Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disease that primarily targets the lining of the joints, known as the synovium. This condition causes pain, swelling, and stiffness, most often affecting the hands, wrists, and feet. While RA is primarily associated with joint destruction, its effects can extend throughout the body, directly impacting the systems responsible for maintaining stability. RA can cause balance problems, leading to unsteadiness and instability that significantly increases the risk of falling. This loss of balance stems from both structural damage in the upper spine and peripheral changes in the lower extremities and nervous system.
How RA Affects the Upper Spine and Balance
The inflammation characteristic of RA can affect the delicate joints of the neck, particularly the cervical spine. The most direct threat to balance comes from involvement of the atlantoaxial joint, which consists of the first two vertebrae, C1 (atlas) and C2 (axis). Chronic inflammation here can erode the surrounding ligaments and bone, leading to atlantoaxial subluxation (AAS).
AAS is a misalignment where the C1 vertebra slips forward over the C2 vertebra. This instability is a significant concern because the joint is located immediately beneath the brainstem and spinal cord. If the slippage is substantial—three millimeters or more is often considered unstable—it can compress these vital neurological structures. This compression can manifest as neck pain, vertigo, dizziness, and a loss of equilibrium.
This structural instability directly interferes with the proprioceptive input from the neck, which is essential for spatial orientation and balance. The resulting neurological dysfunction can cause gait changes and clumsiness. For patients with RA, the cervical spine is the third most frequently affected area of the musculoskeletal system, after the hands and feet, making vigilance for these symptoms important.
Peripheral Factors Contributing to Unsteadiness
Beyond the central structural issues, RA creates peripheral problems that erode stability from the ground up. Joint destruction in the feet and ankles is extremely common, affecting over 90% of people with RA over the course of the disease. Damage to the midfoot and hindfoot can cause the arch to collapse and the bones to shift out of alignment, leading to deformities like claw toes and severe bunions.
These changes alter the mechanical foundation of the body, fundamentally changing a person’s gait and how weight is distributed while walking. When the foot’s structure is compromised, the body receives faulty proprioceptive signals, which leads to unsteadiness, especially on uneven surfaces. Furthermore, the chronic inflammation can affect the peripheral nerves themselves, a condition known as peripheral neuropathy.
Peripheral neuropathy causes numbness, tingling, and muscle weakness, typically starting in the feet. This nerve damage compromises the sensory feedback loop that communicates with the brain to maintain balance, making steps less confident and increasing the risk of tripping. Systemic factors of RA, such as chronic pain, severe fatigue, and sarcopenia (the loss of muscle mass and strength), also contribute to overall physical instability.
Identifying and Treating Balance Problems
Identifying the cause of RA-related balance issues begins with a thorough physical and neurological examination to assess reflexes, coordination, and gait. Imaging is often required to look for structural causes, particularly if cervical spine involvement is suspected. X-rays, specifically taken while the patient gently flexes and extends the neck, are used to visualize any instability or subluxation in the C1/C2 joint.
If neurological symptoms are present, a magnetic resonance imaging (MRI) scan can provide detailed images of the soft tissues to check for spinal cord or brainstem compression. Management is centered on disease control, using medications to reduce systemic inflammation and prevent further joint and nerve damage. Physical therapy is a cornerstone of treatment, focusing on exercises for strength, gait training, and proprioceptive re-education.
For patients with significant foot and ankle deformities, custom orthotics and supportive footwear can help stabilize the gait and improve balance. In cases of severe and progressive atlantoaxial subluxation that causes neurological deficits, surgical intervention, such as spinal fusion, may be necessary to permanently stabilize the neck and protect the spinal cord.