Postsurgical hindfoot deformity of a patient with rheumatoid arthritis treated with custom-made foot orthoses and shoe modifications.

Key Words: Foot orthoses, Rehabilitation, Rheumatoid arthritis, Shoe modifications, Triple arthrodesis.

Fifteen to 20 years ago, patients with long-standing and unremitting rheumatoid arthritis (RA) were often expected to become dependent on a wheelchair for mobility. As a result, foot and ankle care was not given high priority. Subsequent to successful total hip and knee reconstructive surgery in patients with RA, health care professionals now need to direct more attention to disorders of the feet. Foot and ankle involvement has been reported in up to 90% of persons with RA.[1] A 1994 study of 99 outpatients with clinically proven RA revealed that 93 of those patients had foot or ankle involvement, and yet only 4 patients had received any treatment involving shoe inserts, foot orthoses, prescription footwear, or shoe modifications.[2] Three of those 4 patients had received custom-molded shoes. These findings indicate that the three patients had advanced foot deformities and were unable to use standard or extra-depth footwear. Because large joint replacements and pharmacological advances for patients with RA are allowing for ambulation for many more years, there is an increased need for early and ongoing foot care. One important area of this care is the use of foot orthoses. When indicated, we believe that the provision of foot orthoses and appropriate footwear can play a major role in the overall management of patients with RA.

Several authors[3-7] have advocated the use of pads of various shapes and sizes, strategically placed in shoes, as well as cushioned insoles and arch supports for patients with RA. Extra-depth shoes and a multitude of shoe modifications, including rocker bars, rocker or roller bottoms, Thomas heels, medial sole wedges, medial stabilizers (which act like extended reinforced heel counters), and molded shoes, also are often recommended for patients with RA.[3-7] Dimonte and Light[8] described the use of two kinds of foot orthoses for patients with arthritis: "functional" and "balance" types. Merritt[9] gave an extensive overview of the most common orthoses used for patients with arthritis and emphasized the need for controlled clinical studies of their efficacy. Locke et al[10] conducted one of the few studies designed to demonstrate the value of an ankle-foot orthosis (AFO) in the treatment of patients with ankle and hindfoot pain and deformity due to arthritis. Locke and colleagues used the extended University of California Biomechanics Laboratory orthosis. Although little has been written about the benefits of these devices, we have found that the use of foot orthoses, prescribed after a detailed biomechanical lower-extremity evaluation, can help in the rehabilitation of patients with RA, either before or after surgery.

The purpose of this report is to describe the improvement in ambulation in a patient with severe RA when using accommodative foot orthoses and shoe modifications after hindfoot surgery.

Methodology

History

The patient was a 73-year-old woman with a 30-year history of seropositive RA. She was nonambulatory due to a severe malalignment of her right hindfoot in a varus position. Right-foot weight bearing occurred exclusively through the fibular malleolus and the lateral head and base of the fifth metatarsal. The planter surface of the foot did not make contact with the floor. The patient could transfer independently to and from a wheelchair with the use of a standard cane. She reportedly had been using the cane for 6 years for community ambulation only because of right ankle pain. Her medical and surgical history was extensive, which is common for a patient with long-standing severe RA (Tab. 1).

Table 1.
Medical/Surgical History

Age (y) Important Events

43   Diagnosed with rheumatoid arthritis; painful hands and feet
45   Began use of gold, prednisone, Indocin [R],(a)  and tandearil
49   Accepted at the National Institutes of Health for 1-month
study
       of chloroquine
50   Left hip cup arthroplasty and synovectomy of right knee
51   Synovectomies of all metacarpophalangeal joints and left thumb
       tendon repair
52   Silastic(b) joint implants of right metacarpophalangeal joints
54   Hospitalization for septic right knee
60   Diagnosed with bronchitis
62   Hospitalization for acute tracheobronchitis; began use of
       methotrexate
63   Left total hip replacement; left ankle fracture
65   Double Klansak orthosis prescribed by rheumatologist for right
       ankle pain
66   Right total knee replacement
68   Diagnosed with malignant carcinoma of breast; modified
       mastectomy
69   Continued malalignment of right hindfoot into varus position;
       discontinued use of brace due to pressure-induced ulceration
       of right lateral malleolus
71   Right wrist fusion with tendon graft and transfer; tenolysis
       of right third flexor tendon
73   Referral made for rehabilitation at the National Institutes of
       Health Rehabilitation Medicine Department; triple
arthrodesis
       of right hindfoot; fit with custom-made foot orthoses to
       accommodate postsurgical rigid hindfoot deformity

(a) Merck & Co Inc, West Point, PA 19486.

