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The lastest issue of Rheumatology has these 3 publications: Forefoot joint damage, pain and disability in rheumatoid arthritis patients with foot complaints: the role of plantar pressure and gait characteristics Rheumatology 2006 45(4):465-469
Objective. To assess (i) the relationship between forefoot joint damage and foot function (expressed as gait and pressure parameters), (ii) the relationship between foot function and pain, and (iii) the relationship between foot function and disability in patients with foot complaints secondary to rheumatoid arthritis (RA).
Methods. Sixty-two patients with RA-related foot complaints were included. Measurements of joint damage, gait characteristics, plantar pressure, pain and disability were obtained. Data were analysed using descriptive and correlational techniques.
Results. Joint damage on radiographs of the forefoot correlated significantly with forefoot pressure (r = 0.296, P = 0.020). Further investigation of the metatarsophalangeal joints (MTPs) showed joint damage to correlate significantly with peak pressure and pressure–time integral (PTI) of MTP1 and MTP4. A significant correlation between PTI under the forefoot and barefoot pain was found (r = 0.290, P = 0.022). Gait parameters (total contact time and the duration of heel loading) and disability, measured with the Foot Function Index, were significantly correlated (r = 0.315, P = 0.013 and r = 0.266, P = 0.037, respectively).
Conclusion. Forefoot joint damage in the rheumatoid foot is related to increased pressure under the forefoot, especially pressure under the first and fourth MTP joints. High forefoot pressure is associated with pain during barefoot walking. A prolonged stance phase and delayed heel lift are related to disability in daily activities.
Objective. To evaluate the effectiveness of foot orthoses using the foot function index (FFI) in a group of patients with rheumatoid arthritis (RA) during a period of 6 months.
Methods. Thirty-six rheumatoid subjects with foot pain were examined and appropriate foot orthoses were prescribed according to each patient's needs. All the patients were evaluated 30, 90 and 180 days after the baseline visit. FFI values, daily time of wearing the orthoses and adverse effects were noted at each appointment. The Stanford Health Assessment Questionnaire (HAQ) was used at the initial visit to evaluate the influence of physical condition on FFI response.
Results. With the use of foot orthoses, FFI values decreased in all subscales (pain, disability and activity limitation). This reduction was noted in the first month and was maintained throughout the trial. Those using EVA (ethyl-vinyl acetate; n = 28) orthoses presented results similar to those for the total group. Patients wearing made-to-measure orthoses (n = 8) exhibited higher initial FFI values and worse evolution during the trial, significant for pain and disability but not for activity limitation. Minor adverse reactions were noted; none required interruption of treatment. There was no relation between HAQ and FFI evolution.
Conclusions. Foot orthoses were effective as an adjuvant in the management of rheumatoid foot. They significantly reduced pain, disability and activity limitation, as measured by the FFI, with minor adverse effects.
Objective. To evaluate the effects of loss of range of motion (ROM) of the metatarsophalangeal (MTP) joint on the kinematic parameters of walking in rheumatoid arthritis (RA) patients.
Methods. Inclusion of RA patients with inactive disease, no synovitis of the inferior limb and reduced ROM of the MTP joints. Evaluation of the ROM of the MTP dorsal and plantar flexion, and gait analysis using a three-dimensional computerized movement analysis. Calculation of gait parameters and maximal flexion and extension of the hips and knees during walking. Analysis 1 compared the ROM of dorsal and plantar flexion in patients with or without walking pain; 2 compared the gait parameters between patients and controls; 3 investigated a relationship between gait parameters and (i) the ROM of the MTP dorsal and plantar flexion and (ii) the pain at walking; 4 investigated the relationship between the ROM of the MTP dorsal and plantar flexion and maximal flexion and extension of the hip and knee joints during walking.
Results. Nine patients and seven controls were included. The MTP ROM was no different in patients presenting with or without pain at walking. The walking velocity was lower and the stride length shorter in patients than in controls. The walking velocity and the stride length were positively related to the MTP dorsal flexion ROM (r2=0.75 and 0.67). There was a negative relationship between maximal flexion of the knee and hips during walking and the underlying MTP dorsal flexion ROM (r2=0.67 and 0.54).
Conclusion. In RA patients, reduced MTP dorsal flexion mobility induces changes in the walking parameters, including the kinematics of the overlying lower limb joints. Treatment of an RA-impaired forefoot should focus on MTP mobility as well as on pain.
BACKGROUND: Rheumatoid arthritis patients alter their gait pattern to compensate for painful foot symptoms. The centre of pressure may be a useful indicator of these altered loading patterns. Our purpose was to undertake a comparison of the regionalised duration and velocity of the centre of pressure between rheumatoid arthritis patients with foot impairments and healthy able-bodied adults.
METHODS: The progression of the centre of pressure through the foot, heel, midfoot, forefoot and toe regions was measured using an EMED-ST pressure platform. Patients walked at self selected cadence. Variables analysed were the average and maximum velocity and the duration of the centre of pressure (as % stance).
RESULTS: In comparison with able-bodied adults, rheumatoid arthritis patients had a statistically significant decrease in the average velocity of the centre of pressure in the total foot (P<0.001), heel (P=0.001) and midfoot (P<0.001) regions. The maximum velocity of the centre of pressure was slower in rheumatoid arthritis patients in only the midfoot region (P=0.002). During stance, the duration of the centre of pressure was longer in the midfoot (P<0.001) and shorter in the forefoot (P=0.001) in the rheumatoid arthritis patients.
INTERPRETATION: Alteration of the foot loading patterns in patients with rheumatoid arthritis can be characterised by changes to the centre of pressure patterns. Off-loading the painful and deformed forefoot was a characteristic feature in this patient cohort.
