Pathomechanics, Gait Deviations, and Treatment ... - Physical Therapy

Pathomechanics, Gait Deviations, and Treatment of 

the Rheumatoid Foot : A Clinical Report 

Phyllis Dimonte and Hollis Light 

PHYS THER. 1982; 62:1148-1156. 

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Pathomechanics, Gait Deviations, and Treatment 

of the Rheumatoid Foot 

A Clinical Report 

PHYLLIS DIMONTE 

and HOLLIS LIGHT 

This article describes the five major foot deformities or problems often seen in 

patients with rheumatoid arthritis: hallux valgus, pronation of the foot, depression 

of the metatarsal heads, hammer or claw toes, and tendocalcaneal bursitis 

or subplantar spur formation. These deformities contribute to the development 

of common rheumatoid gait deviations such as decreased velocity, cadence, 

and stride length; poor heel-toe pattern; and abnormal patterns of weight 

bearing. Nonsurgical treatment for these problems includes joint protection 

methods, assistive gait devices, orthotic intervention, and physical therapy 

procedures. Surgical intervention provides stability for the weight-bearing joints 

of the foot and reduces pain. Consideration of these problems and an early 

intervention effort may help to prolong the ambulatory status of the patient with 

rheumatoid arthritis. 

Key Words: Gait; Rheumatoid arthritis; Foot deformities, acquired. 

Individuals who have rheumatoid arthritis frequently 

develop a combination of foot deformities 

unique to this disease. Although almost 90 percent of 

these patients are reported to have foot involvement, 

the literature discussing the rheumatoid foot, when 

compared with information about the rheumatoid 

hand, is rather scant. 1 

In the lower extremity, weight-bearing stresses that 

are transmitted through the foot create the potential 

for injury, overuse, or strain at this site. The pathologic 

tissue and joint changes occurring in rheumatoid 

arthritis promote these problems and lead to changes 

in the structure of the foot. Advances in hip and knee 

surgery have allowed many otherwise wheelchairbound 

patients to remain ambulatory. In an effort to 

maintain the tolerance of the foot for ambulation, 

preventive measures may be employed to manage 

deformities and correct resultant gait deviations. 

Ms. DiMonte is Physical Therapy Consultant to the Rehabilitative 

Engineering Research & Development Center, Box 20, Edward 

Hines, Jr, Veteran Administration Hospital, Hines, IL 60141 (USA), 

and to the Department of Orthopaedics & Rehabilitation, Loyola 

University Medical Center, Maywood, IL 60153. 

Mrs. Light is Senior Physical Therapist and Clinical Supervisor, 

West Suburban Hospital, Oak Park, IL 60302. 

This article was submitted August 3, 1981, and accepted January 

26, 1982. 

The purpose of this paper is to present the major 

deformities or problems of the rheumatoid foot and 

their pathomechanics, associated gait deviations, and 

physical examination findings. Nonsurgical and surgical 

treatments are also briefly outlined. 

DEFORMITIES AND PROBLEMS 

In the rheumatoid joint, there is initial involvement 

of the synovium with the eventual loss of joint integrity. 

Tendons, ligaments, cartilage, and the joint capsule 

are all subject to inflammation and destruction. 2 

When the inflammatory process characteristic of 

rheumatoid arthritis affects the foot, the patient may 

develop painful deformities that increase stress during 

weight bearing. It is no wonder that many patients 

resort to progressively less ambulation. If treatment 

can be initiated to correct these deformities and provide 

relief, ambulation tolerance may be restored. 

The major foot deformities associated with rheumatoid 

arthritis involve the hindfoot along with the 

forefoot. Talonavicular joint destruction seems to occur 

early and results in a malalignment during weight 

bearing. 3, 4 In the normal gait cycle, after heel contact, 

the compressive forces on the subtalar (talocalcaneal) 

1148 PHYSICAL THERAPY 



Fig. 1. Major deformities in the foot affected by rheumatoid arthritis. 

and midtarsal joints (talonavicular and calcaneocuboid) 

cause the foot to become a rigid lever: the head 

of the talus locks into the navicular cavity, and the 

midtarsal joints become fixed. In the foot affected by 

rheumatoid arthritis, however, as the midtarsal and 

subtalar joints become less stable, the head of the 

talus shifts in a plantar and medial direction, keeping 

this locking mechanism from occurring. Because the 

normal line of weight bearing begins in the lateral 

heel and advances medially, the instability in the 

hindfoot joint allows for increased medial motion. 