(b) Dow Corning Corp, PO Box 994, Midland, MI 48686.

The patient was initially seen in a multidisciplinary foot clinic of the Rehabilitation Medicine Department of the Warren Grant Magnuson Clinical Center at the National Institutes of Health (Bethesda, Md), with representation from physical therapy, orthopedics, rheumatology, physiatry, podiatry, and pedorthics. The team recommended that the patient should have surgery immediately. The patient was treated by an orthopedic surgeon, who performed a triple arthrodesis procedure on the right hindfoot (fusion of three joints: talonavicular, talocalcaneal, and calcaneocuboid).[4] Postoperatively, she was provided a leg-hindfoot orthosis[11] and was instructed to wear it for 3 months. In this case, the surgeon felt that the leg-hindfoot orthosis would provide sufficient immobilization of the surgical site and eliminate the need for a heavy cast. This orthosis was designed to relieve subtalar joint pain by providing relative immobilization of the subtalar joint while allowing full ankle motion. The leg-hindfoot orthosis essentially looks like a short version of an AFO with anterior placement of the medial and lateral trim lines (edges of the brace) but with a shortened footplate extending only to the mid-foot. The patient was referred for physical therapy 1 month after surgery, with instructions to maintain partial weight bearing of the right lower extremity. The primary reason for the referral for physical therapy was to receive an evaluation for, and fabrication of, custom-made foot orthoses to improve ambulation. The physical therapist is a board-certified pedorthist with advanced training in the fabrication of foot orthoses, shoe modifications, and other related devices for foot and ankle rehabilitation.

Subjective Information

The patient's primary complaint was a feeling of unsteadiness while walking, described as "losing my balance to the right side." Due to this problem, she did not feel comfortable walking without a cane. The patient denied any history of falls. Additional complaints, reported by the patient in order of importance to her, included pain in her right foot and ankle during walking (with partial weight bearing) rated as 3 on a scale of 0 to 10 (0=no pain, 10=excruciating pain). She also felt that her left hand and wrist were more painful than usual due to increased reliance on cane use. She stated that all these problems became worse when she tried to engage in social activities such as going shopping and attending bridge games, keeping hair appointments, and going to church. She had been accustomed to participating in each of these activities at least once per week and no longer could participate in such activities due to increasing pain in her right foot and ankle and left hand and wrist and to unsteadiness during gait.

Evaluation

A complete lower-extremity evaluation was performed in three 1-hour sessions, per patient tolerance. The first two sessions were conducted 2 days apart; the third session was conducted 6 weeks later when stance and gait could be evaluated and the patient had full weight bearing.

The patient was evaluated while positioned sitting, supine, and prone. Range-of-motion testing (Tab. 2) revealed that tibiotalar, subtalar, and midtarsal joint motions were severely limited bilaterally. Hip motion was full and pain-free bilaterally. The left knee was painful and had mild mediolateral instability. Manual muscle testing[12] (Tab. 3) revealed that strength was Good at both hips, but there were limitations at the left knee and both feet and ankles. Reliability of the manual muscle test results was not established as part of this case.

Table 2. Range of Motion (in Degrees) of Lower-Extremity Joints

Position                          Right               Left

Sitting or supine
  Ankle dorsiflexion (knee
    flexed and extended)             0                  0
  Ankle plantar flexion              2                  4
  Calcaneal inversion               25(a)               0(a)
  Calcaneal eversion               -25(a)               0(a)
  Knee flexion                     120                120
  Knee extension                    -5                 -5
  Hip medial (internal)
    rotation                        35                 45
  Hip lateral (external)
    rotation                        35                 25
  Straight leg raise                90                 90
Standing
  Great toe extension               35                 40
  Resting calcaneal position        25 varsus (a)       0(a)
  Tibial valgum                     10                  2
  Genu valgum                        0                 15
Prone
  Hindfoot-to-lower leg
    relationship                    25 varsus (b)    Neutral
  Farefoot-to-hindfoot
    relationship                     Varus           Neutral

(a) Fixed deformity.