In vivo three-dimensional skeletal alignment analysis of the hindfoot valgus deformity in patients with rheumatoid arthritis. J Orthop Res. 2006 Nov 14;
Liu H, Sugamoto K, Itohara T, Tomita T, Hashimoto J, Yoshikawa H
The purpose of this study was to analyze the skeletal alignment of the hindfoot valgus deformity in patients with rheumatoid arthritis using bone models reconstructed from three-dimensional computerized tomography data. Computed tomography was performed on 21 feet of patients with rheumatoid arthritis, and magnetic resonance imaging was taken of 10 normal feet of eight volunteers. An image processing system was used to create bone models and analyze the three-dimensional displacement of the calcaneus, talus, navicular, and cuboid bones. With a standard coordinate system in the distal tibia and a local coordinate system in each bone of the hindfoot, three rotational parameters and three translational parameters were used to evaluate the relative displacement. The talus showed plantar flexion. Both the calcaneus and navicular bones had valgus and lateral shift displacements. However, the cuboid had no displacement relative to the calcaneus, and the navicular showed no displacement relative to the cuboid. The calcaneus, navicular, and cuboid bones have the same pattern of deformity in patients with rheumatoid arthritis. This three-dimensional image-based technique successfully quantified the hindfoot valgus deformity resulting from rheumatoid arthritis and is beneficial for better understanding the deformity pathomechanism.
Kinematic changes of the foot and ankle in patients with systemic rheumatoid arthritis and forefoot deformity J Orthop Res. 2006 Dec 1;
Khazzam M, Long JT, Marks RM, Harris GF
Minimal published data exist characterizing the effect of rheumatoid arthritis of the forefoot (RA) on multi-segmental gait kinematics. The purpose of this study was to examine specific changes in segmental foot motion in patients with RA as compared to persons without foot/ankle pathology. This was a cross-sectional, descriptive study consisting of 22 preoperative adult patients (29 feet) diagnosed with RA and 25 adult patients with no known foot pathology (Control). All RA patients were evaluated by the same orthopaedic surgeon. This group consisted of 20 women and 2 men with a mean age of 54 years (range, 17-76 years). The Control cohort consisted of 13 men and 12 women with a mean age of 41 years (range, 27-73 years). Foot and ankle motion data for the RA population were obtained using a 15-camera Vicon Motion Analysis System (Vicon Motion Systems, Inc., Lake Forest, CA). Anterior-posterior, lateral, and modified coronal radiographic views were obtained to relate marker position to underlying bony anatomy. Temporal and three-dimensional kinematic parameters were obtained via the 4-segment Milwaukee Foot Model. Quantitative comparisons of range of motion values during the seven phases of gait were made between RA and Control ankles using unpaired nonparametric methods. The RA group showed significant differences (p < 0.001) as compared to Controls with prolonged stance time, shortened stride length, increased cadence, and a walking speed that was 80% of Control. Overall, kinematic data in the RA cohort showed significant differences (p < 0.001) in motion for tibial, hindfoot, and forefoot motion as compared to Controls. The effect of RA on segmental foot motion is poorly understood. This study characterized the effect that RA has on motion about the foot and ankle during gait, providing insight into this pathology to improve quantitative assessment, treatment planning, and rehabilitative care.
Partial intertarsal joint arthrodesis was performed on 12 feet of 11 patients as a surgical treatment for planovalgus deformity of the foot and lesions of the intertarsal joints caused by rheumatoid arthritis. Single arthrodesis was performed on the talocalcaneal joint in eight feet, two of which underwent simultaneous total ankle arthroplasty, and on the talonavicular joint in two feet. Double arthrodesis was done on the talocalcaneal and talonavicular joints in one foot and on the talonavicular and calcaneocuboid joints in one foot. Screws or staples were used for fixation. Patients were followed for 2 years to 8 years 7 months (average 4 years 3 months). Osseous fusion was achieved in all feet, and satisfactory pain relief was obtained in all cases except one. We performed this surgery in patients who were relatively active, and the results indicated that arthrodesis of a small number of joints that caused pain and deformity was effective in reducing pain and correcting the deformity. We concluded that partial tarsal arthrodesis should be performed on a limited number of joints during the early stages of planovalgus deformity of the foot because more joints are found to be fixed during the advanced stages. However, progression of the osteoarthritis was found in the neighboring joints. Close follow-up observation is needed.
Ultrasonography and magnetic resonance imaging of heel fat pad inflammatory-oedematous lesions in rheumatoid arthritis. Scand J Rheumatol. 2006 Nov-Dec;35(6):454-8.
Falsetti P, Frediani B, Acciai C, Baldi F, Filippou G, Galeazzi M, Marcolongo R.
OBJECTIVE: To study heel fat pad (HFP) inflammatory-oedematous lesions in selected patients with rheumatoid arthritis (RA) using ultrasonography (US) and power Doppler US (PDUS), to describe and compare US features of these lesions with those obtained with magnetic resonance imaging (MRI), and to describe changes in the lesions after a short-term follow-up with conventional or anti-tumour necrosis factor-alpha (TNFalpha) therapy.
METHODS: Twelve heels of eight RA outpatients with HFP inflammatory-oedematous lesions were studied by US, PDUS, and unenhanced MRI. All the patients were followed up and US was performed after 3 months. Five patients started on anti-TNFalpha therapy.
RESULTS: HFP lesions appeared at US as a heterogeneous and hypoechoic subcalcaneal mass, with loss of normal lobular structure and increased thickness of HFP, because of focal rupture of fibrous septae with oedema and fluid. PDUS showed peripheral vascularization of HFP lesions in 9/12 heels. In 3/12 heels some vascular signals was also detectable inside the lesion, always along the residual echoic septa. No detectable flow was observed within the central fluid-filled spaces. MRI of the HFP lesions showed areas of mean intensity in T1-weighted sequences and high intensity in T2-weighted sequences, with poorly or well-defined margins. After 3 months, PDUS showed reduction in HFP lesion vascularity (associated with reduction in pain) in 10/12 heels, while poor regression of grey-scale US abnormalities was observed.
