A Qualitative Study Exploring Foot Pain and Its Impact on Daily Function in Early Rheumatoid Arthritis

Abstract

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease frequently associated with significant foot pain, even in early stages. This study aimed to explore how patients with early RA perceive foot pain and its impact on daily activities. Methods: Semi-structured interviews were developed based on the Spanish Foot Function Index (FFI-Sp) in 25 patients with RA of less than five years’ duration. Four key themes emerged: (1) limitations in performing daily activities due to foot-related problems; (2) descriptions of pain, such as burning and throbbing sensations; (3) emotional responses, including frustration and sadness; and (4) perceived changes in mobility, balance, and muscle strength. Results: Patients reported pain as influenced by both intrinsic disease mechanisms and external factors. Conclusions: These findings highlight the early and substantial impact of foot involvement in RA and support the need for multidisciplinary interventions—encompassing orthopaedic care, psychosocial support, and patient education—to improve functional outcomes and quality of life. Level of Evidence: V (Qualitative study).

1. Introduction

Rheumatoid arthritis (RA) is a chronic, disabling autoimmune inflammatory disease that typically manifests between the ages of 20 and 40, with a prevalence of approximately 0.5% to 1%, being more common in women in developed countries, according to the World Health Organization (WHO). Its main symptoms include pain, swelling, and stiffness in the peripheral joints symmetrically, although extra-articular manifestations and associated comorbidities can also occur. These not only limit daily activities and work capacity but also significantly impact patients’ quality of life [1].

In addition to the physical impact, RA presents significant psychological challenges, such as anxiety and depression. Previous studies indicate that between 13% and 20% of RA patients experience depression, and up to 65% report psychological distress without meeting full diagnostic criteria [2]. These issues not only increase the burden on healthcare systems due to frequent consultations and poor treatment adherence but also highlight the need to address patients’ psychological needs to improve both their well-being and treatment efficacy [1,3].

Fatigue is another common symptom experienced by RA patients, affecting between 40% and 90% of cases [4]. This severe fatigue is associated with various factors, including chronic pain, sleep problems, and low physical activity, contributing to a reduced quality of life [5] and greater healthcare utilization [6].

The management of RA involves both pharmacological treatments [7] and non-pharmacological interventions, such as health education and promoting physical exercise. These interventions are part of the nursing role in rheumatology [8], playing a crucial role in disease management and improving patients’ quality of life [9]. According to the 2020 EULAR recommendations [10], nurses play a significant role in targeted care, highlighting the importance of multidisciplinary attention in the treatment of this disease [11,12].

Previous studies have shown that foot involvement in rheumatoid arthritis negatively affects mobility, participation in daily activities, social interactions, and quality of life. However, much of the available evidence is based on quantitative measures of pain, disability, and foot function. While these studies quantify the burden of foot symptoms, they provide limited understanding of how patients experience and interpret the impact of foot problems in their daily lives.

Qualitative research in rheumatoid arthritis has highlighted the importance of understanding patients’ lived experiences, including the effects of pain, fatigue, emotional wellbeing, and functional limitations. Nevertheless, relatively little attention has been paid to the specific experience of foot pain and foot-related disability, despite the high prevalence of foot involvement in RA. A deeper understanding of patients’ perspectives may help identify unmet needs and support the development of more patient-centred approaches to foot care.

Focusing on patients in the first years after diagnosis is particularly relevant because this period represents a crucial stage of adaptation to the disease. During this time, patients are learning to manage symptoms, maintain daily activities, and adjust to the physical and psychosocial consequences of RA. Exploring their experiences may provide valuable information for early intervention and support strategies.

Although foot-related symptoms are common in RA and have been associated with reduced function and quality of life [5], there is limited qualitative evidence exploring how patients experience these symptoms in their daily lives. The aim of this study is to explore, using the Spanish Foot Function Index (FFI-Sp), how patients with early-stage RA perceive foot pain and its impact on their ability to perform daily activities.

2. Methods

The present study adopted a qualitative approach to explore experiences of patients with RA with less than 5 years of evolution in terms of foot function.