(b) Subtalar joint neutral position could not be attained.

Table 3. Strength of Selected Lower-Extremity Muscles[12]

Muscle/Muscle Group              Right          Left

Gastrocnemius/soleus             NA/(a)         NA
Tibialis anterior                NA             NA
Tibialis posterior               NA             NA
Peroneals                        NA             NA
Extensor hallucis longus          3              4+
Extensor digitorum longus         4              4+
Flexor hallucis longus            4+             4
Flexor digitorum longus           4+             4
Quadriceps femoris                5             NT(b)
Hamstrings                        4+            NT
Hip
  Flexors                         4+            4-
  Extensors                       4             4
  Abductors                       5             5
  Adductors                       5             5
  External rotators               4             NT
  Internal rotators               4             NT

(a) NA indicates joint motion not adequate to assess muscle strength.

(b) NT indicates not tested due to left knee pain.

Inspection of both feet revealed tight shiny skin, with hair loss and dislocated metatarsophalangeal joints of toes 2 through 4. Both feet were cool to the touch, and there appeared to be widespread muscle atrophy of the anterior, posterior, and lateral compartments of both lower extremities below the knees. This clinical presentation is common in patients with long-standing RA, beginning with acute inflammation early in the course of the disease and progressing to chronic inflammation and scarring as the disease is "burning out."[3] The left distal tibia was displaced laterally due to a previous ankle fracture (Tab. 1). The right hindfoot was fused in 25 degrees of varum (apparently the best result that could be obtained during surgery because of the severity of joint malalignment).

Although diminished sensation to light touch is uncommon in patients with RA, it is standard protocol to check for such diminished sensation whenever an orthosis is being considered. Sensation was tested with Semmes-Weinstein monofilaments using 1-, 10-, and 75-g filaments. Protective sensation, the ability to feel the 10-g filament (procedure described by Birke and Sims[13]), was present over the entire dorsal and planter aspects of the left foot and over most of the right foot, with the exception of five areas (Fig. 1). These areas of diminished sensation coincided with the same areas on which the patient had been weight bearing for months prior to her referral to our department and subsequent surgery.

[Figure 1 ILLUSTRATION OMITTED]

Weight-bearing plantar pressure distribution was evaluated on a podoscope and showed excessive lateral-column weight-bearing pressure on the right foot and no midfoot pressure on the left foot (Fig. 2). The podoscope gives useful qualitative information regarding planter pressure distribution, which can be helpful when designing foot orthoses.[14]

[Figure 2 ILLUSTRATION OMITTED]

With the patient lying supine, limb lengths were measured from the anterior superior iliac spine to the medial malleoli with a tape measure. The right limb was found to be 10 mm longer than the left limb (structural limb length). This discrepancy increased to 12 mm when measured with the patient in a standing position by palpating the most superior aspect of both iliac crests and placing boards of various widths under the shorter limb until crests were level with each other (functional limb length).[15]

The patient was wearing extra-depth oxford shoes featuring deerskin uppers, a roomy toebox, a supportive heel counter, and cushioned neoprene soling, all appropriate for her condition. These shoes, however, were well worn and in need of replacement. The right lateral sole, in particular, was very worn.

Gait was evaluated by visual observation, with shoes on, 10 weeks postsurgery. The patient was using a standard cane in her left hand, was still wearing the leg-hindfoot orthosis, and was full weight bearing on her right lower extremity, although she had been instructed to wait until 12 weeks postsurgery to do so. She complained of right ankle pain, rated as 3 on a scale of 0 to 10 (0=no pain, 10=excruciating pain) during right stance phase and was developing skin irritation over the right lateral malleolus due to pressure from the leg-hindfoot orthosis. She stated, "I can't wait to stop using this brace." Extremely slow cadence, short left step length, decreased left hip and knee flexion and extension, and very little push-off on the left side were observed. The pelvis was clearly lower on the left side than on the right side. The right lower extremity demonstrated near-normal hip and knee flexion-extension-flexion pattern, modest heel-to-toe progression, and modest push-off. Weight bearing was clearly accomplished through the lateral border of the right foot, and the medial edge of the right shoe sole did not contact the floor.