CONCLUSIONS: Both US and MRI are capable of demonstrating structural abnormalities in the HFP. PDUS is useful to assess and monitor inflammatory vascularization of the HFP lesions.
BACKGROUND: Rheumatoid arthritis is a chronic inflammatory joint disease which affects the joints and soft-tissues of the foot and ankle. The aim of this study was to evaluate biomechanical foot function and determine factors associated with localised disease burden in patients with this disease.
METHODS: Seventy-four rheumatoid arthritis patients (mean (standard deviation) age, 56 years (12); median (interquartile range) disease duration, 13 (5,19)) and 54 able-bodied adults (mean (standard deviation) age, 55 years (12)) completed the Leeds foot impact scale. Biomechanical foot function was measured using three-dimensional instrumented gait analysis. Disease activity score, the number of swollen and tender foot joints, and rearfoot and forefoot deformity were recorded. Sequential multiple linear regression was undertaken to identify independent predictors of foot disease burden.
FINDINGS: The median (interquartile range) Leeds foot impact scale scores in the impairment and activity/participation subscales were 13 (10,14) and 17 (12,22) for the rheumatoid arthritis and 1 (0,3) and 0 (0,1) for the able-bodied adults, P<0.0001 both subscales. The patients had significantly higher numbers of swollen (P<0.0001) and tender foot joints (P<0.0001) and greater rearfoot (P<0.0001) and forefoot (P<0.0001) deformity. Rheumatoid arthritis patients walked slower (P<0.0001) and had altered biomechanical foot function. Sequential regression analysis revealed that when the effects of global disease activity and disease duration were statistically controlled for, foot pain, the number of swollen foot joints and walking speed, and foot pain and walking speed were able to predict disease burden on the Leeds foot impact scale impairment (P<0.0005) and Leeds foot impact scale activity/participation (P<0.0005) subscales, respectively.
INTERPRETATION: In this cohort of rheumatoid arthritis patients, foot pain, swollen foot joint count and walking speed were identified as independent predictors of impairment and activity limitation and participation restriction. The foot disease burden model comprises important elements of pain, inflammatory and functional (biomechanical) factors.
To investigate the association between body mass index (BMI) and radiographic joint damage (using the Ratingen Score [RS]) in early rheumatoid arthritis (RA).
The study was carried out in 767 patients with early RA. Standard clinical data, RS, and BMI were evaluated at baseline and after 3 years. Multivariate logistic regression analyses were performed in rheumatoid factor (RF)-positive and RF-negative patients to determine the influence of BMI (<25 versus 30 kg/m2) on considerable joint damage (RS 7) after 3 years, adjusting for sex, age, disease duration, and disease activity (using the Disease Activity Scale in 28 joints [DAS28]).
Patients of normal weight already had significantly more joint damage at study entry than obese patients (mean RS 4.5 versus 2.4; P = 0.004) and experienced significantly more progression than obese patients (RS 3.4 versus 1.3; P = 0.011). At 3 years, their RS score was twice as high as that of the obese patients (7.5 versus 3.7; P < 0.001). Multivariate regression analyses in both serologic groups revealed significantly higher odds of RS 7 in RF-positive patients of normal weight than in RF-positive obese patients (odds ratio [OR] 3.3), but not in RF-negative patients. Male sex (OR 1.6), osteoporosis (OR 2.0), C-reactive protein levels >15 mg/liter versus <5 mg/liter (OR 2.6), and disease activity (DAS28 5.1 versus <3.2; OR 1.9) were independently associated with RS 7.
BMI provides a risk estimate of joint damage in RA patients. Further studies are needed to elucidate the association between BMI, RF, and joint damage in RA and the possible role of adipose tissue.
Methodological considerations for a randomised controlled trial of podiatry care in rheumatoid arthritis: lessons from an exploratory trial.
Turner DE, Helliwell PS, Woodburn J. BMC Musculoskelet Disord. 2007 Nov 6;8(1):109 [Epub ahead of print]
BACKGROUND: Whilst evidence exists to support the use of single treatments such as orthoses and footwear, the effectiveness of podiatry-led care as a complex intervention for patients with rheumatoid arthritis (RA) related foot problems is unknown. The aim of this study was to undertake an exploratory randomised controlled parallel arm clinical trial (RheumAFooT) to inform the design and implementation of a definitive trial and to understand the potential benefits of this care.
METHODS: Patients with a definite diagnosis of RA, stable drug management 3 months prior to entry, and a current history of foot problems (pain, deformity, stiffness, skin or nail lesions, or footwear problems) were recruited from a hospital outpatient rheumatology clinic and randomised to receive 12 months of podiatry treatment or no care. The primary outcome was change in foot health status using the impairment/footwear (LFISIF) and activity limitation/participation restriction (LFISAP) subscales of the Leeds Foot Impact Scale. Disease Activity Score (DAS), Health Assessment Questionnaire (HAQ) score and walking speed (m/s) were also recorded.
RESULTS: Of the 80 patients identified, 64 patients were eligible to participate in the pilot and 34 were recruited. 16 patients were randomised to receive podiatry led foot care and 18 received no care. Against a backdrop of stable disease (DAS and HAQ scores), there was a statistically significant between group difference in the change in foot health status for foot impairment (LFISIF) but not activity/participation (LFISAP) or function (walking speed) over 12 months. In the podiatry arm, 1 patient declined treatment following randomisation (did not want additional hospital visits) and 3 self-withdrew (lost to follow-up). Patients received an average of 3 consultations for assessment and treatment comprising routine care for skin and nail lesions (n=3), foot orthoses (n=9), footwear referral to the orthotist (n=5), and ultrasound guided intra-articular steroid injection (n=1).