2.1. Participants

A sample of patients with RA was recruited from the Rheumatology Department of the Virgen de las Nieves University Hospital in Granada (Spain). Eligible participants were asked to ascertain willingness to participate in the qualitative study. After they agreed to take part in the study, written informed consent was provided.

Inclusion criteria were provision of informed consent, age between 18 and 60 years, and a diagnosis of rheumatoid arthritis (RA) made less than 5 years before enrolment and based on the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria [13].

Participants were excluded if they did not present the ability to understand or express themselves in Spanish and/or they had previous lower limb surgery.

Interviews took place in March 2024.

2.2. Ethical Considerations

This study was conducted in compliance with the Declaration of Helsinki and received approval from the Ethics Committees of the University of Malaga (Ceuma-91-2015-H) and the Andalusian Health Service (PEIBA ARC0001). This study was carried out in full accordance with the provisions of the Declaration of Helsinki regarding ethical principles for medical research involving human subjects and was approved by the Ethics Committee.

Eligible participants received verbal and written information about the purpose of the study, the voluntary nature of participation, confidentiality procedures, and their right to withdraw at any time without consequences. Written informed consent was obtained from all participants prior to data collection.

2.3. Data Collection

Data were collected using a semi-structured individual interview. Multiple interviews were carried out to achieve data saturation, meaning that the themes are repeated in some interviews. The following quantitative data were also collected prior to the start of the study:

• Characteristics of the participant: gender (female/male), native country, years of age and years of RA evolution, pharmacological treatment, foot size, FFI score, weight and height.

The Foot Function Index (FFI) [14] is a tool that allows for the quantification of pain, disability and limitations in daily activities in patients presenting with foot symptoms secondary to RA. The FFI-Sp [15] was administered to describe participants’ foot-related pain and disability. In addition, selected FFI domains served as prompts to facilitate discussion during the semi-structured interviews. The FFI was not used as an outcome measure but as a tool to support data collection and contextualize participants’ experiences.

The interviews were conducted by phone, and they were recorded using a digital voice recorder. Furthermore, field notes supplemented the data. The interviews were carried out by a researcher (MGG) who had experience with patients with RA, from both a clinical and research context. Participants were made aware that the researcher was a podiatrist. A code was assigned for each patient, so they were pseudonymized. There was only one person from the research team (data manager, LRP) who knew the relationship between the assigned code and the participants’ data, leading to a blind code. That member accessed the files with a password and was not part of the data collection process, so as to not interfere.

Informed consent forms were signed by the participants during their appointment with their rheumatologist. All these signed consents, together with the data collection sheets and field notes, are archived in an office for 5 years, to which only authorized members have access. After 5 years, those folders will go to a warehouse belonging to the Nursing and Podiatry department from the University of Malaga, where all the documents related to studies that have been carried out are kept, and they will remain under lock and key for 15 years. Later, they will be destroyed.

Data analyses were conducted by two researchers (LRP and MPS). The questions for the semi-structured interview were developed using the FFI questionnaire as a guide and from a review of the literature on patients with RA foot function. The research question that was addressed in this qualitative study was as follows: to explore how patients with short-term RA perceive pain at the level of the foot and its impact when carrying out their activities of daily living. Therefore, the following questions were asked to the participants:

• Limitations in performing daily activities due to foot-related issues.

  ○

  Do you feel that your feet limit you or affect your ability to carry out daily activities?

  ○

  How does your body feel after walking or standing for long periods?

• Description of foot pain.

  ○

  How would you describe your foot pain? Is it a stabbing, burning, throbbing, or other type of painful sensation? Does it vary throughout the day?

  ○

  Could you describe the specific symptoms or discomfort that you experience in your feet due to the RA?

  ○

  What do you think triggers your foot pain? Specific activities, movements or situations?

• Emotional responses to pain.

  ○

  How have changes in your mobility, balance or muscle strength evolved due to the RA?

