DUNFERMLINE & WEST FIFE CHP
DEPARTMENT OF PODIATRY
REVIEW OF PATIENTS WITH ANKYLOSING SPONDYLITIS ATTENDING PODIATRY CLINICS IN FIFE. ADELE OSBORNE SENIOR PODIATRIST FOR RHEUMATIC DISEASES JUNE 2006
INDEX
1. INTRODUCTION 2. METHODOLOGY 3. RESULTS 4. DISCUSSION/CONCLUSION 5. REFERENCES 6. APPENDICES
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INTRODUCTION
Ankylosing Spondylitis (A.S) is a progressive inflammatory rheumatic disease of unknown aetiology. It has a sex distribution of approximately 3:1 male to female with onset of symptoms typically occurring around the mid twenties years of age. There tends to be a familial link with about 96% of suffers sharing the same genetic cell marker, Human Leucocyte Antigen B27 (HLA B27), however this marker also occurs in 7-10% of the healthy population.1
A.S primarily effects the spine, the sacroiliac joint, hip and knee joints although organs such as the heart and eyes can also be effected. Inflammation occurs around the affected joints causing bone erosion at the site of the inflammation. As the healing process takes place new bone is produced, which is termed reactive bone. After repeated attacks this additional reactive bone growth can result in adjacent joints joining together, a process called ankylosing. The main symptoms of A.S are low back pain/aching with a progressive stiffening of the spine.
Another feature of A.S is enthesitis, where inflammation occurs at the site of the insertion of tendons into bone. Two common sites at which this occurs are the insertion of the tendo achilles into the calcaneun and the insertion of the plantar fascia into the calcaneum.
2 , 3, 4
It is estimated that foot involvement
occurs in about 15% of patients with A.S.3
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METHODOLOGY
AIM
The aim of this review was to investigate the incidence, treatment and outcomes of foot problems in those patients with A.S who have been referred to the Rheumatology Podiatry Service via Fife Rheumatic Diseases Unit (FRDD) during the first 4 years of the podiatry service. It was felt that patients attending this clinic were presenting with symptoms that were not always typical of those described in the available literature on A.S and that this warranted further investigation.
METHOD
Information was collected retrospectively from the patient record cards of those patients identified as having a diagnosis of A.S. The Following details were recorded: - Patient sex. - Age at diagnosis of A.S. - Duration of disease at time of referral for podiatry intervention. - Reason for referral to podiatry. - Treatment intervention provided. - Treatment out comes and compliance with treatment.
The data collection tool used is shown in Appendix 1.
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RESULTS
Data was collected on 24 patients who were identified as having A.S. Four of these patients were excluded from the study as they also had a concurrent diagnosis of another inflammatory arthritis. One had rheumatoid arthritis, two had psoriatic arthritis and one also had fibromyalgia.
SEX DISTRIBUTION OF PATIENTS.
Of the remaining 20 patients in the review eleven were male and nine were female as shown in Figure 1.
Figure 1.
SEX DISTRIBUTION OF AS PATIENTS
FEMALE 45%
MALE 55%
MALE FEMALE
AGE AT DIAGNOSIS OF AS.
The age distribution of the patients at diagnosis of A.S ranged from 11- 60 years old. Of those 20 patients in the review, 7 patients (35%) were
diagnosed with A.S between the ages of 21-30 years old, 6 patients (30%) were diagnosed with A.S between the ages of 11-20 years old, with the remaining having a diagnosis at greater than 31 years of unknown, as shown in Figure 2. and 2 being
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Figure 2.
AGE AT DIAGNOSIS OF AS 8 6 4 2 0
AGE AT DIAGNOSIS OF AS
DISEASE DURATION AT TIME OF REFERRAL TO PODIATRY.
The disease duration of A.S at time of referral for podiatry intervention ranged from less than ten years from initial diagnosis to as much as 31-40 years from initial diagnosis, as shown in the table below, and in Figure 3.