During the last physical therapy visit, the patient's gait was evaluated while she walked barefoot and in modified shoes with the foot orthoses, but without the use of a cane. Gait was evaluated with a three-dimensional computerized movement analysis system. The system consisted of four video cameras placed laterally to the path of progression and two force platforms mounted flush with the laboratory walkway. The pelvis, thigh, shank, and foot or shoe were each evaluated during three repeated walks along the laboratory walkway for each limb and footwear condition. Force-plate data were obtained during two stance phases on each repeated walk. The data presented, therefore, represent the mean of six stance phases for each limb and condition. Details of the data collection procedure and system are reported elsewhere.[16,17]

Patient Problem List

Based on the evaluation results and reports made by the patient, a problem list was developed. We used the terminology of disability classification schema proposed by the National Center for Medical Rehabilitation Research (NCMRR) as a template for our problem list (Tab. 4).[18] Goals were derived directly from the list of impairments. The NCMRR model attempts to provide a classification system that conveys the range of problems encompassed by the field of rehabilitation.[18]

Table 4. Summary of Patient Problems by National Center for Medical Rehabilitation Research Domain[18]

Domain                Definition

Pathophysiology       Interruption of or interference with normal
                        physiological and developmental processes
or
                        structures

Impairment            Loss or abnormality of cognitive, emotional,
                        physiological, or anatomical structure or
                        function, including all losses or
                        abnormalities, not just those attributable
                        to the initial pathophysiology

Functional            Restriction or lack of ability to perform an
  limitation            action in the manner or within the range
                        consistent with the purpose of an organ
                        system

Disability            Inability or limitation in performing tasks,
                        activities, and roles to levels expected
                        within physical and social contexts

Societal              Restriction, attributable to social policy or
  limitation            barriers (structural or attitudinal), that
                        limits fulfillment of roles or denies
                        access to services and opportunities that
                        are associated with full participation in
                        society

Domain                  Patient Problem

Pathophysiology         Rheumatoid arthritis

Impairment              Pain: right foot/ankle rated as 3 on 0-10
                          scale (0=no pain, 10=excruciating pain);
                          left hand/wrist pain, not rated
                        Lower-extremity length discrepancy:
combined
                          structural and functional discrepancy
                        Gait disturbance: feeling of unsteadiness
                          while walking, especially when stepping
                          on right foot
                        Joint deformity: 25 [degrees] fixed varus
                          position of the rear foot

Functional              Inability to walk 22.9 m (75 ft) autdoors
  limitation              over uneven terrain while using a
standard
                          cane

Disability              Inability to attend regular social events
                          that she had been attending prior to the
                          development of her foot/ankle deformity
                          and pain
                        Examples with frequencies:
                        Attend church once a week
                        Go shopping twice a week
                        Attend hair appointment once a week
                        Attend bridge games at different friends'
                          homes twice a week

Societal                Inability to fulfill roles as head of
  limitation              household, church member, mother,
                          grandmother, and bridge partner

Physical Therapy Goals

Our treatment goals were directed toward helping our patient return to her roles as described in Table 4. That is, our expected outcome after physical therapy was that our patient would be able to walk at least 22.9 m (75 ft) outdoors over uneven terrain without the use of a cane. This achievement would allow her to participate in the social activities mentioned earlier. In order to achieve this outcome, we set three goals:

1. Adjust for the left structural lower-extremity length discrepancy with a left full-sole shoe lift.

2. Decrease the right foot and ankle pain to 1 on a scale of 0 to 10 and reduce the sensation of unsteadiness during gait when stepping on the right foot by providing custom-made foot orthoses and a right shoe lateral flare.

3. Eliminate left hand and wrist pain by eliminating the need for using a standard cane during gait.

Physical Therapy

The patient attended a total of six physical therapy sessions, which are described in Table 5.

Table 5.
Timeline for Physical Therapy Visits

Visit No.   Time                    Purpose

1, 2         4 wk postoperatively   Performed lower-extremity
                                      examination. Instructed
                                      patient in partial
                                      weight-bearing gait with the
                                      use of a single-point cane.
                                      Instructed patient in a home
                                      exercise program consisting
                                      of non-weight-bearing
                                      therapeutic exercises for
                                      bilateral hip and knee
                                      strengthening. Provided
                                      patient with information
                                      about local aquatic exercise
                                      classes, an arthritis
                                      support group, and a local
                                      pedorthic facility.

3           10 wk postoperatively   Continued lower-extremity
                                      examination, including
                                      standing and gait assessment.
                                      Obtained foot impressions for
                                      foot orthoses.

