Scleroderma and the Foot: Podiatric Manifestations and Management

Scleroderma (systemic sclerosis) produces foot and ankle manifestations through its core pathological processes: vasculopathy affecting digital perfusion, skin fibrosis altering tissue pliability, and musculoskeletal involvement affecting tendons, joints, and periarticular structures. The most clinically urgent foot problem in scleroderma is digital ischemia from Raynaud phenomenon and obliterative vasculopathy — digits that experience repeated ischemic episodes are at risk for developing digital ulcers, which in the setting of fibrotic skin and compromised healing capacity can become limb-threatening wounds. My management of scleroderma foot ischemia prioritizes aggressive vascular protection: well-insulated footwear for cold exposure, avoidance of vasoconstrictive medications and nicotine, calcium channel blockers and prostacyclin therapy for significant Raynaud involvement coordinated with rheumatology. Skin fibrosis causes loss of the normal plantar fat pad cushioning effect as fibrous tissue replaces elastic dermis, increasing metatarsal pressure even with normal foot structure. Accommodative total-contact orthotics with viscoelastic materials compensate for the reduced intrinsic cushioning. Joint contractures from periarticular fibrosis can affect the ankle and subtalar joints, reducing range of motion and altering gait mechanics — physical therapy targeting ankle dorsiflexion preservation is important. Tenosynovitis is common in the wrist and hand in scleroderma but also affects the foot, producing a leathery crepitus on palpation. Digital ulcers require specialized wound care with moist healing environment, pressure offloading, infection management, and often systemic vascular therapy. I screen all scleroderma patients for these complications at each podiatric visit.