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

More documents

Recommendations

Info

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. Downloaded from http://ptjournal.apta.org/ by guest on March 26, 2013 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. Volume 62 / Number 8, August 1982 1151 Downloaded from http://ptjournal.apta.org/ by guest on March 26, 2013 X X
Page 1 and 2: Pathomechanics, Gait Deviations, an
Page 3: Fig. 1. Major deformities in the fo
Page 7 and 8: occurs following heel contact as th
Page 9 and 10: tion, using an assistive gait devic
Page 11: Cited by Pathomechanics, Gait Devia

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?