4           12 wk postoperatively   Fitted patient with bilateral
                                      custom-made foot orthoses and
                                      trained patient to use
                                      orthoses via gait training
                                      session. Sent patient to
local
                                      pedorthic facility for
                                      provision of extra-depth
                                      footwear.

5           Next day                Applied a 10-mm full-sole shoe
                                      lift to the left shoe and a
                                      13-mm lateral flare to the
                                      right shoe (see Fig. 4).
                                      Provided additional gait
                                      training without the use of
a
                                      cane.

6           14 wk postoperatively   Brief discharge evaluation.
                                      Reviewed gait and home
                                      exercise program. Performed
                                      biomechanics laboratory
                                      evaluation.

Orthosis fabrication. Because the right foot and ankle deformities were fixed, a foam impression system could be used to obtain positive plaster molds. Both feet were passively pushed into the foam while the patient maintained the tibial varum and valgum angles that were measured in stance. Due to the slow cadence of gait and relatively wide base of support, we assumed that the varum and valgum angles measured in stance would not change to a meaningful degree during ambulation, and they did not appear to change during visual gait observation. The positive mold was not altered. The orthoses were fabricated on-site by a physical therapist/pedorthist by simultaneously molding 0.64-cm (1/4-in) Plastazote no. 1,(*) cushioned rubber filler, and 3-mm-thick high-density polyethylene over the positive mold in a vacuum press.

For the right foot orthosis, cushioned rubber was used between the Plastazote top cover and the polyethylene semirigid shell to provide medial-column weight-bearing and arch support. Because the patient's right foot deformity was fixed in a position of 25 degrees of varus, the orthosis needed to be constructed such that it would hold the patient's hindfoot in this same position with respect to the floor. That is, posting material, a major component of many types of foot orthoses, was glued to the posterior planter aspect of the shell and then ground flat but at an angle of 25 degrees of varus. Thermo Cork ([dagger]) was used for this process. Increased weight-bearing pressures were likely to continue under the base and head of the right fifth metatarsal, and these areas lacked protective sensation. Therefore, a forefoot extension of PPT, ([double dagger]) a microcellular rubber with exceptional shock-absorption qualities, was added to protect tissue from breakdown (Fig. 3).

[Figure 3 ILLUSTRATION OMITTED]

When fabricating the right foot orthosis, we included the following features: an extra-deep heel seat to stabilize the calcaneus, a cushioned elevated arch (scaphoid) pad to facilitate medial column weight bearing and support the arch, a 25-degree rear-foot post made of cork to stabilize the orthosis in the position of the patient's deformity, a 5-degree intrinsic forefoot post to accommodate a mild forefoot varus deformity with respect to the floor, a soft forefoot extension, a semirigid shell with anterior trim line just proximal to the patient's metatarsal heads, and an unusually high lateral trim line or clip to help keep the patient's foot on the device. A lateral clip is a superiorly directed extension of the trim line of the foot orthosis that is placed on the lateral posterior aspect of the shell to keep the foot from sliding off the orthosis.

A left foot orthosis was also fabricated. This orthosis was designed to provide total-contact weight bearing only. No postings or other special additions were made to the left foot orthosis.

Results

A brief discharge evaluation was performed on the sixth and final visit. Observation indicated that the patient's pelvis was level in a standing position, and she reported that she was ambulating without a cane for household and short-distance community ambulation, such as walking from her car to the church or hair salon. With the use of the modified footwear and custom-made foot orthoses, she appeared to have an increased stride length and improved push-off on the right lower extremity. The medial side of the right shoe sole now was in contact with the ground (Fig. 4). The left side of the pelvis no longer dropped lower than the right side during gait. The patient had been wearing the foot orthoses and modified footwear for 2 weeks and reported good balance during ambulation, a feeling of stability and security during weight bearing, and increased comfort. She reported no pain in the right foot or ankle, and she reported the ability to continue activities that she enjoyed, such as shopping and attending bridge games twice a week and going to church once a week. She stated that she was wearing the orthoses every day and did not feel comfortable or safe without them.

