Sir, Foot problems in rheumatoid arthritis are common, under-researched and frequently neglected . Although evidence-based multidisciplinary clinics are well established in the care of people with diabetes , the case for dedicated podiatry care as part of the service provided by a multidisciplinary team in rheumatology has yet to be made. Traditionally, patients with foot problems are referred to an orthotist in an appliance department, where stock or bespoke footwear together with an insole (either ready-made or manufactured to a cast of the foot) are provided. Communication between doctor and orthotist is minimal and the patient may never see a podiatrist, as specialist podiatry is generally only provided for diabetic patients within the hospital environment. This system results in high levels of patient dissatisfaction and poor compliance with footwear and orthotics . Within this system, rheumatology trainees receive little instruction in the problems of the rheumatoid foot and, as consultants, are poorly equipped to assess foot problems and make appropriate prescription and recommendations. Furthermore, the dearth of postgraduate courses on the assessment and treatment of foot problems perpetuates this problem.
One way to address the lack of service provision and educational opportunities is to conduct specialist foot clinics at which professionals from different disciplines can meet to assess and treat patients with particular problems in their feet. There is evidence in the field of diabetes that such an approach improves outcomes such as the amputation rate ; while people with rheumatoid arthritis seldom have such a devastating end-point, health-related outcomes may also be improved in rheumatology by the provision of such a service.
A multidisciplinary foot clinic was established at St Lukes’ Hospital, Bradford, in July 1998. The multidisciplinary team consisted of a consultant rheumatologist, an orthotist and a podiatrist, with occasional support from a physiotherapist. The orthotist was employed by an external orthotics company who subcontracted his services to the hospital trust. The podiatrist was employed by the NHS Trust serving the community and attended the multidisciplinary clinic within the existing arrangements between hospital and community sectors. The clinic, situated in the orthotics department, was initially scheduled monthly but was rescheduled to run every 2 weeks after the first year. Referrals could be made by any member of the multidisciplinary team, i.e. by a physiotherapist or nurse, or any member of the medical staff. Referrals were not confined to rheumatology but the patient was required to have a problem with the foot or ankle which might benefit from a specialized foot service.
This review of the patients attending the clinic was conducted at the end of December 2000. Some of the data had been collected prospectively as part of the clinic database; this included demographic data, referrer, the nature and site of the foot or ankle problem, diagnosis of the presenting disorder, diagnosis of the foot/ankle disorder, and treatment given. In addition, a number of attendees completed a modified version of the Manchester Foot Health Disability Questionnaire (MFHDQ). The MFHDQ was modified by the exclusion of the last two items relating to work, resulting in a 17-item questionnaire requesting information about pain, mobility, activities and footwear in relation to foot problems; the score range for each item was 0–2, providing a maximum score range of 0–34 .
The number of patients seen in the defined period was 109 (68 females, 41 males, mean age 54.8 yr, range 5–84 yr). The most common diagnosis was rheumatoid arthritis (51 people) followed by osteoarthritis (13), neurological (12), mechanical foot pain (8) and others, all rheumatological (25). The mean duration of disease was 10.8 yr (range 1–45 yr).
The most common presenting foot problem was foot pain (forefoot, rearfoot or both), in 53 people, followed by foot deformity (27), abnormal gait (12) and others (18; these included ankle pain, club foot, foot drop, knee or leg pain, and short leg).
Treatment consisted only of advice for four people, the prescription of shoes for 47 (stock shoes 33, bespoke 14), orthotics for 83 (rigid functional foot orthosis 31, non-rigid orthosis 20, total contact insole 19, metatarsal insole/pad 13) and external modifications to footwear or ankle foot orthoses for 22. Ten people were referred for further treatment: three for surgery, eight for physiotherapy and 10 for foot care (nail-cutting and callus reduction). Three people were given a walking aid. For all people attending the clinic the median score on the MFHDQ was 24.5, range 4–33.
This brief survey has provided a snapshot of the sort of problems seen in a newly established multidisciplinary foot clinic in rheumatology. Not surprisingly, most people referred to this clinic had rheumatoid arthritis. As recent evidence suggests that early intervention with custom-made rigid orthoses can improve symptoms and delay the progression of deformity in rheumatoid arthritis , it was reassuring to record that the commonest intervention was the provision of a rigid functional foot orthosis.
The multidisciplinary clinic also provided a referral point for other non-rheumatoid rheumatic foot problems and for patients with non-rheumatic disease, mostly neurological disorders. In our district, neurological patients of all ages have no recognized provision of expertise for their foot pain and deformity; patients are referred from a variety of sources to the appliance department for assessment by orthotists but the availability of a multidisciplinary team enhanced the care of such patients by providing an appropriate coordinated approach.
An orthopaedic surgeon was not included in the multidisciplinary team at this stage. The main reason for this was logistical, but it was acknowledged by team members that the evidence base for surgical intervention for foot problems, particularly in rheumatoid arthritis, is poor and the indications for surgery remain unclear. There is a need for well-designed randomized controlled trials in this area.
In summary, it might help other people to set up and run a multidisciplinary foot clinic if some simple recommendations, based on our experience, are given.
Ensure the clinic is truly multidisciplinary, with a minimum of the following personnel: consultant medical, podiatry and orthotist. It is helpful to also have a contribution from a physiotherapist. A foot surgeon might usefully be invited to attend the clinic at regular but infrequent intervals.
Ensure sufficient time with patients (generous booking). We provided a clinic of 90 min for four new patients, alternating with a review clinic of 60 min with up to six patients.
Provide appropriate seating for the patient; unless the foot can be raised off the floor the examiners will have to spend most of the clinic on their hands and knees.
Provide sufficient space to observe gait; 5 m is sufficient. As patients are required to walk barefoot, a non-slip surface is recommended.
To ensure the patient is satisfied with the result of the intervention(s), multiple visits may be necessary.
The authors have declared no conflicts of interest.