May is Lupus Awareness Month. Lupus is a systemic autoimmune disease that causes the body's immune system to attack its own otherwise healthy tissues and organs. Lupus may affect the people who have it in different ways, but this condition often affects most body parts including the joints, muscles, and bones of the feet and ankles. It is not uncommon for people with lupus to present with pain and other complaints in the feet even before diagnosis. Lupus is a condition that is characterized by episodes of flare-ups and relaxing of symptoms.

Common foot complaints in lupus

Some two-thirds of lupus patients complain of having arthritis in their feet. Additionally, tenosynovitis and tendonitis often coexist, leading to widespread foot and ankle pain, causing considerable disability. The prevalence of foot complaints in lupus is high, with over three quarters of those with this condition reporting having experienced pain in their feet during the course of their disease both in the forefoot and, more commonly, in the hindfoot. This pain is generally thought to be multi-factorial in origin with contributions from both articular and soft tissue musculoskeletal disorders. There is a higher incidence of vascular complaints with possibly serious consequences such as ulceration and digital gangrene.

Musculoskeletal changes

Foot problems in lupus can involve any of the tissue structures in the foot/ankle. Lupus may cause joint pain and inflammation, leading to arthritis, tendonitis, and unusual looseness in the tendons. Lupus may also bring about myalgia, which is characterized by aches and pains in the muscles. Many patients with lupus develop osteoporosis or low bone density, which can make fractures likelier. Foot problems in lupus can involve any of the tissue structures in the foot/ankle. These may include, but are not limited to, joint pain and swelling, skin lesions causing additional pain, tenderness and vascular and/or neurological manifestations in the lower limbs. Commonly reported foot complaints include pain, impairment and disability. Foot deformities may not be regularly reported since they may be hidden by footwear. Moreover, foot complaints cannot always be attributed to lupus since they are also widespread in the general population.

There is a higher prevalence of foot complaints in the elderly, which does not reflect the usual age range of the demographic with lupus. Significant joint deformity is rarely attributed directly to the disease processes seen in lupus. However, there are certain conditions seen within subgroups of lupus where synovitis, deformity and subluxation are common. Importantly, foot problems in lupus may be compounded by other systemic diseases.

Skin changes

Skin complaints are second only to musculoskeletal-based pain in those with lupus. A range of skin problems commonly arise in the feet. Corns and calluses are the most frequently reported skin problems, affecting almost three quarters of those with lupus. In the foot/leg, the common photosensitive discoid rash typically associated with lupus is less frequently seen. This increased prevalence is most likely to be caused by a combination of mechanical stresses where abnormal loading, due to foot dysfunction, causes lesions. However, joint subluxations and toe deformities may also lead to lesions from footwear. Few people with lupus report foot ulcers which is surprising given the added complications of vascular and neurological disease, especially when coupled with immunosuppressive medications. These medications may also increase skin infections such as fungal infections of both skin and nails and even viral infections.

Vascular changes

People with lupus have a greater risk of having vascular changes due to atherosclerosis. Research has found peripheral vascular disease (PVD) with low ankle brachial pressure is widespread among those with lupus. Vasospastic disease such as Raynaud's phenomenon is often common in persons with lupus. Of greater concern is critical limb threatening ischemia, foot ulcers and digital gangrene that have also been reported. People with lupus frequently complain of a range of circulatory complaints including cold feet, chilblains, Raynaud's phenomenon and pain from intermittent claudication.

Nerve changes

Neurological deficit and abnormal nerve conduction studies have been seen in people with lupus. There is often sensory and motor changes due to damage to the nerves. Numbness and loss of balance are reported, which may lead to an increased risk of falls and changes in the way they walk.

Management of
the lupus foot

Lupus is treated with medications including long-term corticosteroid therapy, disease-modifying medication and, increasingly, biologic therapy can increase the risk of infection and ulcers. People with lupus warrant "high-risk" podiatry care.

As with all patients with high-risk feet, the potential for foot ulceration is increased because of poor blood flow, nerve damage and other coexisting foot deformities. Problems with shoe fitting and increased pressure on the feet due to musculoskeletal dysfunction and deformities also increase these risks and regular assessment of the feet by the podiatrist is needed. The podiatry assessment is comprehensive and will capture not only the musculoskeletal pathology but also the vascular, neurological and dermatological manifestations and guide the management of conditions that may be present. The goal is to prevent serious complications (such as ulceration), reduce pain and increase and maintain mobility, particularly where activities of daily living are limited by foot pain.

Interventions may include conservative podiatry care such as shaving corns and calluses with padding or trapping to take the pressure off the affected area. Foot orthoses and/or footwear to aid with biomechanical control is important to reduce symptoms. Patients are advised about daily foot hygiene, foot inspection and footwear. People with lupus need specialist foot care in an effort to avoid complications including appropriate referral, early examination, preventative treatment, appropriate footwear choices and education about foot health.

When dealing with systemic disease of the feet including lupus, it is extremely important people check their feet routinely, so that any additional problems are caught quickly. If you have lupus and notice new aches, pains, or injuries to your lower limbs, it is suggested that you seek the care of a podiatrist, who can help manage the effects of lupus on your feet and ankles.

• For more information, email foothealth242@gmail.com. To see a podiatrist, visit Family Foot Centre on Independence Highway or telephone 605-3668 or 341-3668; Bahamas Surgical Associates at  East Terrace, Centreville, telephone 603-1814/5/6; Lucayan Medical Center on East Sunrise Highway, telephone 373-7400.

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