There is increased depression of the medial longitudinal 

arch and outward rotation of the calcaneus, 

causing a valgus deformity of the heel as weight 

bearing occurs. The instability at the hindfoot may 

subsequently lead to deformity in the forefoot, specifically 

to hallux valgus and depression of the metatarsal 

heads. 

In hallux valgus, the metatarsophalangeal (MTP) 

joint of the great toe becomes inflamed, and the 

resultant ligamentous laxity causes instability. Lateral 

deviation of the proximal and distal phalanx of the 

great toe occurs, and it angulates toward the second 

toe. As a result, the flexor and extensor muscles of 

the great toe shift laterally and act like a bowstring. 

As they contract, the toe is pulled farther laterally. 

There is an over pull and shortening of the intrinsic 

muscles so that the adductors overpower the overstretched 

abductors, accentuating the lateral movement. 

The bursa located over the medial portion of 

the metatarsal head becomes inflamed resulting in a 

painful bunion. Examination of the patient will reveal 

a prominent, sore first metatarsal head and lateral 

angulation of the great toe. There may be a lateral 

deviation of the second through fifth toes as well. 

The weight-bearing capacity of the MTP joint of 

the great toe diminishes as the hallux valgus deformity 

progresses. This causes the majority of the weight 

to be borne by the lesser metatarsal heads. 5 The 

metatarsal heads are often the site of inflammation 

and capsular distention. With time, the collateral 

ligaments lose integrity, and as the patient walks, the 

constant stress of the toes extending leads to subluxation 

and eventual dislocation of the MTP joints. As 

the MTP joints dislocate, the proximal phalanges 

come to rest dorsally on the necks of the metatarsals 

and force the metatarsal heads downward (plantarward). 

This causes direct pressure on the metatarsal 

heads as the patient walks. The patient may complain 

of pain and the sensation of walking on marbles. The 

fat pad, located directly under the metatarsal heads, 

normally provides a cushion during this weight-bearing 

phase. With this deformity, the fat pad migrates 

dorsally with the proximal phalanx and therefore 

does not provide this protection for the metatarsal 

heads. Thick callouses may develop in this area. 

These are painful with weight bearing and may lead 

to ulceration. As the metatarsal heads dislocate, there 

is also a laxity in the MTP joints and a subsequent 

widening of the forefoot. This may be due to the 

stretching of the intermetatarsal ligaments and weakness 

of intrinsic muscles. 

As the MTP joints dislocate, the long flexor and 

extensor muscles of the toes lose their normally balanced 

position. The extensor muscles on the dorsum 

of the foot become shortened and the flexor muscles 

become stretched. The claw toe deformity occurs with 

hyperextension of the MTP joint and flexion of the 

interphalangeal joint. In hammer toe deformity, not 

only is the MTP joint hyperextended and the proxi- 

Volume 62 / Number 8, August 1982 1149 



mal interphalangeal joint flexed, but the distal interphalangeal 

joint is hyperextended. As the toe flexor 

muscles contract at the end phase of ambulation, the 

hammer and claw toe deformities are exaggerated. 

Pressure and friction within the shoe may then cause 

callouses to develop on the dorsum of the toes and on 

their plantar tips. 

Finally, the patient may develop heel problems. 

The two areas of common involvement are at the 

Fig. 3. Osteokinematics of the leg, ankle, and foot during 

the normal gait cycle. The dots signify the division between 

phases of gait 

1150 

Fig. 2. Divisions of gait cycle. 

calcaneal insertions of the Achilles tendon and at the 

plantar aponeurosis. In the first situation, the bursa 

between the Achilles tendon and the calcaneus may 

become inflamed as a result of the arthritis. Further, 

pressure from the shoe counter may cause additional 

irritation and the patient will experience more pain. 

In the second instance, a bony spur may result from 

calcaneal erosion causing an irregularity at the site of 

the attachment of the plantar aponeurosis. Also, the 

rheumatoid nodules, which commonly develop on the 

calcaneus, may also be a source of pain to the patient. 