CONCLUSIONS: In this exploratory trial patients were difficult to recruit (stable drug management and co-morbid disease) and retain (lack of benefit/additional treatment burden) but overall the intervention was safe (no adverse reactions). Twelve months of podiatry care maintained but did not improve foot health status. These observations are important for the design and implementation of a definitive randomised controlled trial.
BACKGROUND: To assess the relation between rupture of the Flexor hallucis longus (FHL) tendon and range of motion, deformities and joint damage of the forefoot in RA patients with foot complaints.
METHODS: Thirty RA patients with painful feet were assessed, their feet were examined clinically for the presence of pes planus and range of motion (ROM), radiographs were scored looking for the presence of forefoot damage, and ultrasound examination was performed, examining the presence of the FHL at the level of the medial malleolus. The correlation between the presence or absence of the FHL and ROM, forefoot damage and pes planus was calculated.
RESULTS: In 11/60(18%) of the feet, a rupture of the FHL was found. This was associated with a limited motion of the MTP1-joint, measured on the JAM (chi2 =10,4, p=0.034), a higher prevalence of pes planus (chi2 =5.77, p=0,016) and a higher prevalence of erosions proximal at the MTP-1 joint (chi2 =12.3, p=0,016.), and joint space narrowing of the MTP1 joint (chi2 =12.7, p=0,013).
CONCLUSIONS: Rupture of the flexor hallucis longus tendon in RA-patients is associated with limited range of hallux motion, more erosions and joint space narrowing of the MTP-1-joint, as well as with pes planus.
BACKGROUND: Patients with Rheumatoid Arthritis often suffer from pain and deformities in the feet. Previous studies demonstrated that pedography is a useful tool in clinical practice for detecting structural changes. Therefore, the aim of the present study was to compare Rheumatoid Arthritis patients' clinical, radiographic and pedographic status in order to investigate the relationship between mechanical damage and plantar pressure distribution under the forefoot.
METHODS: Sixteen right feet of sixteen patients with Rheumatoid Arthritis and 21 right feet of healthy controls were included. Weight-bearing radiographs of the forefoot were obtained for all rheumatoid feet. The grade of erosion in the forefoot was assessed with the established Larsen score. Foot loading parameters were analyzed with pedography.
FINDINGS: The present study revealed no correlation between walking pain and the level of joint destruction in patients with Rheumatoid Arthritis. However, the study revealed a strong correlation between joint erosion in the lateral metatarsophalangeal joints and local pressure values under the lateral forefoot (r=0.85) and a negative correlation between joint erosion in the proximal interphalangeal joint and local pressure values under the lateral toes (r=-0.64).
INTERPRETATION: In patients with Rheumatoid Arthritis, the intensity of walking pain does not characterize the degree of joint destruction under the forefoot. Pedography appears useful for an early diagnosis of pathologic changes in the forefoot. However, even though pedographic measurements might be able to provide indications for destructive changes, they cannot provide information about the exact grade of joint erosion.
The purpose of this study was to clarify variations in patterns of flattening in rheumatoid hindfoot. Out of 232 outpatients with rheumatoid arthritis treated at our hospital from 2001 to 2003, we studied lateral radiographs of feet of 216 patients (423 weight-bearing views). We measured the medial arch angle (MAA) and talar angle (TA) and compared the alignment of the talonavicular joint-sagittal plane of each foot. We also evaluated the relationship between the severity of flattening and inclination of the talus and performed cluster analysis. Three groups were clustered by MAA and TA. In group I, joints were normal or close to normal. In group II, both talonavicular and subtalar joints were affected. In group III, talonavicular joints were minimally affected, and the subtalar joints were primarily affected. Groups II and III were thought to be a different pattern of flattening. The present results suggest that there are at least two patterns of flattening in rheumatoid hindfoot.
Gait pattern in rheumatoid arthritis
Rüdiger J. Weissa, Per Wretenberga, André Starka, Karin Palmbladb, Per Larssonc, Lollo Gröndala, Eva Broströmb Gait and Posture (in press)
The purpose of this study was to analyse kinematic and kinetic gait changes in rheumatoid arthritis (RA) patients in comparison to healthy controls and to examine whether levels of functional disability (Health Assessment Questionnaire (HAQ)-scores) were associated with gait parameters. Using a three-dimensional motion analysis system, kinematic and kinetic gait parameters were measured in 50 RA patients and 37 healthy controls. There was a significant reduction in joint motions, joint moments and work in the RA cohort compared with healthy controls. The following joint motions were decreased: hip flexion–extension range (Δ6°), hip abduction (Δ4°), knee flexion–extension range (Δ8°) and ankle plantarflexion (Δ10°). The following joint moments were reduced: hip extensor (Δ0.30Nm/kg) and flexor (Δ0.20Nm/kg), knee extensor (Δ0.11Nm/kg) and flexor (Δ0.13Nm/kg), and ankle plantarflexor (Δ0.44Nm/kg). Work was lower in hip positive work (Δ0.07J/kg), knee negative work (Δ0.08J/kg) and ankle positive work (Δ0.15J/kg). Correlations were fair although significant between HAQ and hip flexion–extension range, hip abduction, knee flexion–extension range, hip abductor moment, stride length, step length and single support (r=−0.30 to −0.38, p<0.05). Our findings suggest that RA patients have overall less joint movement and specifically restricted joint moments and work across the large joints of the lower limbs during walking than healthy controls. There were only fair associations between levels of functional disability and gait parameters. The findings of this study help to improve the understanding how RA affects gait changes in the lower limbs.
Course of damage to the hallux over 5 years after forefoot resection arthroplasty in rheumatoid arthritis patients.
Hattori H, Mibe J, Nohara A, Yamamoto K. Int Orthop. 2007 Aug;31(4):477-81.
