmed by histologic examination.
Background: Metatarsalgia is a common affliction in rheumatoid arthritis (RA), often requiring aggressive pharmacologic treatment that carries associated adverse effects. The aim of this study was to investigate whether simple insoles would have a beneficial effect on forefoot pain, disability, and functional limitation in participants with RA experiencing forefoot pain.
Method: A prospective, quasi-experimental, pretest-posttest trial was performed at a rheumatology outpatient clinic. Participants were supplied with a simple insole comprising a valgus pad and a plantar metatarsal pad and covered with a cushioning material. The Foot Function Index (FFI) was self-administered before and 3 months after insole use.
Results: Reductions in forefoot pain (from 56.78 to 42.97) and total (from 41.64 to 33.54) FFI scores were noted. Statistical significance for this reduction was achieved following the t test (P = .002 and P = .0085, respectively). However, although reductions in mean disability and activity limitation scores were recorded (from 50 to 44.85 and from 18 to 14.57, respectively), these did not reach significance (P = .151 and P = .092, respectively)
Conclusions: Simple insoles have been shown to be effective in reducing total and forefoot pain FFI scores in patients with RA experiencing metatarsalgia. This treatment offers advantages because these devices can be fabricated simply and cheaply, thus initiating the patient on an effective orthosis therapy immediately in the clinic without having to wait for prolonged periods until custom orthotic devices can be supplied.