In summary, the major foot deformities and problems 

seen in the patient with rheumatoid arthritis 

(Fig. 1) are 1) pronated foot, 2) hallux valgus, 3) 

depression of the metatarsal heads, 4) hammer or 

claw toes, and 5) tendocalcaneal bursitis or subplantar 

spur formation. 

GAIT ANALYSIS AND PHYSICAL 

EXAMINATION 

A brief review of normal gait is provided before 

consideration is given to evaluating the types of gait 

deviations seen in patients with rheumatoid arthritis. 

Recall that the major divisions of the gait cycle are 

the swing and the stance phase and that the stance 

phase may be further divided into the contact period, 

midstance, and propulsion (Figs. 2 and 3, Tab. 1). 5 

Within each of these phases, the aspects to consider 

in evaluation are the osteokinematics and muscular 

activity occurring at the foot. 


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PHYSICAL THERAPY

Gait analysis may be performed using a variety of 

techniques, from complex methods using sophisticated 

diagnostic equipment, to simple methods using 

clinical observations and test results. When using 

these simpler methods, a few basic rules must be 

observed. The patient should be barefoot and the 

walking surface must be level. The physical therapist 

should note each division of the gait cycle and document 

the patient's compliance or deviation from the 

normal standard. Because involvement of the subtalar 

joint is believed to occur early in rheumatoid arthritis 6 

and this joint's alignment affects the subsequent progression 

of deformities of the involved foot, analysis 

of this joint position is of particular importance during 

midstance. A method proposed by Root for this 

assessment is to note the direction and alignment of 

the curves seen on the lateral border of the lower leg 

proximal and distal to the lateral malleous (Fig. 4). 7 

In the correctly aligned foot, the curves are in the 

same direction and the vertical alignment is in the 

same plane. In the pronated or supinated foot, the 

convexities are not in the same plane or direction. 

This malalignment can be easily observed and documented. 

For the patient with rheumatoid arthritis, several 

authors have proposed some general gait deviations 

not attributed to a specific anatomical deformity. 8 " 10 

These deviations are decreased velocity, cadence, 

stride length, and range of motion of the knee as 

compared with matched subjects without rheumatoid 

arthritis. It is also possible, however, to identify specific 

deviations in the gait cycle caused by the progression 

of the rheumatoid deformities in the foot. 

PRACTICE 

TABLE 1 

EMG Activity, a Using Wire Electrodes, of the Critical 

Muscles Functioning at the Foot and Ankle During 

Normal Gait Cycle 

Anterior 

tibialis 

Posterior 

tibialis 

Extensor 

digitorum 

longus 

Flexor 

digitorum 

brevis 

Abductor 

hallucis 

Lumbricals 

Gastrocnemius/ 

Soleus 

Contact 

XX 

X 

Midstance 

XX 

XX 

X 

Stance 

a XX = greater contraction than X. 

Propulsion 

X 

XX 

X 

XX 

Swing 

Table 2 summarizes the gait deviations, findings on 

physical examination, and treatment goals. 

Because hindfoot instability is a component in each 

of the deformities, the resultant malalignment is 

thought to have a causative role in the other foot 

deformities. Though many of the resultant gait patterns 

are similar, the physical examination and treatment 

differs with each deformity. It is important 

therefore that each deformity be evaluated individually. 

Fig. 4. Posterior view of hindfoot during stance. Note alignment and direction of curves 

proximal and distal to the lateral malleolus. 




X 

X

Pronated foot 

Hallux 

valgus 

Metatarsophalangeal 

joint subluxation 

Hammer or 

Claw Toes 

Painful Heel 

Pronated Foot 

TABLE 2 

Analysis of Gait Deviations, Physical Examination Findings, and Treatment Goals 

Gait Deviations 

Shuffled progression 

Decreased step length 

Initial contact with medial border 

of foot 

Decreased single-limb balance 

Prolonged double-support phase 

Late heel rise 

Plantar flexion of ipsilateral limb 

in swing 

Genu valgus with weight bearing 

Lateral and posterior weight shift 

Late heel rise 


Diminished roll off 

Decreased single-limb stance 

Apropulsive progression 


Diminished roll off 

Decreased single-limb stance 

Apropulsive progression 


Toe-heel pattern 

No heel contact in stance 

Decreased stride length 

Decreased velocity 

Plantar flexion of ankle in swing 

Increased hip flexion in swing 

Decreased step length of contralateral 

limb 

The specific gait deviations seen with a pronated 

foot occur primarily during the weight-bearing phases 

of gait. Pronation occurs as a combination of motions 

at the subtalar joint and the midtarsal joints. The 

mechanics of the subtalar joint allow rotatory stresses 

from the lower limb to be passed on to the floor 

without excessive rotation between the foot and the 

floor. Subtalar joint movements (inversion and eversion) 