A retrospective study of 34 feet from 20 consecutive patients with rheumatoid arthritis was performed to investigate the development of damage to the hallux over 5 years after forefoot resection arthroplasty. Radiographically we analysed changes in two valgus angles and the interphalangeal joint (IP) damage of the hallux. These parameters were measured preoperatively, 12 months postoperatively, and at the latest follow-up. Although the average HVA (between the first metatarsal and the proximal phalanx) significantly decreased from 38.7 degrees preoperatively to 8.66 degrees postoperatively, the angle increased to 23.0 degrees during the first 12 months following surgery. Further deterioration of the angle at the last follow-up was not detected (25.3 degrees ; P=0.252). The average IPV (between the proximal phalanx and the distal phalanx) angle significantly increased from 6.65 degrees preoperatively to 12.1 degrees 12 months postoperatively and thereafter slightly increased to 13.3 degrees at the latest follow-up. The average of the Sharp/van der Heijde score of the IP joint significantly increased from 5.71 preoperatively to 8.58 12 months postoperatively and thereafter slightly increased to 9.65 at the latest follow-up. The deterioration and destruction process of the hallux after resection arthroplasty occurred soon after surgery, and the progression of the deformity was temporary.
To establish the prevalence of foot ulceration in patients with rheumatoid arthritis (RA) in secondary care.
A postal survey of all patients with RA (n = 1,130) under the care of rheumatologists in Bradford, West Yorkshire, UK was performed. The prevalence data were validated through clinical examination, case-note review, and contact with health professionals. The false-negative rate was investigated in a subsample of patients (n = 70) who denied any history of ulceration.
The postal survey achieved a 78% response rate. Following validation, the point prevalence of foot ulceration was 3.39% and the overall prevalence was 9.73%. The false-positive rate was initially high at 21.21%, but use of diagrammatic questionnaire data to exclude leg ulceration reduced the rate to 10.76%. The false-negative rate was 11.76%. The most common sites for ulceration were the dorsal aspect of hammer toes, the metatarsal heads, and the metatarsophalangeal joint in patients with hallux abducto valgus, with 33% of patients reporting multiple sites of ulceration. Patients with open-foot and healed-foot ulceration had significantly longer RA disease duration, reported significantly greater use of special footwear, and had a higher prevalence of foot surgery than ulcer-free patients.
Foot ulceration affects a significant proportion of patients with RA. Further work is needed to establish risk factors for foot ulceration in RA and to target foot health provision more effectively.
The optimal assessment of the rheumatoid arthritis hindfoot: a comparative study of clinical examination, ultrasound and high field MRI.
Wakefield RJ, Freeston JE, O'Connor P, Reay N, Budgen A, Hensor EM, Helliwell PS, Emery P, Woodburn J. Ann Rheum Dis. 2008 Feb 7 [Epub ahead of print]
OBJECTIVES: The aim of this pilot study was to compare clinical examination (CE) and ultrasound (US) with high field MRI (as the reference standard) for the detection of rearfoot and midtarsal joint synovitis and secondly tenosynovitis of the ankle tendons in patients with established RA.
METHODS: Patients with RA (modified ACR criteria) with symptoms of mid- and rearfoot disease were recruited. Demographic data were collected. All underwent CE, US and high field MRI (with iv gadolinium contrast) of their right foot. Percentage exact agreement (PEA), sensitivity and specificity were calculated for CE and US when compared to MRI. Inter-reader reliability for CE and US was also assessed.
RESULTS: Compared to the gold standard of MRI, for CE (joint synovitis) the ranges for sensitivity, specificity and PEA were 55-83%, 23-46% and 46-60%, and for US were 64-89%, 60-80% and 64-78%. Compared to the gold standard of MRI, for CE (tenosynovitis) the ranges for sensitivity, specificity and PEA were 0-100%, 20-91% and 55-91%, and for US were 0-67%, 86-100% and 59-86%.
CONCLUSION: CE was sensitive but US more specific in identifying hindfoot pathology in RA when compared to the reference standard of MRI. There was poor inter-observer variability between ultrasonographers suggesting a need for standardization of acquisition and interpretation of US images of the hindfoot.
AIM: Hallux valgus combined with flat foot is one of the most common foot deformities affecting patients with rheumatoid arthritis. The Lapidus procedure is indicated when the hallux valgus angle is more than 15 degrees or the first tarsometatarsal joint is hypermobile. We aimed to evaluate the results of the Lapidus procedure in patients with rheumatoid arthritis.
METHOD: We performed the Lapidus procedure in 31 patients between 2002 and 2005. In ten patients we performed a bilateral procedure and in ten patients we performed a single Lapidus procedure. In 27 cases we combined the procedure with a resection of the second-fifth metatarsal heads (Hoffmann procedure), in four cases with a Weil osteotomy of the second-fifth metatarsal necks. We performed an excision of the articular surface of the first metatarsal head (Mayo) in 10 patients, a Keller resection procedure in 9 patients, an arthrodesis of the first metatarsophalangeal joint in 3 patients, and an Akin wedge osteotomy of the proximal phalanx of the thumb in 3 patients. Arthrodesis was fixed by two K-wires in 5 cases, by 2 compression screws in 7 cases, and in thirty-four cases we used memory staples.
RESULTS: We evaluated the outcomes of forty-one procedures in thirty-one patients (24 female, 7 male). The averge age at surgery was 54.3 years. Thirty-two feet were without pain after the procedures, in five cases the patients felt moderate pain in the dorsal part of the foot and in four cases the patients felt pain in the transverse arch of foot. Complications included delayed primary wound closure in five cases, in one case we performed a revision procedure for a deep infection. Delayed hallux valgus developed in 5 cases. The mean first intermetatarsal angle before surgery was 19.5 degrees (range 12 - 27 degrees) and improved to 8 degrees after surgery. In 3 cases we found an unsatisfactory intermetatarsal angle correction with partial renewal of the hallux valgus.
CONCLUSION: A correctly performed Lapidus procedure enables correction of the varus position of 1st metatarsus and hallux valgus.