  ○

  How do you deal with your foot pain? Pharmacological treatment, type of footwear, or other alternative techniques or treatments.

• Changes in mobility, balance, or muscle strength due to the disease.

  ○

  How does this affect your independence and your ability to lead a fulfilling life?

  ○

  Have you sought any type of treatment or therapy to improve your foot function? How was your experience?

  ○

  How would you describe the importance of physical activity in your daily life? What benefits do you think physical activity provides and how does it make you feel?

No repeat interviews were conducted, and transcripts were not returned to participants for comment.

2.4. Data Analysis

The six-step thematic analysis framework from Braun and Clarke [16] was followed for the data analysis. First, researchers became familiar with the data through repeated reading of the verbatim transcripts and reading the field notes. Second, initial codes were generated by identifying meaningful segments of text related to participants’ experiences of foot pain, foot function, and their impact on daily life. A code was defined as a word, phrase, sentence, or passage that captured a relevant concept or experience expressed by participants. Particular attention was paid to both the frequency of emerging codes and their importance for multiple participants.

Third, related codes were grouped into potential themes based on conceptual similarity and shared meaning. Fourth, themes were reviewed and refined by comparing them against the coded extracts and the complete dataset to ensure coherence and consistency. Fifth, themes were defined and named to accurately reflect the underlying patterns of meaning in the data. Finally, the findings were organized and reported using representative participant quotations to support each theme. Initial coding was conducted independently by two researchers (LRP and MPS). Differences were discussed and resolved through consensus, and the resulting coding framework was used to develop themes and subthemes. MAXQDA 24 qualita tive data analysis software was used to facilitate coding and analysis.

The quantitative information was presented as mean and standard deviation (SD) when its distribution was normal and as median and interquartile range (IQR) if it did not follow a normal distribution. Normality of the distribution was examined using the Shapiro–Wilk test. The analysis was carried out using the statistical program IBM SPSS Statistics^®, Version 28.0.1.1 (Armonk, NY, USA).

3. Results

A total of 25 interviews were analyzed thematically. Five of the participants were male and 20 were female, aged between 24 and 58 years old, with an RA evolution from one to five years. The details of the participants are available in Table 1.

Table 1. Characteristics of the participants.

N = 25	Mean/Median	Standard Deviation/IQR
Years of age	47.88	9.05
RA duration (years)	2.88	1.60
Height (cm)	162.96	8.45
Weight (Kg)	72.65	19.95
Foot size (EU)	38.85	2.20
General VAS score	5.42	2.77
Foot VAS score	4.88	2.94
FFI	31.50	23.42
FFI_Pain	40.31	24.46
FFI_Disability	15	44
FFI_Physical_Activity	2	11

RA: rheumatoid arthritis; VAS: visual analogue score; FFI: foot function index.

Regarding pharmacological treatment, 3.8% of patients were not undergoing treatment, 46.2% were receiving methotrexate, 30% were on biological therapy, 19.2% were on a combined treatment of methotrexate and biological therapy, and 38.5% of the total patients, regardless of their treatment, were also taking corticosteroids.

A total of 209 codes were identified, which were subsequently organized into four themes. The resulting themes were agreed upon by the researcher and co-authors to enhance the validity of the data:

• Limitations in performing daily activities due to foot-related issues.
• Description of foot pain.
• Emotional responses to pain.
• Changes in mobility, balance, or muscle strength due to the disease.

3.1. Limitations in Performing Daily Activities Due to Foot-Related Issues

Half of the participants reported feeling limited by the condition of their feet, particularly when leaving their homes and where greater effort is required, such as climbing slopes or running. This discomfort mainly occurs in the forefoot area due to the development of hammer toes and in the ankle area. Participants also reported limitations in their choice of footwear and in their ability to make plans involving walking beyond their physical capacity. These restrictions lead to feelings of sadness as they have to adjust their social lives accordingly:

Participant 007: “It affects me every day and at any time; just walking down a small slope hurts.”

Participant 008: “It limits me when making plans that require more physical activity. If I have more pain, I have to refuse such plans.”