occur about a single axis. Viewed superiorly, 

this axis is at an angle 23 degrees medial to the long 

axis of the foot, and viewed laterally, it is at an angle 

41 degrees superior to the top of the calcaneus. The 

Physical Examination Findings 

Tenderness over subtalar midtarsal 

area 

Limited inversion range 

Weak and painful posterior tibialis 

muscle 

Pronated weight-bearing posture 

of foot 

Lax medial collateral ligament of 

knee 

Lateral deviation of great toe 

Swelling of first MTP joint 

Shortening of flexor hallucis 

brevis muscle 

Tenderness of great toe 

Weakness of great toe abduction 

Painful MTP heads with weight 

bearing 

Callus formation over MTP heads 

Ulcerations over MTP heads 

Limited MTP flexion 

Prominent MTP heads 

Posture of MTP joint hyperextension 

with proximal and distal 

interphalangeal joint flexion 

Posture of MTP and distal interphalangeal 

joint hyperextension 

with proximal interphalangeal 

flexion 

Callus formation at plantar tips 

and dorsum of proximal interphalangeal 

joint 

Limited MTP flexion 

Painful active plantar flexion 

Painful passive and active dorsiflexion 

Swelling and pain at Achilles insertion 

Tenderness over spur 

Decreased ankle dorsiflexion 

range 

Treatment Goals 

Relieve subtalar & midtarsal joint 

stresses 

Increase ankle inversion 

Strengthen posterior tibialis muscle 

Stabilize hypermobile joints with 

rigid orthosis 

Maintain neutral alignment in 

stance by foot positioning 

Accommodate foot with wide toe 

box shoe 

Increase extension of great toe 

Relieve weight-bearing stresses 

Redistribute pressure with metatarsal 

bar 

Relieve pressure with soft cutout 

shoe insert 

Increase flexion mobility of MTP 

joints 

Accommodate foot with extradepth 

shoe 

Improve toe alignment with metatarsal 

bar 

Accommodate foot with extradepth 

shoe 

Diminish pressure with soft insert 

Increase toe mobility 

Decrease inflammation with steroid 

injection or modalities 

Relieve weight-bearing stress 

Decrease pressure over spur 

with soft shoe insert 

Maintain ankle mobility 

midtarsal joints allow the motion of adduction and 

abduction. In the normal foot, the talonavicular joint 

is much more mobile than the calcaneocuboid joint. 

During the stance phase in ambulation, pronation 

occurs during contact. As body weight is transferred 

from the heel to the forefoot during propulsion, the 

hindfoot inverts. The midtarsal joints then lock during 

weight bearing, and the midfoot becomes a rigid 

lever to accept the body weight across all five metatarsal 

heads. 

In the early stages of rheumatoid joint destruction, 

joints become hypermobile. The unrestricted movement 

at the talonavicular joint allows the foot to go 

into excessive pronation with weight bearing. This 




occurs following heel contact as the leg internally 

rotates on a planted foot, which causes subtalar 

eversion. The calcaneus then lies lateral to the talus 

while the cuboid and navicular are almost parallel. 

In this position, free motion is further allowed at the 

midtarsal joints, and the midfoot locking mechanism 

is absent. Therefore, the deformity of the subtalar and 

midtarsal joints that ensues with progressive rheumatoid 

arthritis is both a direct result of the disease 

process at the joints and an indirect result of the 

acquired abnormalities of the resultant gait pattern. 

Observational analysis of the gait patterns of a 

patient with a pronated foot reveals an overall pattern 

of decreased step length with slow and clumsy forward 

progression. Initial contact with the floor is 

made with the medial border of a flat foot. There is 

diminished balance in single-limb support because of 

the inability of the subtalar joint to provide stability 

between the leg and the foot. This results in a prolonged, 

double-support phase of the gait cycle. 

