Foot problems can arise with JIA, so special footwear may be needed.
Podiatry is the care of all foot problems. In children, the podiatrist is especially interested with the way the foot moves when walking and running. This is a speciality called biomechanics. The podiatrist would look at how the bones in the feet are aligned, how the joints in the feet and lower leg are synchronised and how the stability is maintained during movement so that walking is pain free and efficient. The podiatrist is also interested in how the foot may influence pain in other joints such as the knee, hip and back. The podiatrist would also consider how footwear can improve the foot and gait and whether insoles (orthoses) in the footwear can enhance the foot function or reduce any overload on the tissues that might be causing pain.
Many healthy children have foot positions and walking styles that may be considered less than perfect, but in general, if the foot (and lower leg) is pain-free and the child can walk without fatigue for good distances then the foot can be considered to be working well for that individual. The caveat to this is when the joint inflammation is not fully controlled. We know that when a joint swells, the soft tissues around the joint can become stretched and – particularly in joints that take body weight – the joints can stretch into poor positions. These positions may not correct when the swelling resolves. For example, swelling around the ankle and rear foot joints might take a normally arched foot into a flatfooted position (called a pronated position). When the inflammation comes under control the foot often does not correct back to its original position.
The first item in any treatment plan for any foot problem would be good footwear. For an adult or a child, the general principle is that our footwear should conform to the shape of our feet and should allow normal joint motion to occur, and be strong enough to prevent some of the abnormal movement that might be occurring. A boot will generally give more support than a shoe if the heel counter is reinforced but the boot needs a front fastening – a side zip is not good enough.
A good shoe will have the following features:
• a strong heel counter (back) to hold the heel well.
• a front fastening so the foot is held in the strong supportive heel counter.
• a good fit around the heel and ankle to aid stability.
• room for the toes to lie flat
• a flexible sole to allow the foot to rock from heel-contact to toe-off
The heel counter should be strong when squeezed in your hand and should not easily collapse – remember it has to support all of your body weight over many steps.
Because everyone has different shaped feet, there is no one brand of shoe or boot that will suit everyone. It is recommended to go to a shop where the fitter is experienced so they can choose the footwear to suit the foot. A shoe shop that sells a range of brands is best so that the fitter can measure the foot and then has a wide range to choose from. Recommended brands for children’s feet include Ricosta, Angulus, ECCO, Geox, Garvalin, Petasil, Startrite, Clarks. High street fashion brands for the school shoes are not recommended.
The podiatrist often uses orthoses to improve the foot position and function. Orthoses are specialised insoles that are placed into the footwear. These should conform closely to the shape of the foot and will alter the position of the heel on the leg, the forefoot on the rearfoot or they may change the timing of the movements of the foot. Orthoses are used when the foot or lower limb joints are painful, when regular swelling occurs in the foot joints or the foot function is considered to likely to cause long term problems.
There are many different ready-made brands available to the foot specialist which fit well and avoid the need to custom-make the orthoses. If the foot shape is difficult then custom made orthoses may be needed. There is one study on orthoses in children with JIA. This study found that custom orthoses significantly improved pain and function over ready-made orthoses or just footwear. A point of note about this study however is that the ready-made orthoses were simple, flat insoles and were not the more sophisticated orthoses that are now readily available. Present evidence in adults suggests that ready-made orthoses are as beneficial as custom made devices.
There are many different ready-made brands available to the foot specialist which, if they fit well, avoid the need to custom-make the orthoses. If the foot shape is difficult then custom-made orthoses may be needed in order to ensure a good fit. There are two good studies on foot orthoses in children with JIA which support the use of foot orthoses. One study compared custom-made orthoses to a flat insole and to using trainers only. The study found that the custom orthoses significantly improved pain and function compared to using the flat insoles or just trainers. The second study compared ready-made orthoses adjusted to suit each individual child to ready-made orthoses with no adjustment. The study found that the individually adjusted orthoses significantly reduced pain and improved quality of life measures compared to the non-adjusted orthoses. Both of these studies therefore suggest that orthoses tailored to suit the individual child can be beneficial in reducing pain, improving function and improving quality of life and are therefore an important consideration in children with JIA related foot problems.
When considering the biomechancis of the foot and lower limb, there is some overlap with the role of the podiatrist, physiotherapist, orthotist and osteopaths. Within all of these professions there will be people who are very good at looking after foot mechanics. There is no evidence to say which of these professions is most successful at treating foot problems so it will be best to ask your rheumatology consultant or team to recommend a professional to you. Should you need to see a podiatrist, you will find that every local primary care trust has a podiatry department but the availability of a paediatric podiatrist does vary considerably depending upon local demands and funding. Most podiatry services allow you to self-refer and this is preferable to going through the GP who are not always fully informed on the scope of the podiatry service.
Dr. Jill Ferrari, Podiatrist, Great Ormond Street Hospital, London