Characterising the clinical and biomechanical features of severely deformed feet in rheumatoid arthritis
Deborah E. Turner and James Woodburn Gait & Posture (Article in Press)
Foot deformity is a well-recognised impairment in patients with rheumatoid arthritis (RA) which results in functional disability. Deformity can occur at the rearfoot, midfoot, forefoot or in combination and the impact that site-specific foot deformities has on functional disability is largely unknown. The aim of this study was to describe the clinical and biomechanical characteristics of patients with severe rearfoot, forefoot or combined deformities and determine localised disease impact.
Twenty-eight RA patients with severe forefoot (FF group n = 12), rearfoot (RF group n = 10) or combined deformities (COMB group n = 6) were recruited. Each patient underwent 3D gait analysis and plantar pressure measurements. Localised disease impact and foot-specific disease activity were determined using the Leeds Foot Impact Scale and clinical examination respectively. Comparison was made against a normative control group (n = 53).
Patients in the COMB group walked slowest and the double-support time was longer in the RF and COMB groups compared to those in the FF group. Patients in the RF and COMB group had higher levels of foot-related disability and demonstrated excessive rearfoot eversion and midfoot collapse compared to those in the FF group. Forefoot deformity was associated with reduced toe contact, high forefoot pressures and delayed heel lift.
Abnormal gait patterns were identified and were distinguishable among those patients with predominantly forefoot, rearfoot or combined foot deformity.
BACKGROUND: Few studies have focused on the long-term results of triple arthrodesis in patients with rheumatoid arthritis. We retrospectively reviewed fusion rate, arthritis of the adjacent joints, clinical outcome, and patient satisfaction.
MATERIALS AND METHODS: Between 1990 and 1998, 28 patients with rheumatoid arthritis were managed with a total of 32 triple arthrodeses. Of the 28 patients, 20 (24 cases) had been followed for 5.2 (range, 4 to 7) years. Fusion was performed with rigid staple fixation and autologous bone graft. Assessment included plain radiographs, CT scans, and various clinical scores.
RESULTS: Complications were limited to superficial wound healing problems in 8 patients (8 cases). No revision surgery was necessary. Radiographically, all feet showed fusion. Progression of arthritis was found in 17 cases, mostly in the midfoot. The visual analogue scale for pain averaged 47 (range, 3 to 94) points. The SMFA scores were 45 (range, 10 to 71) points for dysfunction and 38 (range, 10 to 72) points for bother with a significant association (p < 0.05) between the SMFA- and the AOFAS-Score. The mean Short Form-36 (SF-36) physical component outcomes score was 51 (range, 18 to 98) points and the AOFAS score averaged 70 (range, 40 to 94) points. All patients stated that they would have the procedure again under similar circumstances.
CONCLUSION: Triple arthrodesis in rheumatoid patients is effective in relieving pain and improving functional deficits. High fusion rates can be expected. There is, however, a high risk for consecutive arthritis of the neighboring joints, especially in the midfoot
The use of musculoskeletal ultrasound (MSUS) in the diagnosis and management of foot and ankle musculoskeletal pathology is increasing. Due to the wide use of MSUS and the depth and breadth of training required new proposals advocate tailored learning of the technique to discrete fields of practice. The aims of the study were to evaluate the inter-observer agreement between a MSUS radiologist and a podiatrist, who had completed basic skills training in MSUS, in the MSUS assessment of the forefoot of patients with Rheumatoid Arthritis.
A consecutive sample of thirty-two patients with rheumatoid arthritis was assessed for presence of synovitis, erosions and bursitis within the forefoot using MSUS. All MSUS assessments were performed independently on the same day by a podiatrist and one of two Consultant Radiologists experienced in MSUS.
Moderate agreement on image acquisition and interpretation was achieved for bursitis (kappa 0.522; p<0.01) and erosions (kappa 0.636; p<0.01) and fair agreement for synovitis (kappa 0.216; p<0.05) during the primary assessments. Following a further training session, substantial agreement (kappa 0.702) between the two investigators was recorded. The sensitivity of the podiatrist using MSUS was 82.4% for detection of bursitis, 83.0% for detection of erosion and 84.0% for detection of synovitis. Specificity of the podiatrist using MSUS was 88.9% for detection of bursitis, 80.7% for detection of erosion and 35.9% for detection of synovitis.
This study demonstrated good inter-observer agreement between a podiatrist and radiologist on MSUS assessment of the forefoot, particularly for bursitis and erosions, in patients with rheumatoid arthritis. There is scope to further evaluate and consider the role of podiatrists in the MSUS imaging of the foot following appropriate training and also in the development of reliable protocols for MSUS assessment of the foot.
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Background: The FOOTSTEP self-management foot care programme is a clinical and cost-effective programme for basic foot care in the elderly. The aim of this study was to determine if patients with rheumatoid arthritis (RA) would be physically able to participate.
Methods: A consecutive cohort of RA patients undergoing podiatry care underwent tests for sight, reach and grip strength to determine their physical ability to undertake self-managed foot care.
Results: Thirty RA patients (10 male, 20 female), with a median age of 61 years (range 42 to 84) and disease duration of 10 years (range one to 40), were recruited. All patients passed the sight test, whereas the reach and grip tests were passed by 77% and 67% of patients, respectively. Only 57% of patients passed all the physical tests. Patients who failed the physical tests were older, and had longer disease duration and higher physical disability, pain and general health scores but these were not statistically different.
Conclusions: Just over half the patients in this present cohort may be physically able to undertake some aspects of self-managed foot care, including nail clipping and filing, callus filing and daily hygiene and inspection
Cluster analysis to classify gait alterations in rheumatoid arthritis using peak pressure curves
Claudia Giacomozzi, Francesco Martelli, Arne Nagel, Andreas Schmiegel, Dieter Rosenbaum Gait and Posture (Articles in Press)
To detect gait alterations in rheumatoid arthritis (RA) patients using peak pressure curves (PPC) and normalized force curves (NFC) instead of clinical classification based on the health assessment questionnaire (HAQ).
