“The joints in my feet were among the first to be affected — X-rays have shown some [joint] erosion. Even during my best days, my feet have always been a sore point,” Kramer says. Erosion refers to the wearing away of cartilage and bone in the joint. It’s caused by inflammation within the joint lining. RELATED: I Tried Virtual Reality Telehealth for Chronic Arthritis Pain — and Here’s What Happened Kramer is not alone. About 90 percent of people with rheumatoid arthritis have some kind of foot pain, according to the American Orthopaedic Foot & Ankle Society, which makes walking difficult and restricts daily activities. And yet, the researchers warned, not enough attention is paid to foot care. Rheumatoid arthritis can attack any of the foot’s joints, leaving them inflamed and painful.

You might find that pain is affecting both your feet in the same locations. For some people, the ankles hurt the most and might appear swollen. You might feel other symptoms as well. “Patients complain of pain in the toe joints, ligaments, or ankles mainly upon arising from bed. It is associated with joint swelling, redness, and warmth. Rheumatoid nodules can also develop. This can lead to joint deformities and widening of the forefoot, necessitating an increase in shoe size,” explains Maya Mattar, MD, a rheumatologist at the Louis Stokes Cleveland Veterans’ Administration Medical Center in Ohio. Dr. Mattar adds that the pain and stiffness may be worse in the morning, forcing you to get up an hour or more early in order to prepare yourself for the day. A study published in the July 2018 issue of Journal of Foot and Ankle Research compiled the recommendations of a panel of 24 medical professionals and patients to diagnose and treat foot problems related to RA. Based on the foot issues, treatments include medication, exercise therapy, a variety of shoes, braces, and orthotics, or surgery. Your rheumatologist can also prescribe you medications, called disease-modifying anti-rheumatic drugs (DMARDs), that control the inflammation and prevent joint damage, notes Mattar. “Inflamed joints can be eroded and leave a scarred joint; the ball of the foot then becomes a rough, bumpy bone,” says Robert W. Lightfoot, MD, a professor of internal medicine in the division of rheumatology at the University of Kentucky in Lexington. “Active inflammation and eroded, damaged bones cause pain.”

One of the targets of this inflammation is the joint capsule, which normally acts like a sleeve, protecting the joint by adding stability to it. Some of the deformities related to rheumatoid arthritis include:

Bunions (Hallux Valgus) This is an enlargement of the joint at the base of the big or little toe.Hammertoe Hammertoes and claw toes occur when the toes are permanently bent under.Bursitis Fluid-filled sacs (called bursae) develop under the ball of the foot and may become inflamed and swollen. They commonly occur along with bunions.Charcot Arthropathy, Also Called Charcot Foot and Ankle If one or more joints in the ankle or foot become severely damaged, the foot may collapse, resulting in a deformity called Charcot arthropathy.Plantar Fasciitis Inflammation of the plantar fascia in the sole of the foot causes pain under the heel.Rheumatoid Nodules These firm lumps, which are the size of a pea, occur where pressure is put on the foot, like the soles and the big toe joints.Valgus Heel Joint damage may cause the heel to push outward, which results in valgus heel.

Rheumatoid Arthritis May Lead to Other Foot and Ankle Issues

Another foot problem experienced by people with RA is nerve pain. “Peripheral nerve pain in the foot can cause burning, tingling, and tenderness,” Dr. Lightfoot says. “Continued pressure on the medial side of the foot can then result in nerve entrapment, or tarsal tunnel syndrome.” Foot pain often occurs in the joints or ball of the foot. In fact, for about 20 percent of people with RA, foot and ankle issues are the first symptom of rheumatoid arthritis, according to AAOS.

Manage the Rheumatic Disease, Manage the Foot Pain

Surgery is often needed to alleviate the pain associated with bunions, hammertoes, and nodules, according to AAOS. Foot surgery may involve resetting the bones or fusing joints to correct the position of bones and joints. Local steroid injections are particularly beneficial for inflamed joints and plantar fasciitis. But before you schedule surgery or an office visit for injections, you might try non-invasive approaches such as braces, or choose shoes or inserts designed to support your feet, AAOS recommends. Uncontrolled inflammation leads to joint bone erosions and other damage, which leads to foot deformities, said Lightfoot. “Early use of the newer and much more effective remittive drugs to lesson or eliminate inflammation is key to preventing bone damage and resulting deformities,” Lightfoot says.

What’s the Right Footwear When You Have RA?

“Narrow-toed or pointy-toed shoes, as well as heels, are bad for the foot as they cause the wearer to put pressure on the ball of the foot and can cause marked deformities,” Lightfoot says. “An oxford-type shoe with a low heel, wide toe, and high ceiling that will not rub the foot is best.” Good arch support will help distribute the weight evenly on the entire foot, and orthotics — special devices put into the shoe — can alleviate foot pain caused by rheumatoid arthritis and possibly prevent deformities in the foot, Lightfoot adds.

8 Tips to Relieve or Avoid Foot Pain

In addition to the right footwear, pain medications, and surgery, there are things you can do to reduce foot pain from rheumatoid arthritis: The best way to manage your foot pain is by keeping your rheumatoid arthritis under control. If you do, you can keep your feet happy. Additional reporting by Madeline Vann, MPH.