Participant 011: “I can’t wear what I want or walk as much as I want.”

Participant 024: “Even if I don’t want to, I have to sit down, and I feel very limited because I’m struggling, especially with my toes.”

The other half of the participants indicated that, although some currently experience more foot discomfort than at the time of diagnosis, they do not feel that their feet limit them in performing daily activities. They attribute this improvement to both pharmacological treatments (including disease-specific medication, anti-inflammatory drugs, and corticosteroids) and non-pharmacological measures (such as comfortable, wide, cushioned footwear, insoles, and visits to podiatrists and physiotherapists). Some also mentioned making lifestyle adjustments, such as leaving their jobs or learning to live with the discomfort, to avoid feeling limited:

Participant 003: “Right now, my feet are fine; they don’t limit me. I’m currently on biological treatment, and it’s working great.”

Participant 004: “My daily activities are not very limited because I use insoles, comfortable footwear, etc.”

Participant 009: “Right now, it doesn’t affect me at all. At the beginning of the disease, it did affect me a lot.”

However, most participants noted an inability to stand still for extended periods, with some adding that walking was also challenging. They related this to being forced to take breaks during everyday activities, such as walking or washing dishes, which they stated had a negative psychological impact:

Participant 005: “I need to sit down; I can’t stand or walk for long. I used to be able to do it perfectly.”

Participant 007: “I can’t stand still; I walk as much as I can, but slower.”

Participant 012: “I can’t cook without taking breaks in between.”

Participant 013: “When I wash two dishes and then have to sit down, I end up crying from frustration.”

Participant 023: “I can walk fine, but standing in one place is awful. For example, standing in line at the supermarket for three minutes is unbearable.”

3.2. Description of Foot Pain

When participants were asked to describe the foot pain they experience, a few reported no current pain. However, the majority described their pain in two main ways, stabbing and burning, associating it with inflammation. They compared the sensation to the pain of severe muscle soreness. This pain is often worse in the mornings, subsides during the day, and intensifies again in the evening. At times, it is so severe that it becomes incapacitating:

Participant 001: “It’s a stabbing pain; it varies throughout the day and gets worse at night.”

Participant 002: “I’m worse when I get out of bed in the morning and at night, but as I go about my daily life, it gets better.”

Participant 013: “It’s a burning pain due to inflammation, and when I’m doing something, like washing dishes, it becomes completely incapacitating.”

Participant 022: “Mostly sharp, stabbing pain, like contractures. When I have inflammation, it also burns. That pain is unbearable.”

Participant 025: “It’s like intense muscle soreness; I can’t move my legs, and I feel like an 80-year-old man.”

When asked to specify the location of their pain, participants commonly pointed to the joints of their toes, the metatarsophalangeal joints (both dorsally and plantarly), and the ankle. Muscularly, they mentioned the plantar fascia and the Achilles tendon. They also noted that the pain was exacerbated by certain footwear, such as safety shoes required for work, or by disease progression, which might lead to increased toe deformities, including hammer toes and hallux abducts valgus:

Participant 004: “One toe is starting to go under another, and they are becoming deformed.”

Participant 013: “My toes aren’t like they used to be; they’re all in bad shape. All my toes are twisted with bunions, and that area hurts terribly. The pain is constant all day; there’s never a moment without pain.”

Participant 017: “Only my toes hurt, but that’s enough to completely limit me.”

Participant 023: “During a flare-up, my ankles and toes hurt. The rest of the time, it’s the plantar fascia.”

The main trigger for this pain is periods of rest, even though participants recognize they need it. Other triggers include certain types of footwear (work shoes, narrow shoes, or high heels), stairs, slopes, and uneven terrains. Some participants reported that virtually any activity triggers their pain:

Participant 004: “I can’t stand wearing any shoes that aren’t wide enough or don’t fit my insoles, even for events. I always think more about the shoes than the outfit.”

Participant 013: “Everything hurts—any shoe or slipper, uneven ground, even walking around the house or standing to do something for a while. It’s horrible.”