Three RA groups – 30 patients each – were classified according to their HAQ score. Cluster analysis based on a k-means algorithm was applied to PPCs and NFCs in order to classify RA patients with respect to amplitude and shapes of such gait parameters.
The best gait pattern identification was obtained by clustering PPCs into three clusters. Peak pressures of the three identified patterns were 1169.5±99.4kPa for cluster 1, 885.8±165.2kPa for cluster 2 and 402.0±128.5kPa for cluster 3 (statistically different, Student’s t-test, p<0.001). 41 patients were included in cluster 3, 31 in cluster 2 and only 18 patients in cluster 1. Most RA3 patients – 17 out of 30 – showed low peak pressures and almost normal PPCs (cluster 3). Cluster 2, which incorporated altered PPCs, was mainly formed by RA1 and RA2 patients.
PPC appears as a reliable gait parameter for a shape-based clustering algorithm. The proposed cluster analysis was proved to be reliable and the delivered classifications stable. The distribution of RA patients among the three identified PPC clusters showed only a partial agreement between clinical and functional classification, thus revealing the development of specific gait strategies related to the pathology more than to its clinical level of severity. This finding may be clinically relevant and support effective treatment of RA gait related pathologies.
Purpose. To compare the effectiveness of functional foot orthoses and unshaped (flat) orthotic material on plantar pressure redistribution, forefoot pain reduction and walking ability in rheumatoid arthritis (RA) patients. Methods. Forty patients with RA were randomised to receive unshaped material (UM) (n = 20) or functional foot orthoses (n = 20). Plantar pressure measurement was performed with an F-scan system. Foot pain was assessed by the pain subscale of the Foot Function Index. Walking ability was assessed by the 6-min walking test. Investigations were performed at baseline, 1 week after the patient received shoes with orthoses and 6 months later. Results. Plantar pressures were significantly higher at painful than at non-painful foot areas. No differences in plantar pressure redistribution were found between the groups. Notable reduction of pain and improvement of activity (walking ability) was observed in both groups. Foot pain has moderate impact on the walking ability of RA patients. Conclusions. The study showed no clear advantage of functional foot orthoses over UM.
The FOOTSTEP self-management foot care programme: are rheumatoid arthritis patients physically able to participate?
Semple R, Newcombe LW, Finlayson GL, Hutchison CR, Forlow JH, Woodburn J. Musculoskeletal Care. 2009 Mar;7(1):57-65.
BACKGROUND: The FOOTSTEP self-management foot care programme is a clinical and cost-effective programme for basic foot care in the elderly. The aim of this study was to determine if patients with rheumatoid arthritis (RA) would be physically able to participate. METHODS: A consecutive cohort of RA patients undergoing podiatry care underwent tests for sight, reach and grip strength to determine their physical ability to undertake self-managed foot care. RESULTS: Thirty RA patients (10 male, 20 female), with a median age of 61 years (range 42 to 84) and disease duration of 10 years (range one to 40), were recruited. All patients passed the sight test, whereas the reach and grip tests were passed by 77% and 67% of patients, respectively. Only 57% of patients passed all the physical tests. Patients who failed the physical tests were older, and had longer disease duration and higher physical disability, pain and general health scores but these were not statistically different. CONCLUSIONS: Just over half the patients in this present cohort may be physically able to undertake some aspects of self-managed foot care, including nail clipping and filing, callus filing and daily hygiene and inspection.
OBJECTIVE: To evaluate the prevalence and 8-year course of forefoot impairments and walking disability in patients with rheumatoid arthritis (RA).
METHODS: A total of 848 patients with recent-onset RA from 1995 through the present were included. The patients were assessed annually. Pain and swelling of the metatarsophalangeal (MTP) joints, erosions and joint space narrowing of the MTP joints and first interphalangeal joints, and the Health Assessment Questionnaire walking subscale were analyzed using descriptive and correlational techniques.
RESULTS: Pain and swelling of > or = 1 MTP joint was present in 70% of patients at baseline, decreasing to approximately 40-50% after 2 years. The forefoot erosion score was > or = 1 in 19% of the patients at baseline, and the prevalence of forefoot erosion increased to approximately 60% after 8 years, during which the mean forefoot erosion score increased from 1.3 to 7.9. At least mild walking disability was present in 57% of patients at baseline, stabilizing at approximately 40% after 1 year.
CONCLUSION: The prevalence rates for pain and swelling of the MTP joints and walking disability are initially high and then stabilize, but the prevalence and severity of forefoot joint damage increase during an 8-year course of RA. The findings of this study quantitatively emphasize the importance of forefoot involvement in patients with RA.
BACKGROUND: In-shoe pressure redistribution to provide relief of forefoot pain in rheumatoid arthritis (RA) is based on assumed links between pressure and pain. However, little is known about the size of the pressure change required to reduce pain or the capacity of other plantar regions to bear increased pressure. Our primary aim was to quantify the plantar pressure pain threshold (PPT) in RA and compare it to age- and gender-matched control participants.
MATERIALS AND METHODS: This controlled trial involved 10 RA participants and 10 age- and gender-matched control subjects. PPT, measured using a force gauge, and touch sensitivity, measured via Semmes-Weinstein monofilaments, were tested in 19 plantar regions.
RESULTS: RA plantar PPTs were significantly reduced in eight foot regions (p < 0.05) and were more uniform across the plantar surface. Touch sensitivity was not different between groups. Plantar PPT was significantly related to age (p < 0.05) and to touch sensitivity (p < 0.05) in multiple foot regions of the control group but not in RA. PPT was significantly correlated with disease duration (p < 0.05).
CONCLUSION: Plantar PPTs in RA were 60% to 80% of the control group and may be helpful in predicting the amount of pressure reduction needed to relieve pain. This study provides further evidence that RA disturbs normal pain sensory mechanisms.