[Figure 4 ILLUSTRATION OMITTED]

A biomechanical evaluation was performed in our laboratory on the patient's final visit to gain additional insights into the nature of her improvements. The patient's gait was evaluated while she walked barefoot to provide information on unassisted walking. During the other evaluation condition, the patient walked with the use of modified shoes and orthoses to document the effect of this treatment on gait. Temporal and distance measures of gait revealed abnormalities during the barefoot condition. The addition of modified shoes and foot orthoses resulted in a gait pattern that was closer to normal with greater symmetry (Tab. 6).[19] Cadence remained essentially unchanged; however, stride length increased (Tab. 6). This finding implies that for a given number of steps per minute, the patient could walk a greater distance, which increased her walking speed by 33%.

Table 6.
Biomechanics Laboratory Results

                        Age-Matched                Shoes and
Gait Variable           Control[19]    Barefoot    Orthoses

Stride length (m)         1.04          0.45        0.76
Cadence (steps/min)     101            88          86
Speed (m/s)               0.89          0.39        0.52
Stance duration
  (% of gait cycle)
  Right                                57          66
  Left                                 70          65

The addition of modified shoes and foot orthoses improved the patient's mediolateral stability on the right side during the right stance phase, as documented by an altered lateral excursion of the center of pressure (Fig. 5). The center of pressure represents the centroid of the pressure distribution under the foot in the plane of the ground.[20] During barefoot walking, lateral excursion of the center of pressure under the right forefoot in late right stance phase was excessive (Fig. 5). This finding is consistent with the patient's report of "losing balance to the right side when stepping on the right foot." The lateral excursion of the center of pressure was reduced more than 50% by the addition of modified shoes and foot orthoses to a pattern more consistent with that of normal gait (Fig. 5). This finding may account for the patient's report of improved lateral stability and her decreased need for a cane while walking in shoes and orthoses.

[Figure 5 ILLUSTRATION OMITTED]

The application of the left shoe lift to correct the apparent structural lower-extremity length discrepancy improved symmetry of pelvic vertical excursion. During normal gait, pelvic height above the floor is lowest during double-limb support and highest during single-limb support.[21] If lower-extremity lengths are equal and gait is symmetrical, as was the case with our patient after treatment, then maximum pelvic height during right single-limb support should equal maximum height during left single-limb support, and minimum pelvic height should be equal during the two phases of double-limb support. During barefoot gait, the total vertical pelvic excursion was 3.4 cm and abnormal in pattern (Fig. 6). With the addition of modified shoes and orthoses, total vertical pelvic excursion decreased to 2.7 cm and resembled a more normal pattern (Fig. 6).[20]

[Figure 6 ILLUSTRATION OMITTED]

Discussion and Clinical Implications

We found that the use of custom-made foot orthoses in addition to extra-depth shoes and shoe modifications was instrumental in helping our patient after surgery. Preoperatively, this patient's right foot deformity required that weight bearing occur exclusively on the lateral malleolus and base and head of the fifth metatarsal. We present this case because of the severity of the patient's condition and the positive functional gains that were made (de, the continued ability to participate in several activities that are important to her). This patient benefited greatly from orthopedic surgery, but she still had several problems postoperatively, including right foot and ankle pain and a feeling of unsteadiness during walking at least in part due to her varus hindfoot deformity and subsequent lateral weight-bearing pattern during the late stance phase. She also had a lower-extremity length discrepancy and difficulty with ambulation (greater than household distances), and she felt compelled to use a cane at all times, which was painful for her left wrist and hand.

As with any case report, our results should not be generalized to all persons with RA. This case report has some limitations, such as the lack of long-term follow-up. Our patient did not meet the inclusion criteria for the medical research protocol for which she was initially referred; therefore, on discharge from our department, she was discharged from our institution to private-sector care and was lost to our follow-up. In addition, the contributions of each single intervention, including footwear prescription, shoe modifications, foot orthoses, therapeutic exercises, and gait training, were not evaluated independently of one another.

This case report not only illustrates the important role of appropriate orthopedic intervention but also highlights the contributions of foot orthoses and shoe modifications, which resulted in an improvement of the total care of this patient. The report promotes the use of carefully prescribed foot orthoses placed in appropriate footwear. We are unaware of any reports in the literature that document functional improvements in gait with the use of foot orthoses combined with shoe modifications for patients with RA. We strongly urge the use of controlled clinical trials of ankle-foot and foot orthoses and modified footwear to further establish their efficacy for patients with systemic disease.

