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

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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- 1154 PHYSICAL THERAPY Downloaded from http://ptjournal.apta.org/ by guest on March 26, 2013
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 Volume 62 / Number 8, August 1982 1155 Downloaded from http://ptjournal.apta.org/ by guest on March 26, 2013
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Page 3 and 4: Fig. 1. Major deformities in the fo
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