Analysis of foot structural damage in rheumatoid arthritis: clinical evaluation by validated measures and serological correlations.
Biscontini D, Bartoloni Bocci E, Gerli R. Reumatismo. 2009 Jan-Mar;61(1):48-53.
OBJECTIVE: To examine foot involvement in rheumatoid arthritis (RA) and to characterize structural alterations in patients with anti-cyclic citrullinated peptide (CCP) antibody-positive and -negative disease.
METHODS: Seventy-eight patients with RA with foot pain were consecutively enrolled. The Manchester Hallux Valgus (MHV) rating scale was used to evaluate the hallux valgus deformity degree. The Foot Posture Index (FPI6), a novel, foot-specific outcome measure, was adopted in order to quantify variation in the position of the foot. The findings were correlated with disease duration and presence or absence of anti-CCP antibodies.
RESULTS: About 84.6% patients had different degrees of hallux valgus and 65.4% subjects had a pronated foot. These two foot alterations were prevalently found in patients with long-standing disease and circulating anti-CCP antibodies. On the contrary, RA patients without anti-CCP and early disease essentially displayed a supinated foot without relevant hallux valgus deformity.
CONCLUSION: Our findings allowed to identify different anatomic foot alterations in RA patients according to disease duration and negative prognostic factors such as anti-CCP antibodies. Our findings support the role of an accurate analysis of foot structural damage and may suggest the usefulness of a correct plantar orthosis prescription also in early phases of the disease.
BACKGROUND: At diagnosis, 16% of rheumatoid arthritis (RA) patients may have foot joint involvement, increasing to 90% as disease duration increases. This can lead to joint instability, difficulties in walking and limitation in functional ability that restricts activities of daily living. The podiatrist plays an important role in the multidisciplinary team approach to the management of foot problems. The aim of this study was to undertake a clinical audit of foot problems in patients with RA treated at Counties Manukau District Health Board.
METHODS: Patients with RA were identified through rheumatological clinics run within CMDHB. 100 patients were eligible for inclusion. Specific foot outcome tools were used to evaluate pain, disability and function. Observation on foot lesions were noted and previous history of foot assessment, footwear/insoles and foot surgery were evaluated.
RESULTS: The median age of the cohort was 60 (IQR: 51-64) years old with median disease duration of 15 (IQR: 7.3-25) years. Over 85% presented with foot lesions that included corns and callus over the forefoot region and lesser toe deformities. Moderate to high disability was noted. High levels of forefoot structural damage were observed. 76% had not seen a podiatrist and 77% reported no previous formal foot assessment. 40% had been seen at the orthotic centre for specialised footwear and insoles. 27% of RA patients reported previous foot surgery. A large proportion of patients wore inappropriate footwear.
CONCLUSIONS: This clinical audit suggests that the majority of RA patients suffer from foot problems. Future recommendations include the provision of a podiatrist within the current CMDHB multidisciplinary rheumatology team to ensure better services for RA patients with foot problems.
Setting: Outpatients of physical medicine and rehabilitation clinic at university hospital.
Subjects: Forty-two patients with rheumatoid foot lesions were randomly assigned to two different orthotic intervention groups. The anatomical locations of the foot lesions were recorded (hindfoot or forefoot).
Intervention: Participants were provided with an extra deep forefoot-rockered shoe and either a custom-made semi-rigid insole or a ready-made simple soft insole. They wore the provided footwear for at least 3 hours a day over six months.
Main outcome measures: Primary outcome measures were foot pain visual analogue scale (VAS) scores and Foot Function Index (FFI). Secondary outcome measures were erythrocyte sedimentation rate and C-reactive protein levels in blood, amounts of medications and active joint counts. These were checked at baseline and post intervention.
Results: Eight patients dropped out at follow-up after six months of treatment. At six-month follow-ups, VAS scores and total Foot Function Index scores had decreased significantly in both groups versus baseline but intergroup comparison showed no significant differences in view of type of insoles and anatomical locations of foot pathology.
Conclusions: We were unable to identify differences between the types of insoles in terms of their clinical effects or between anatomical locations of foot lesions in the two groups, but both groups improved. Therapeutic shoes plus soft insoles might be effective enough in terms of foot pain and foot function for specific patients with rheumatoid foot problems regardless of the location of foot pathology.
BACKGROUND: Alterations in the feet of patients with rheumatoid arthritis (RA) are a cause of disability in this population. The purpose of this research was to evaluate the impact that foot impairment has on the patients' global quality of life (QOL) based on validated scales and its relationship to disease activity.
METHODS: This was a cross-sectional study in which 95 patients with RA were enrolled. A complete physical examination, including a full foot assessment, was done. The Spanish versions of the Health Assessment Questionnaire (HAQ) Disability Index and of the Disease Activity Score (DAS 28) were administered. A logistic regression model was used to analyze data and obtain adjusted odds ratios (AORs).
RESULTS: Foot deformities were observed in 78 (82%) of the patients; hallux valgus (65%), medial longitudinal arch flattening (42%), claw toe (lesser toes) (39%), dorsiflexion restriction (tibiotalar) (34%), cock-up toe (lesser toes) (25%), and transverse arch flattening (25%) were the most frequent. In the logistic regression analysis (adjusted for age, gender and duration of disease), forefoot movement pain, subtalar movement pain, tibiotalar movement pain and plantarflexion restriction (tibiotalar) were strongly associated with disease activity and disability. The positive squeeze test was significantly associated with disability risk (AOR=6,3; 95% CI, 1.28-30.96; P= 0,02); hallux valgus, and dorsiflexion restriction (tibiotalar) were associated with disease activity.
CONCLUSIONS: Foot abnormalities are associated with active joint disease and disability in RA. Foot examinations provide complementary information related to the disability as an indirect measurement of quality of life and activity of disease in daily practice.