Foot and ankle pathologies in juvenile idiopathic arthritis: A narrative review

Abstract

Introduction: Foot and ankle pathologies are common in juvenile idiopathic arthritis (JIA) and can cause physical disability and reduce quality of life (1). Early detection and evidence-based treatment of these symptomatic pathologies are an important first step in preventing ongoing pain and long-term disabilities in children with JIA.

Objectives: To search the literature and provide an update on the types of foot and ankle pathologies reported in children with JIA.

Methods: MEDLINE (Ovid) was searched for relevant papers published in English with preference given to papers published in the last 10 years, and older highly regarded cited papers.

Results: Foot and ankle pathologies are highly prevalent in JIA (1–3). Foot and ankle pathologies in JIA include joint disease, tenosynovitis, muscle atrophy, enthesitis, digital deformities and biomechanical abnormalities (1–9). One study surveying foot problems found that in a cohort of 30 children with JIA, 63% reported some level of foot-related impairment and 60% with foot-related participation restriction (1). This review outlines and describes each of these foot and ankle pathologies.Joint disease – Joint disease in JIA may include joint swelling, tenderness, pain, warmth and stiffness (4). These symptoms typically occur as a result of synovitis (4) and may be involved in 35-58% of cases (2, 3, 5, 10).

Tenosynovitis – inflammation of the tendon sheath in JIA commonly affects the tibialis posterior and peroneal tendons (5).

Muscle atrophy – Plantar-flexor muscle atrophy may be observed in children with JIA. This may be more noticeable when there is active joint disease in the ankle (6, 7). A reduction of plantar-flexion strength at the ankle may have implications in the propulsive phase of the gait, by delaying heel lift and increasing plantar pressures on the rear and midfoot.

Enthesitis – Inflammation at the site of insertion of a tendon or ligament to the bone is common at the Achilles tendon and the medial tubercle of the calcaneus. These are typically seen in male patients with the enthesitis-related subtype of JIA (4). One recent study with 26 JIA participants (average age of 11.6 years) reported a prevalence of 45% for the Achilles tendon and 20% for the plantar fascia (8). The mean recorded pain on a 100 mm visual analogue scale was 48 mm (8). Quality of life was not measured in this study; however, this level of pain may reduce physical and social well-being.

Digital deformities – Inflammation in the forefoot may lead to digital deformities such as clawed toes in children and adolescents with JIA. One study reported a prevalence of 17% in 144 participants (average age = 10.6) with JIA and hallux abducto valgus (2). Children with polyarticular subtype of JIA and those with a longer duration of disease were more likely to have hallux abducto valgus (2).

Biomechanical abnormalities – Biomechanical abnormalities of the foot and ankle are associated with prolonged synovitis (3). Synovitis can disrupt normal articulation of the rear and midfoot joints, and can contribute to an excessively pronated foot and abnormal plantar pressures (9). One study found that the prevalence of excessively pronated rear and midfoot joints in 144 JIA participants, was 73% and 72% respectively (2).

Conclusion: A range of foot and ankle pathologies are highly prevalent in JIA and contribute to physical morbidity. Allied health professionals may be involved as part of the paediatric rheumatology multidisciplinary team to assist in the early detection and management of these lower limb pathologies. Further research is required to attain accurate prevalence rates and the long-term implications that these foot and ankle conditions may have on a child or adolescent with JIA.