Marshall and associates 10 reported that two major 

gait deviations are seen with rheumatoid changes at 

the subtalar joint. Plantar flexion of the ipsilateral leg 

occurs during the swing phase, and heel rise during 

the stance phase occurs after the contralateral heel 

strike. These deviations have the effect of reducing 

horizontal forces through the ankle at initial contact 

and prolonging the double-support phase of gait, 

which diminishes the stresses on a single foot. 

Shields and Ward proposed that the deformity of 

pronation of the foot leads to genu valgum of the 

ipsilateral leg in patients with rheumatoid arthritis. 11 

The medial displacement of the ground reaction force 

throughout the stance phase was reported to cause a 

valgus stress at the knee. Genu valgum was reported 

to be clinically observable during the period of singlelimb 

support. Physical examination revealed a lax 

medial collateral ligament of the knee. 

Physical examination of the foot and ankle of a 

patient with a pronated foot deformity reveals several 

characteristic findings. The patient notes tenderness 

to palpation in the area of the subtalar and midtarsal 

joints and complains of feeling foot fatigue after 

prolonged standing. Passive range of motion may be 

limited in inversion. Testing of the posterior tibialis 

muscle will show diminished strength and may elicit 

pain. The weakness is caused by the chronically 

elongated position the muscle assumes with a pronation 

deformity. Tenosynovitis can occur in the posterior 

tibial tendon near its attachment on the cuboid. 

When this occurs, the patient will perceive pain during 

resistive strength testing of the muscle. The patient 

may also complain of pain during the midstance 

phase of gait as this muscle contracts. The posterior 

tibialis muscle is responsible for limiting pronation 

and providing medial stability when weight bearing 

occurs. With advanced disease, the tendon erodes, 

PRACTICE 

lending further instability to the midtarsal joints. 

Examination at this stage reveals hypermobility in 

the pronation range. 

Hallux Valgus 

In the development of hallux valgus, the hallux 

internally rotates and migrates with a valgus angulation. 

This position causes ah overstretch of the medial 

ligaments and tendons and a shortening of the lateral 

structures. With the hallux in this abnormal position 

during ambulation, the normal kinematics of the 

MTP joints are disrupted. Normally, in a diarthrodial 

joint, a smooth gliding motion occurs with flexion 

and extension. The surface velocities are tangential to 

the joint surface until the extremes of range of motion, 

when they become perpendicular to the joint and 

compression or distraction occurs. Hallux valgus, with 

or without bunion formation, results in an alteration 

of the surface velocity direction. This causes extreme 

compression and distraction at the first MTP joint 

during the motion necessary for normal gait. Thus, 

the arthritic changes in the great toe are the result of 

both the primary disease and the secondary effect of 

weight bearing in an abnormal posture. The deformity 

of hallux valgus prevents the first metatarsal head 

from making floor contact and accepting the normal 

weight-bearing loads. 

Observational gait analysis of the patient with hallux 

valgus will show deviations in the middle and late 

stages of stance. As the body weight moves forward 

on a planted foot, the patient with hallux valgus will 

tend to keep his weight on the lateral border of the 

foot. If the patient also has a pronation deformity, 

and thus is unable to supinate, he will tend to keep 

his body weight posterior. This posterior shift results 

in a late heel rise. The period of single-limb support 

will be diminished. 

Hammer or Claw Toes and Metatarsal Head 

Subluxation 

As in the other deformities, hammer or claw toes 

and metatarsal head subluxation are results of both 

the primary disease changes and the forces and kinematics 

of normal ambulation. Synovitis of the MTP 

joints causes capsular distension and eventual loss of 

cartilage. The proximal phalanx subluxation occurs 

in a dorsal direction. Muscle activity of the toe extensor 

muscles during the swing phase of gait and the 

passive dorsiflexed position of the toes in terminal 

stance tend to contribute to the dorsal subluxation. 