3.3. Feelings Provoked by Foot Pain

Participants who reported minimal or no pain stated that despite their disease, they felt they could lead fulfilling, independent lives:

Participant 009: “It doesn’t affect me at all right now.”

For those experiencing pain, there were two main responses regarding their sense of independence and living a full life.

Some participants described feeling older and less capable due to their pain, relying on external help and expressing feelings of frustration, sadness, or desperation:

Participant 010: “It affects me a lot because during flares, I can’t move and need help.”

Participant 023: “This affects me emotionally because all these limitations make me sad at work, and I don’t feel like meeting friends or doing anything. I need psychological help.”

Participant 025: “I’m very desperate and anxious. I’m even seeing a psychologist now. It limits not just me but also those around me.”

Others reported that they did not let the disease stop them from leading a normal life, continuing their activities independently despite pain:

Participant 011: “I’m independent, with more discomfort and limitations, but I still do everything myself.”

Participant 021: “I do everything I used to, with more limitations and pain, but I do it all. I endure and internalize the pain.”

All participants agreed that physical activity significantly helped them mentally, even when it was challenging to perform due to fatigue. They emphasized its psychological benefits but cautioned against overexertion, as excessive activity could worsen their condition:

Participant 004: “It’s life-giving. Mentally and physically, I feel more agile. It helps me lose weight, improves my lab results, and gives me motivation. Mentally, it relaxes me and helps me forget any problems.”

Participant 014: “It helps me mentally; it cheers me up and clears my mind. When I can’t go out, I feel more depressed and irritable.”

Participant 018: “For me, it’s just another form of treatment.”

3.4. Changes in Mobility, Balance, or Muscle Strength

When asked about changes in their mobility, balance, or muscle strength due to the disease, some participants mentioned improvements since their diagnosis due to effective treatments. However, most noted a progressive deterioration:

Participant 014: “I’ve improved compared to before the treatment, when I couldn’t even walk after my diagnosis.”

Participant 005: “I’ve lost a lot of balance and muscle strength. My mobility is much more limited; it’s nothing like before.”

Participant 011: “I have less strength and balance. Sometimes when I’m walking, I trip as if I didn’t lift my foot enough.”

Participant 016: “Mobility and strength have worsened, especially during flares.”

4. Discussion

This qualitative study was designed to show the experiences of patients with rheumatoid arthritis, with a focus on people in the early stages of RA. To achieve this, patients diagnosed with RA for less than 5 years were selected.

The results provide an in-depth insight into the impact of RA on patients’ daily lives, analyzing functional limitations and pain, and focusing on activities of daily living. Participants experienced foot symptoms hindering their participation in everyday activities, which might lead to limitations in their daily life.

Also, the findings of this study have important implications for podiatric practice. Participants described foot pain, functional limitations, and difficulties performing daily activities during the early stages of RA, suggesting that podiatric assessment should be considered early in the disease course. Early identification of foot-related problems may facilitate timely interventions aimed at reducing pain and improving function. In addition, podiatrists may play an important role in patient education, footwear assessment, activity modification strategies, and the prescription of orthotic interventions when appropriate. Participants’ accounts suggest that addressing foot symptoms at an early stage may help patients maintain mobility, independence, and participation in everyday activities. These findings also support the integration of podiatry within multidisciplinary rheumatology services, ensuring that foot-related concerns are routinely assessed and managed as part of comprehensive patient care.

Mobility is crucial for performing daily activities, making them especially challenging for patients with RA. Participants reported that the limitations caused by various activities negatively affect their physical condition and their quality of life. Foot pain is a limiting factor for patients in their daily activities, with reports of being unable to tolerate standing, difficulty walking, or needing frequent breaks when performing tasks. This is a determining factor that affects the patient’s daily life [17].

The progressive reduction in mobility, balance, and loss of muscle tone reported by study participants are expected manifestations with current treatments in the later stages of the disease [18]. While some patients reported improvements since starting pharmacological treatment, most perceived a gradual deterioration in their physical condition.