Table of disease duration at referral to podiatry. < 10 yrs Number patients % patients of 40% 30% 10% 10% 10% of 8 11-20 yrs 6 21-30 yrs 2 31-40 yrs 2 Unknown 2
< 11 10 - 2 yrs 21 0 - yrs 31 30 - 4 yrs 41 0 - yrs 51 50 - 6 yrs 0 un yr kn s ow n
6
DISEASE DURATION AT REFERRAL TO PODIATRY (YRS) 10 8 6 4 2 0
yr s
yr
yr
yr
-2
-3
-4
11
21
Figure 3.
REASON FOR REFERAL TO PODIATRY.
The reasons for referral to the podiatry department were numerous, 7 patients (35%) complained of pain in the ankle joint area, 6 patients (30%)
complained of heel pain, 5 patients (25%) complained of pain in the metatarsal phalangeal joints (MPJ), 2 patients (10%) complained of mid
tarsal pain and 1 patient (5%) complained of tendo Achilles (T.A) pain, 1 patient (5%) complained of knee pain, 1 patient (5%) had no problems, 1 patient (5%) had fungal nail infection and 1 patient (5%) complained of
constant burning pains in their feet, 5 patients (25%) complained of more than one foot problem, as shown in the table below and in Figure 4. Table showing reason for podiatry referral
Ankle pain Heel pain MPJ pain Mid tarsal pain
Number of patients
Fungal nail
31
un
<
kn o
0
0
10
0
Burning sensation
w
DISEASE DURATION AT REFERRAL TO PODIATRY (YRS)
s
s
s
n
T.A pain
Knee pain
No foot Poly problem symptoms
7
6
5
2
1
1
1
1
1
5
7
Figure 4.
FOOT PROBLEMS IN A.S
ANKLE HEEL MPJ MID TARSAL
5 1 1 1 1 1 2 5
FUNGAL NAIL
7 6
BURNING TA KNEE NO FOOT PROBLEM MORE THAN 1 PROBLEM
All patients who were referred for podiatry intervention were given a biomechanical lower limb assessment to establish range and quality of movement in the joints and to assess whether or not there was excessive rear foot pronation evident. Of the 20 patients assessed 16, (80%), were found to have excessive rear foot pronation. Of those16 patients who had excessive rear foot pronation in 13 instances, (81%), this was correctable, as shown in Figure 5 & Figure 6.
Figure 5.
PRONATION IN PATEINTS WITH A.S
20 15 10 5 0 PRONATION NO PRONATION
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Figure 6.
CORRECTABLE PRONATION IN PATIENTS WITH A.S
15 10 5 0 CORRECTABLE NON CORRECTABLE
TREATMENT INTERVENTIONS USED
The type of treatment used for this group of patients is primarily that of biomechanical intervention by the use of functional foot orthotics to reduce excessive rear foot pronation, for the purpose of this review an orthotic is “a device that is designed to promote stuctural integrity of the joints of the foot and lower limb by resisiting ground reaction forces that cause abnoraml skeletal motion to occur during the stance phase of gait”
7
. Numerous studies
8
have established that the use of functional orthotics can relieve symptoms associated with malaligment syndromes of the lower limb/foot . Of this
sample a total of 15 patients, (75%) received orthotics, 11 of these patients (55%) were prescribed orthotics only with 4 patients (20%) receiving a combination of orthotics and insoles, 3 patients in total (15%) were supplied with insoles only, 1 patient (5%) was given anti-fungal treatment and 1 patient (5%) did not receive any intervention, as shown in Figure 7.
Figure 7.
TREATMENTS INTERVENTIONS only insoles
1 1 4 orthotics only 3 insole and orthotic antifungal 11 no treatment
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TREATMENT OUTCOMES AT 12 MONTHS
Of the 20 patients who attended for podiatry intervention 4 were lost to follow up, leaving information available on 16 patients. Treatment outcomes were assessed at 12 months, or nearest review date to this, on the remaining patient cohort. The outcomes were found to be variable in success and looking at the patient cohort as a whole the outcomes were, 2 patients (12%) whose symptoms resolved completely, 11 patients (69%) whose symptoms resolved partially and 3 patients (19%) whose symptoms remained unchanged, as shown in Figure 8. Overall in this sample 13 of the 16 patients, (81%), on whom final data was available had a positive outcome to treatment intervention.