Once the displacement occurs, the intrinsic muscles 

cannot function as flexors of the MTP joints. The 

tendons migrate to the intermetatarsal space and 

become extensors of the proximal phalanx. In ambulation, 

the intrinsic muscles function in the terminal 




Type 

Prophylactic synovectomy 

Tendon repair or transfer 

Soft tissue excision 

Osteotomy 

Partial or total arthroplasty 

Resection of bone 

Joint fusion 

TABLE 3 

Surgical Management of the Rheumatoid Foot 

Indication 

Persistent inflammation 

Ruptures 

Toe deformities 

RA nodules 

Angular deformity 

Joint destruction 

Pain 

Instability 

Joint destruction 

Pain 

Deformity 

Instability 

Pain 

stages of stance. If the tendons of the intrinsic muscles 

have become displaced dorsally, each time the muscles 

contract the toe deformities and dorsal subluxation 

will be accentuated. 

Observational gait analysis of the patient with hammer 

or claw toe deformities and metatarsal head 

subluxation will reveal diminished roll off at terminal 

stance, decreased single-limb stance time, and decreased 

cadence. He loses the propulsive forces during 

the end of stance phase, resulting in an awkward 

progression in gait. His single-limb balance is diminished 

as the length of the functional lever of his foot 

is shortened. 

Painful Heel 

The final problem to be discussed is a painful heel 

secondary to subplantar spur formation and tendocalcaneal 

bursitis. When a subplantar spur exists, 

pain is caused by direct soft tissue compression from 

the spur with weight bearing. The pain perceived with 

an inflamed bursa under the Achilles tendon occurs 

whenever this bursa is compressed. Compression occurs 

with a stretch of the Achilles tendon or with 

active contraction of the gastrocnemius or soleus muscles. 

The position of comfort for a patient with this 

problem is one of passive plantar flexion. 

Observational gait analysis of the patient with these 

problems reveals certain characteristic findings. With 

both diagnoses, the patient will complain of pain at 

initial heel contact and therefore will try to avoid this 

stage by various maneuvers. The least painful alteration 

usually is to make initial contact with the toe 

rather than the heel and then to keep the heel slightly 

off the ground throughout the gait cycle. If the pattern 

of heel strike is maintained, the patient will usually 

take shorter steps and decrease his velocity. Both of 

Area 

MTP joints 

Achilles tendon 

Flexors/extensors of toes 

Great toe, abductor/adductor 

Plantar surface 

Achilles tendon 

Forefoot 

MTP joints 

Ankle 

Metatarsal heads 

Talonavicular joint 

Tibiotalar and subtalar joints 

Subtalar and midtarsal joints 

Interphalangeal joints 

these maneuvers result in a diminished ground reaction 

force. 

If the pain problem is caused by a bursitis, the 

ankle may be held in plantar flexion during swing 

phase rather than in the normal position of neutral. 

If this occurs, there will be an increase in hip flexion 

during swing phase to clear the advancing limb. To 

decrease both the time of contraction and the length 

of elongation of both the gastrocnemius and soleus 

muscles in midstance and late stance, the patient may 

take a shorter stride with the uninvolved limb. 

During physical examination, tendocalcaneal bursitis 

will cause painful active plantar flexion and 

painful passive and active dorsiflexion. Swelling will 

be observable at the site of the insertion of the 

Achilles tendon. The patient will perceive tenderness 

to palpation over the spur. Longstanding bursitis 

about the heel will result in decreased ankle range of 

motion in dorsiflexion. 

TREATMENT 

Both nonsurgical and surgical treatment approaches 

can be considered when dealing with the 

rheumatoid foot. Specific recommendations for nonsurgical 

and surgical management are delineated in 

Tables 2 and 3. 

Nonsurgical Management 

Few data have been reported on the actual effects 

of nonsurgical management. Joint protection methods 

are known to be generally helpful to the patient with 

rheumatoid arthritis. Methods of joint protection in 

the foot consist of selecting appropriate footwear, 

decreasing weight-bearing stresses during exacerba- 




tion, using an assistive gait device or orthosis, and 

paying attention to pain or swelling. 