We must consider that the patients interviewed are at an active stage of their lives, with high demands at the work, family, and social levels, which may be associated with increased stress, anxiety, and emotional repercussions [19,20]. Based on our results, we observed a significant impact on the patients’ ability to lead a fulfilling life, which can be linked to their functional limitations, forcing them to adapt activities such as walking, work, household tasks, and social relationships.

Foot pain is the primary symptom that participants associate with functional limitation [17], and they describe it as sharp and burning. They also report fluctuations throughout the day, ranging from manageable to incapacitating. To avoid reaching these levels, patients reduce, take breaks from, or postpone activities they want to do during the day, depending on the sensations they experience.

It is interesting to note that participants associate pain-triggering factors at two levels: internal and external. Internal factors include morning inflammation or flare-ups of symptoms, which are typically modified by pharmacological treatment. External factors, such as the type of footwear and uneven surfaces, are areas where we must work in a multidisciplinary manner, using health education [21] and specific orthopedic treatments [22] as tools to help the patient improve their functionality and navigate daily life [23].

Regarding physical exercise, many described a sense of incapacity to maintain a consistent physical routine during periods of increased activity, pain, and inflammation. They recognize that, while exercise is beneficial in the long term [24,25], it is difficult to perform, and they perceive it as an aggravating factor rather than a relief. With personalized guidance to safely manage exercise, adapted to their symptoms, patients could establish a healthy habit despite symptom fluctuations [26].

The impact of pain on emotional well-being was another recurring theme. Participants expressed feelings of sadness, helplessness, and frustration when having to limit their daily and social activities due to pain [26]. Some described feelings of “hopelessness” and the need for psychological support, highlighting the emotional component [27,28].

However, some participants express an attitude of adaptation to the pain, choosing to “endure” and continue with their usual activities despite the discomfort. This ability to adapt varies among individuals. Thomsen et al. (2024) include the variable “acceptance of the disease” and suggest the importance of psychosocial interventions that promote exercise, emotional well-being, and coping with the disease [29].

In our results, we also found patients without pain who continue with their daily activities and attribute this to the success of pharmacological treatment and the use of non-pharmacological measures, such as emotional integrity, adapted footwear, and orthotics. This emphasizes the importance of personalized therapeutic interventions that allow patients to better control symptoms, improve functionality, and optimize their quality of life [21].

Several aspects of the present study need to be addressed. First, it has several strengths. With the selected methodology, we reflected the experience of patients with less than 5 years of RA progression and the limitations they face when they present foot symptoms that hinder physical activity and even daily living activities. The participants were selected by their referring rheumatologists, with the condition diagnosed for less than 5 years. It is worth noting that responses from both men and women were similar, showing that the limitations probably caused by foot symptoms are not gender-related but are instead associated with the disease’s symptoms. Additionally, the study benefits from the clinical and research experience of the team, which includes nurses and podiatrists with expertise in rheumatology, aiding the interpretation of the data obtained.

Secondly, it is important to note the limitations identified in the study. Specifically, the treatment the participants were undergoing at the time of the interview was not considered, nor was it taken into account whether they were in an exacerbation phase of their symptoms.

To ensure trustworthiness, strategies addressing credibility, dependability, and transferability were incorporated throughout the study. Credibility was enhanced through the use of semi-structured interviews, verbatim transcription, and regular discussions among the research team during coding and theme development. Dependability was supported by maintaining a clear description of the research process and analytical decisions. Transferability was addressed by providing detailed descriptions of the participants, study setting, and research context, allowing readers to assess the applicability of the findings to other settings.

5. Conclusions

This study demonstrates the functional impact that RA has on patients in the early stages of the disease, especially those with foot symptoms. This alteration leads to limitations in their daily activities and emotional well-being. The results highlight the need for a multidisciplinary treatment approach that combines clinical care with orthopedic interventions and the promotion of healthy lifestyle habits. A comprehensive approach addressing both the physical and psychosocial aspects of the disease is crucial for improving patients’ quality of life and providing effective tools to mitigate the functional limitations associated with RA.