Figure 8.
TREATMENT OUTCOME- NUMBER OF PATIENTS 15 10 5 0 RESOLVED PARTIALLY RESOLVED UNCHANGED
The treatment outcomes were further broken down to assess whether outcomes could be linked to either disease duration or excessive rear foot pronation.
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TREATMENT OUTCOME RELATED TO DURATION OF A.S
Of the 8 patients whom data was available for, who presented with foot pathologies at a disease duration of less than 10 years the outcomes were, 2 patients (25%) whose symptoms resolved completely and 6 patients (75%) whose symptoms resolved partially.
Of the 3 patients whom data was available for, who presented with foot pathologies at disease duration of 11-20 years the outcomes were, 3 patients (100%) in whom no improvement was noted.
Of the 3 patients whom data was available for, who presented with foot pathologies with disease duration of 21-30 years the outcomes were, 3 patients (100%) whose symptoms resolved partially.
For the 1 patient whom data was available for, who presented with foot pathologies at disease duration of 31-40 years, the outcome was that foot symptoms resolved partially.
For the 1 patient whom data was available for, who presented with unknown disease duration, the outcome was that foot symptoms resolved partially. As shown in Figure 9 overleaf.
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Key to Figure 9: R= Resolved, PR =Partially resolved, UR= Unresolved.
Figure 9.
TREATMENT OUTCOMES RELATED TO DISEASE DURATION IN YEARS
120 100 80 60 40 20 0
R PR PR PR R <1 0 <1 0 21 >3 0 11 >2 0 31 >4 0 KO W N PR U
PERCENTAGE OF PATIENTS
Overall in this sample treatment outcomes were generally more positive in those patients with shorter disease duration.
TREATMENT OUTCOME AS RELATED TO EXCESSIVE REAR FOOT PRONATION
Analysis of the 16 patients on whom data was available revealed that 13 patients, (81%), had excessive rear foot pronation. Of the patients who did have excessive rear foot pronation correction was possible in 11 patients, (85 %).
In the 11 cases where correction of excessive rear foot pronation was correctable treatment outcomes were variable. In 1 patient, (9%), symptoms resolved completely, in 9 patients, (82%), symptoms resolved partially and in 1 patient (9%), symptoms remained the same, as shown in Figure 10.
U
N
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Figure 10.
TREATMENT OUTCOME WITH CORRECTABLE PRONATION
100 80 60 40 20 0
PARTIALLY RESOLVED RESOLVED UNCHANG ED
PERCENTAGE OF PATIENTS
In the 2 cases where correction of excessive rear foot pronation was not correctable there was no improvement in symptoms, as shown in Figure 11.
Figure 11.
TREATMENT OUTCOME WITH UNCORRECTABLE PRONATION
120 100 80 60 40 20 0
RESOLVED PARTIALLY RESOLVED UNCHANGED
PERCENTAGE OF PATIENTS
In the 3 cases where there was no excessive rear foot pronation in 1 patient, (33%), symptoms resolved completely and in 2 cases, (67%), symptoms resolved partially, as shown in Figure 12. 13
Figure 12.
TREATMENT OUTCOME WHEN NO REARFOOT PRONATION
80 60 40 20 0
PARTIALLY RESOLVE D RESOLVE D UNCHANG ED
PERCENTAGE OF PATIENTS
Overall in this sample treatment outcomes were more positive in patients who either had correctable rearfoot pronation or no excessive rear foot pronation.
COMPLIANCE
Compliance was reported to be good in all cases that were successfully followed up, with all patients reporting that they followed the treatment plan as advised.