Appropriate footwear can accommodate the deformity, 

stabilize the hypermobile joints, and reduce 

deforming forces. The forefoot deformities are best 

accommodated in a shoe with an extra-depth or extrawidth 

toe box or both. When the upper portion of the 

shoe is made of a soft leather, the pressure on the toes 

from hammer or claw deformities is decreased. Plantar 

spurs or ulcerations under the metatarsal heads 

require a soft, closed-cell foam insert with cutout 

areas for the spur or protruding metatarsal heads. An 

extra-depth shoe should always be used to accommodate 

for height of an insert. Heel height should be 

approximately 2.54 cm (1 in), and the insert should 

be made of a soft material such as crepe. A soft sole 

diminishes the joint compression force occurring with 

weight bearing and is therefore beneficial. A firm 

medial counter and longitudinal arch support are 

suggested to support the hindfood in a neutral position 

rather than allowing valgus to occur with weight 

bearing. If excessive pronation still occurs with weight 

bearing, orthotic intervention should follow. Three 

commercially available types of shoes are applicable 

to the needs of the rheumatoid foot. These are the 

oxford, the protective shoe with a rigid sole (postoperative 

shoe), and the shoe made with an extra-depth 

or extra-width toe box. When these shoes are needed 

but cannot be worn in comfort, a custom-molded 

shoe should be considered. 

During periods of exacerbation, avoidance of 

weight-bearing stresses on the affected joints is necessary 

and appropriate. Complete bed rest may be 

indicated, but the use of assistive gait devices may be 

sufficient to "unload" the affected joints. These restrictions 

are usually acceptable to the patient with 

rheumatoid arthritis during periods of exacerbation. 

Limited weight bearing should be continued until 

strength of the lower extremity musculature and reduction 

of joint swelling is sufficient to avoid further 

joint damage. Assistive devices, such as crutches, add 

the function of weight bearing to the joints of the 

upper extremity. Therefore, judiciously choosing an 

appropriate aid and monitoring the status of the 

upper extremity joints are important. 

Data from studies of joint protection on the rheumatoid 

hand suggest that although an orthosis is often 

used as a means of protection, a deformity cannot be 

corrected without surgical intervention. 12 However, 

just as the various wrist orthoses give an advantageous 

mechanical alignment to more distal hand structures, 

a hindfoot orthosis can afford better function to the 

distal forefoot. 

Devices can be classified as functional or balance 

orthoses. The purpose of a functional device is to 

stabilize an anatomical segment during the function 

of either that segment or a distal part. A functional 

PRACTICE 

orthosis is indicated for a hypermobile joint and thus 

must be constructed of a rigid material to restrict 

motion adequately. The main indication that a functional 

orthosis should be used for the rheumatoid foot 

is the instability seen at the subtalar and midtarsal 

joints. An example of a functional orthosis is a custom-molded 

thermoplastic device inserted in the shoe 

to limit motion and is designed to be worn during all 

weight-bearing activities. 

If malalignment or hypermobility in a mediolateral 

plane exists in joints proximal to the subtalar joint, 

orthotic stabilization may be needed at the ankle and 

knee. The desired resultant alignment is that of normal 

single-limb weight bearing. Therefore, the knee 

should have no varus or valgus angulation, and the 

foot should be supported in neutral. 

A balance orthosis functions to distribute pressure. 

An example of this is a metatarsal bar that is placed 

exteriorly on the sole or inside the shoe to redistribute 

the weight-bearing pressure. To do this most effectively, 

the bar should be placed proximally to the 

metatarsal heads. During walking, as body weight is 

transferred to the forefoot, the weight is not borne on 

the subluxed metatarsal heads but is absorbed proximally 

in the foot. As the body advances over a planted 

foot, the patient rolls over the metatarsal bar and not 

over the painful metatarsal heads. The definitive 

orthotic management may involve a combination of 

both the functional and the balance types. 

Recognition of swelling and pain experienced by 

the patient in particular areas of the foot is the 

responsibility of all health professionals working with 

the patient. Swelling is the first visible abnormality, 

and intervention should be initiated at this stage. 

Swelling and pain occur at the metatarsal heads, at 

the Achilles tendon insertion, and over the dorsum of 

the tarsal bones. As mentioned above, the patient 

may report a feeling of "walking on marbles" from 

depressed metatarsal heads and may gradually develop 

a flat foot from the pronation occurring at the 

subtalar and talonavicular joints. When these situations 

develop, the patient should be referred to an 

appropriate member of the management team. 

