What are the next steps to manage swelling in a patient with a history of rheumatoid arthritis (RA) and a previous injury to the right foot, who has been advised to elevate and ice the affected area, wear compression socks, and has a pending 3-view X-ray of the right foot?

Management of Unilateral Foot Swelling in a Patient with Rheumatoid Arthritis

For a patient with rheumatoid arthritis and unilateral foot swelling, the recommended approach is to continue elevation, ice, and compression socks, while adding thermal modalities and considering referral to physical therapy for comprehensive foot/ankle assessment and treatment.

Initial Management Approach

• Continue the current management with elevation and ice as needed, as these are appropriate initial interventions for reducing swelling, though evidence for RICE (Rest, Ice, Compression, Elevation) alone is limited 1
• Compression socks are appropriate for managing foot swelling and should be continued 1
• The ordered 3-view X-ray of the right foot is appropriate to evaluate for structural changes, joint damage, or other pathology related to both the RA and previous injury 1

Additional Interventions to Consider

Physical Therapy Referral

• Refer to physical therapy for comprehensive assessment and management of foot/ankle involvement, as this is conditionally recommended by the American College of Rheumatology (ACR) for patients with RA who have foot/ankle involvement 1
• Physical therapy can provide individualized treatment including:
  • Proper fitting and recommendation of appropriate bracing, orthoses, and/or taping for the foot/ankle 1
  • Exercise prescription specific to foot/ankle function 1
  • Joint protection techniques and activity modification 1

Thermal Modalities

• Add thermal modalities (heat or cold therapy) which are conditionally recommended by ACR for RA management 1
• Patient can self-administer many thermal modalities at home, though guidance from a physical therapist may be beneficial 1
• When combined with exercise therapy, cryotherapy has been shown to have greater effect on reducing swelling compared to heat application alone 1

Pharmacological Considerations

• Consider NSAIDs if not contraindicated (after evaluating gastrointestinal, renal, and cardiovascular status) 1, 2, 3
• For RA patients, naproxen has been shown to reduce joint swelling and improve mobility 2
• Ibuprofen can be used at doses of 400mg every 4-6 hours as needed for pain relief 3

Monitoring and Follow-up

• Assess disease activity regularly using tender and swollen joint counts, patient's and physician's global assessments, ESR, and CRP 1
• Monitor the foot swelling at 1-3 month intervals until improvement is achieved 1
• Evaluate the X-ray results to determine if there are structural changes that may be contributing to the swelling 1

Common Pitfalls to Avoid

• Don't rely solely on RICE protocol without additional interventions, as evidence for RICE alone is inconclusive 1
• Avoid electrotherapy modalities (such as TENS) as these are conditionally recommended against by the ACR for RA management 1
• Don't overlook the possibility that the swelling may be related to an RA flare requiring adjustment of disease-modifying antirheumatic drugs (DMARDs) 4, 5
• Avoid chiropractic therapy, which is conditionally recommended against by the ACR for RA management 1

Special Considerations

• If swelling persists despite these interventions, consider further evaluation for other potential causes such as infection, fracture, or venous insufficiency 6
• The previous foot injury from 10 years ago may be contributing to the current swelling and should be considered when interpreting X-ray results 6
• Monitor for extra-articular manifestations of RA that could contribute to foot swelling 6, 4