Acknowledgments

We gratefully acknowledge Charles McGarvey, PT, and Jerome Danoff, PhD, PT, for their advice during the preparation of this article and John Crawford for taking the photographs.

(*) BXL Plastics Ltd, Mitcham Rd, Croydon, Surrey, England CR9 3AL.

([dagger]) Apex Foot Health Industries, 170 Wesley St, South Hackensack, NJ 07606.

([double dagger]) Langer Biomechanics Group, 450 Commack Rd, Deer Park, NY 11729.

References

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[3] Gerber LH, Hunt GC. Evaluation and management of' the rheumatic foot. Bull NY Acad .Med. 1985;61:359-368.

[4] Clayton ML, Smyth CJ. Surgery for Rheumatoid Arthritis. New York, NY: Churchill Livingstone Inc; 1992:311-313, 329.

[5] Ehrlich GE. Rehabilitation Management of Rheumatic Conditions. 2nd ed. Baltimore, Md: Williams & Wilkins; 1986:279-281.

[6] McGuire T, Kumar VN. Rehabilitation management of the rheumatoid foot. Orthopaedic Review. 1987;16:671-676.

[7] Glass MK, Karno ML, Sella EJ, Zeleznik R. An office-based orthotic system in treatments of the arthritic foot. Foot Ankle Int. 1982;3:37-40.

[8] Dimonte P, Light H. Pathomechanics, gait deviations, and treatment of the rheumatoid foot: a clinical report. Phys Ther. 1982;62:1148-1156.

[9] Merritt JL. Advances in orthotics for the patient with rheumatoid arthritis. J Rheumatol. 1987;14(suppl 15):62-67.

[10] Locke M, Perry J, Campbell J, Thomas L. Ankle and subtalar motion during gait in arthritic patients. Phys Ther. 1984;64:504-510.

[11] Hunt GC, Fromherz WA, Gerber LH, et al. Hindfoot pain treated by a leg-hindfoot orthosis. Phys Ther. 1987;67:1384-1388.

[12] Kendall FP, McCreary EK Muscles: Testing and Function. 3rd ed. Baltimore, Md: Williams & Wilkins; 1983.

[13] Birke JA, Sims DS. Plantar sensory threshold in the ulcerative foot. Lepr Rev. 1986;57:261-267.

[14] Fromherz WA. Examination. In: Hunt GL, McPoil TG, eds. Physical Therapy of the Foot and Ankle. 2nd ed. New York, NY: Churchill Livingstone Inc; 1995:111.

[15] Schuitt D, McPoil TG, Mulesa P. Incidence of sacroiliac joint malalignment in leg-length discrepancies. J Am Podiatr Med Assoc. 1989;79:380-383.

[16] Siegel KL, Stanhope SJ, Caldwell GE. Kinematic and kinetic adaptations in the lower limb during stance in gait of unilateral femoral neuropathy patients. Clin Biomech. 1993;8:147-155.

[17] Siegel KL, Kepple TM, O'Connell PG, et al. A technique to evaluate foot function during the stance phase of gait. Foot Ankle Int. 1995;16:764-770.

[18] Research Plan for the National Center for Medical Rehabilitation Research. Bethesda, Md: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Child Health and Human Development; 1993:33. NIH Publication No. 93-3509.

[19] Himann JE, Cunningham DA, Rechnitzer PA, Paterson DH. Age-related changes in speed of walking. Med Sci Sports Exerc. 1988;20:161-166.

[20] Rogers MM, Cavanagh PR. Glossary of biomechanical terms, concepts, and units. Phys Ther. 1984;64:1886-1902.

[21] Inman VT, Ralston HJ, Todd F. Human Walking. Baltimore, Md: Williams & Wilkins; 1981:38.

JA Shrader, PT, is Senior Staff Physical Therapist, Rehabilitation Medicine Department, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bldg 10, Room 6s235, 9000 Wisconsin Ave, Bethesda, MD 20892-1604 (USA) ([e-mail]). Address all correspondence to Mr Shrader.

K Lohmann Siegel, PT, is Senior Staff Physical Therapist/Research Coordinator, Biomechanics Laboratory, Rehabilitation Medicine Department, Warren Grant Magnuson Clinical Center, National Institutes of Health.

The opinions expressed in this article reflect the views of the authors and not necessarily those of the US Public Health Service or the National Institutes of Health.

This article was submitted February 6, 1996, and was accepted November 22, 1996.