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DISCUSSION/CONCLUSION
The typical sex distribution of patients with A.S is three males for every one female. The sex distribution of patients in this sample is less than one and a half males for every one female, this sample therefore may not be a typical representation of this patient group in the population in this respect. However, females do tend to have more peripheral joint disease than males, so this could account for this finding.6
The typical age at diagnosis for patients with A.S is 24 years of age, the largest group of patients in this sample were diagnosed between the ages of 21-30 years of age, 35% of the sample, although almost as many were diagnosed between the ages of 11-20 years, 30 % of sample. It can therefore be assumed that this sample is fairly representative of this patient group in that respect.
The largest group of patients in this sample were referred for podiatry treatment at less than 10 years from AS diagnosis, (40%), although almost as many were referred at between 11-20 years from diagnosis, (30%). Consequentley up to 60% of patients have disease duration of more than 10 years at referral, this has the potential to influence treatment outcomes.
The reasons for referral to podiatry were numerous. The largest group of patients in this sample presented with ankle pain, (35%), followed by heel pain, (30%), only 5% presented with TA pain and 25% presented with more than one foot problem. This is not wholly consistent with other findings in this condition as ankle pain is rarely mentioned as a common foot problem in A.S., whereas tendo achilles involvement is frequently mentioned. This finding warrants further investigation the commonly reported foot problems in patients with A.S.
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As the patient numbers in this review are very low, and indeed the patient numbers in the general population are also low, no firm conclusions can be made on the treatment outcomes for foot pathologies in patients with A.S. from this review. However, from the results available here it is possible to state that overall 81% of patients found podiatry intervention beneficial with a degree of improvement in foot symptoms reported. In general terms those patients with correctable rear foot pronation or no rear foot pronation had more positive outcomes along with those patients with shorter disease duaration at presentation of foot symptoms. The only patients with full resolution of symptoms has disease duration of less than 10 years, however, one of these patients had a fungal nail infection that resolved with anti fungal therapy.
As A.S. is a disease that has a pattern of presentation that results in peroids of active joint disease followed by periods of quiesence it would be of interest to establish disease activity at times of foot symptoms and then again when symptoms have resolved, this may reveal whether foot symptoms are exacerbated at times of active disease. Furthermore, as the use of functional orthotics can effect the mechanics of the hip and lower back this is a consideration when treating this patient group. A.S. often has sacoiliac joint involvement so this may influence the choice of treatment for foot symptoms and compromise treatment outcomes.
RECOMMENDATIONS
The primary limitation of this review is the small sample size. The population of Fife is in the region of 350,00 and the prevalence of A.S in the general population is estimated at 150 per 100,000 5, this means that there are potentially around 525 patients with A.S in Fife. If foot problems occur in 15% of these patients there must be around 80 patients with foot problems, 55 of who were not included in this sample. Recommendations for future review would be: 16
-
Review with a larger sample to provide more valid results. Ensure early referral for those patients with foot symptoms. Explore other treatment therapies such as accupuncture, steroid injections.
-
Explore a more multidsiciplinary approach to treatment.
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REFERENCES
1. Arthritis Research Campaign, Patient Information Booklet, Ankylosing Spondylitis. 2. West, S G and Woodburn, J, (1997), ABC of Rheumatology, BMJ Publishing. 3. Neal, D, (1997),Common Foot Disorders. 4. Gallez, P, (1998), Rheumatology for Nurses, Patient Care, Whurr Publishers. 5. Keat, A, ABC of Rheumatology, (1997), BMJ Publishing. 6. The National Ankylosing Spondylitis Society, A Guide Book for Patients 7. Antony, R as quoted by Olson, W.R in, Clinical Biomechanics of the Lower Limb, Valmassy, R.L, (1996), Mosby. 8. Olson, W.R in, Clinical Biomechanics of the Lower Limb, Valmassey, R.L (1996), Mosby.
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APPENDICES APPENDIX 1
ANKYLOSING SPONDYLITIS AUDIT DATA COLLECTION FORM
D.O.B: SEX: YEAR OF DIAGNOSIS: YEAR REFERRED TO PODIATRY: PRESENTING PROBLEM:
ON EXAMINATION:
TREATMENT:
TREATMENT OUTCOME:
COMPLIANCE:
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