Rheumatological and inflammatory foot and related driving restrictions

Rheumatological and inflammatory foot and related driving restrictions Rheumatological and inflammatory foot and related driving restrictions

Rheumatological and inflammatory foot

As an essential integral part of the musculoskeletal system, the foot frequently experiences diverse bone, periarticular and joint conditions, that may be related to other sites and affect the general patient status.

The most important sign is mechanical or inflammatory pain, that will normally subside with analgesic and anti-inflammatory drugs.

Pain of an inflammatory origin is not constant, is usually felt on waking up, worsens when starting to walk, and decreases with warming up of the musculoskeletal system until it finally disappears.

Inflammation is very noticeable in the Achillean, metatarsophalangeal, and toe areas.

Local care includes rest, use of orthopaedic insoles, kinesitherapy, and patient counselling about the most suitable type of footwear for their problem.

Surgery is reserved for advanced deformity causing great difficulty to wear shoes and pain on walking.

Tips

  • Joint deformity and pain prevent driving in many cases.
  • Patient assessment by the physician will allow for knowing driving limitations at any given time to inform and advise on the most convenient action in each case.
  • In cases with advanced disease, the physician may advise against driving for safety reasons.
  • The time of incapacity for driving following surgical treatment will depend on the procedure used and on function recovery allowing for safe pedal control.

Rheumatoid foot

This polyarthritis affects the foot at a very early stage, and occurs symmetrically in most cases.

The condition initially occurs in the forefoot with metatarsal pain of an inflammatory origin, associated to claw toes with metatarsophalangeal subluxations and dislocations.

Lateral deviation of the first four toes sometimes occurs.

Back foot and ankle may also be affected, and the posterior superior process of the calcaneus is often involved.

Clinically, a pain-induced post-static dyskinesia occurs, increasing after immobility periods.

The skin becomes thin, and subcutaneous rheumatoid nodules are formed in bone prominence areas and load or contact areas. Prolonged activity worsens clinical signs.

Multiple adapting insoles may be used depending on the areas bearing more pressure, and use of shoes with low heel, rigid reinforcement, and a wide forefoot must be recommended.

Surgery is indicated in advanced cases to achieve a stable supporting surface or correct painful support points.

Ankylosing spondylarthritis

The backfoot is often the most affected area, experiencing a very painful, inflammatory talar pain in the plant.

This may be diffuse or concentrated in the posterior area, ranging from a disabling pain to an asymptomatic form.

Tenosynovitis of Achilles tendon is common, and a usually painless calcaneal inflammation is seen in more than one half of cases.

The midfoot is little affected, and posterior tibial and peroneal tenosynovitis is usually seen with some frequency.

The forefoot is lees affected than the backfoot, but forefoot sequelae are very disabling, including rapidly deforming hallux valgus associated with increasing footwear difficulties and pain.

Treatment with anti-inflammatory drugs is associated to bandages and local protection, such as heel protectors used for heel pain.

Tips

  • Patients must not drive during acute pain episodes, nor with bandages or immobilisations.
  • Adapted footwear allows for driving if there are no points of severe pain in the sole.
  • The physician will advise against driving if the patient, despite using adapted footwear, has painful points that force him to adopt a posture that avoids pain but may cause an inadequate pedal actuation.
  • The various tenosynovites interfere with movements required for driving, which should be advised for the patient to exercise extreme caution when driving.

Psoriatic foot

This includes polyarthritis, involving distal interphalangeal joints and nails.

Rheumatism in the foot is similar to other rheumatic conditions such as forefoot rheumatoid polyarthritis, and occurs even as a gout attack in the first toe.

Treatment of psoriatic foot is limited to NSAIDs and kinesitherapy.

Tips

  • The condition of the skin does not usually cause a significant interference with driving.
  • Patients must be advised not to drive during acute pain episodes, nor with bandages or immobilisations.

Osteoarthritic foot

Osteoarthritis usually results from trauma or multiple microtraumas, surgery, foot deformity, or a periarticular bone disease, causing mechanical pain and stiffness.

Orthopaedic insoles improve mild and even severe cases, decreasing painful symptoms while standing and walking.

Surgery is aimed at improving weight bearing areas, for which arthroplasties and arthrodesis preventing driving for up to three months are performed.

Tips

  • Joint stiffness impairs multiple movements required for pedal action, thus preventing a rapid response to unexpected traffic situations.
  • Pain and motion restrictions may lead the physician to advise against driving.
  • Depending on the required treatment and existing sequelae, the specialist will determine in each case the ability to drive of the patient and will report it at each revision.
  • Surgical treatment requires in each case a subsequent functional recovery and safety period in which driving will not be allowed until a favourable report is issued by the specialist.

Extraarticular rheumatism

There are multiple constitutional, anatomic, and biomechanical agents causing tendon damage.

Other agents, such as inflammation, inadequate hydration, hyperuricemia, corticosteroid injections, or infections also increase tendon fragility.

Many cases of tendon fatigue due to overuse, inadequate training, or a poor sport technique are seen today because of the increasing sport practice.

Achilles tendinopathy or Achilles tendon bursitis occur in the backfoot.

Peroneal tenosynovitis, often requiring suture, occurs in the lateral aspect.

Tibial posterior tenosynovitis appears in the medial aspect, with the common tarsal tunnel syndrome.

Tendinopathies of the short plantar flexor are seen in the anterior medial aspect.

Pain, mechanical in origin and increasing under strain and pressure, is the warning sign in all cases.

Treatment consists of rest and physical therapy, which are followed by muscle reeducation, together with analgesic and non-steroidal anti-inflammatory drugs.

Tips

  • While the patient has pain, loss of strength, and functional limitation preventing adequate use of the car pedals, driving should not be permitted.
  • Pain prevents movements that are essential when driving, thus causing uneasiness, fatigue, worry, insecurity, and loss of attention. Driving becomes an obligation that worsens the clinical picture.
  • Pain and motion restrictions may lead the physician to advise against driving.
  • Depending on the required treatment, the specialist will determine the ability to drive of the patient and will report it at each revision.
  • Surgical treatment requires in each case a subsequent functional recovery and safety period in which driving will not be allowed until a favourable report is issued by the specialist.
  • Patients cannot drive with a bandaged or immobilised lower limb.
  • Patients must not drive while they have symptoms that may impair safety.