The compositon of the management team will vary 

among institutions as will the responsibilities of each 

team member. Generally, the team includes a rheumatologist, 

a registered nurse, a physical therapist, 

and an occupational therapist. At some centers, a 

podiatrist and orthotist may also be available. Any of 

these professionals should be competent in recognizing 

the outlined deformities. Generally, the physician 

or the physical therapist will observe the gait deviations 

and note the physical exam findings consistent 

with foot deformities associated with rheumatoid arthritis. 

It is then their role to initiate treatment and to 

seek the help of the occupational therapist, orthotist, 

or podiatrist as needed. The registered nurse taking 




care of the patient must be informed of the problems 

and the proposed treatment. The nurse plays an 

important role in helping avoid deforming forces in 

the patient while he is under nursing care. 

Surgical Management 

The goal of surgical management of the rheumatoid 

foot is to provide a stable weight-bearing support 

rather than to return normal motion (Tab. 3). 13 Of 

the commonly employed procedures, resection of the 

metatarsal heads is a particularly effective technique 

that often affords major relief from a painful weightbearing 

foot. 

The postoperative concern of the physical therapist 

is to assist the patient in becoming ambulatory. This 

REFERENCES 

1. Calabro JJ: A critical evaluation of the diagnostic feature of 

the feet in rheumatoid arthritis. Arthritis Rheum 5(1): 10-29, 

1962 

2. Giannestras N: Foot Disorders. Philadelphia, PA, Lea & Febiger, 

1976, p 448 

3. Elbaor J, Thomas W, Weinfeld M, et al: Talonavicular arthrodesis 

for rheumatoid arthritis of the hindfoot. Orthop Clin North 

Am 7:821-826, 1976 

4. Thomas WH: Rheumatoid arthritis of the ankle and foot. In 

Cooper, Funk, Brindley, et al (eds): American Academy of 

Orthopaedic Surgeons: Instructional Course Lectures. St. 

Louis, MO, The CV Mosby Co, 1979, pp 325-336 

5. Inman VT, Ralston HJ, Todd F: Human Walking. Baltimore, 

MD, The Williams & Wilkins Co, 1981, pp 30-75 

6. Mann RA, Coughlin MJ: The rheumatoid foot: Review of 

literature and method of treatment. Orthopaedic Research 8 

(8):105-112, 1979 

1156 

may involve recommending postoperative footwear, 

issuing assistive devices, and reviewing joint protection 

methods in regard to a new level of mobility. 

CONCLUSION 

Foot deformities and problems commonly occur in 

the patient with rheumatoid arthritis. With an understanding 

of the pathomechanics and a recognition of 

the clinical picture of these patients, the physical 

therapist may assist in and encourage early intervention. 

With the appropriate treatment, these patients 

may continue to ambulate with greater efficiency and 

decreased pain. 

7. Root M, Orien W, Weed J: Normal and Abnormal Function of 

the Foot: Clinical Biomechanics. Los Angeles, CA, Clinical 

Biomechanics Corp, 1977, vol 2, pp 156-157, 316-332 

8. Kettlecamp DB, Leaverton PE, Misol S: Gait characteristics 

of the rheumatoid knee. Arch Surg 104:30-34, 1972 

9. Stauffer RN, Chao EY, Gyory AN: Biomechanical gait analysis 

of the diseased knee joint. Clinical Orthopedics and Related 

Research 126:246-255, 1977 

10. Marshall RN, Meyers DB, Palmer DG: Disturbance of gait 

due to rheumatoid disease. J Rheumatol 7 (5):617-623, 

1980 

11. Shields MN, Ward JR: Treatment of related knee-ankle-foot 

deformities in rheumatoid arthritis. Phys Ther 46:600-605, 

1966 

12. Flatt A: Care of the Rheumatoid Hand. St. Louis, Mo, The C 

V Mosby Co, 1963, pp 186-196 

13. Kuhn J: The foot in chronic arthritis. Clin Orthop 16:141- 

151, 1961 



PHYSICAL THERAPY

Cited by 

Pathomechanics, Gait Deviations, and Treatment of 

the Rheumatoid Foot : A Clinical Report 

Phyllis Dimonte and Hollis Light 

PHYS THER. 1982; 62:1148-1156. 

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