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SAMPLE CHAPTER
Rheumatoid Arthritis
Pedorthic Association of Canada Clinical Practice Guidelines
11
Lisa Irish, BSc, C. Ped (C)
Keywords: chronic, progressive, autoimmune, joint inflammation, synovial joints, articular, pannus, nodules,
polyarthritis
Key Messages
■ Early diagnosis and treatment is vital to reducing disabling effects of rheumatoid arthritis.
■ Recognition of signs and symptoms of possible rheumatic disease may speed appropriate diagnostic tests
in previously undiagnosed individuals.
■ There is strong evidence that foot orthoses and specific footwear reduce foot pain and improve functional
ability.
■ Orthotic efficacy may be as much a result of changes in muscle activation, proprioception, and motion
facilitation as skeletal alignment and kinematic changes.
■ Semi-rigid and rigid orthotics in combination with rocker toe footwear were the most effective in relieving
forefoot pain where soft orthoses (plastazote, poron) were less effective.
■ Footwear modifications are an effective treatment option for the rheumatoid foot.
Introduction
A 75-year-old female with rheumatoid arthritis. Note dorsal subluxation
of metatarsophalangeal joints. Photo by Shannon Bunnett, HBSc (Kin),
MSc, CK, C. Ped Tech (C), C. Ped (C).
An X-ray showing rheumatoid arthritis. Photo courtesy Apostolos A.
Tountas, MD, FRCS (C).
This is an excerpt from “Clinical Practice Guidelines: A reference manual of best
practice in pedorthic care.” – © The Pedorthic Association of Canada, 2012
Rheumatoid arthritis (RA) is a chronic, progressive,
autoimmune disease of unknown cause in which the body’s
immune system attacks the joints and surrounding tissues
leading to joint inflammation, pain, joint damage, and
disability. It is a systemic disease that targets synovial joints
but can have extra-articular ramifications in other organs. RA
affects approximately 1% of Canadians (Health Canada, 2003)
and is more than twice as likely to affect women as men.
Rheumatoid arthritis can occur at any age but tends to begin
between the ages of 25 and 60. Children can be affected by a
distinct but closely related inflammatory arthritic condition
called juvenile idiopathic arthritis, or juvenile rheumatoid
arthritis. Rheumatoid arthritis affects all ethnic groups and is
found worldwide (Thould & Thould, 1983).
Symptoms of initial onset of RA most commonly include
insidious fatigue, morning stiffness lasting 30-60 minutes or
more, joint pain and swelling involving the small distal joints
including the wrist, metacarpophalangeal joints, proximal
interphalangeal joints, metatarsophalangeal joints
(Rheumatoid Arthritis, 2011; Tehlirian & Bathon, 2008).
Inflammation of the small joints of the hands and feet in a
symmetrical pattern is specifically characteristic of RA
(Robinson, 2008) and occurs early in the onset of the disease
(Otter et al., 2010). Other joints that may be affected include
elbows, shoulders, hips, knees, ankles, jaw, and neck. In
addition to articular symptoms the early symptoms of RA
can also include low grade fever, fatigue, loss of appetite,
weight loss, swollen glands, weakness, malaise, myalgias, and
anemia. Muscle weakness and atrophy is a common
complaint and may be a result of pain from articular and/or
periarticular inflammation.
A reference manual of best practice in pedorthic care
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Pedorthic Association of Canada Clinical Practice Guidelines
Foot involvement in rheumatoid arthritis is a major
contributing factor to disability causing changes to gait
mechanics, difficulties walking and restrictions in activities
of daily living (Clark, Rome, Plant, O’Hare, & Gray, 2006;
Williams et al., 2011). Over 90% of patients report foot
problems within the first 10 years of disease onset (Clark et
al., 2006; Goksel Karatepe et al., 2010; Otter et al., 2010;
Williams et al., 2011) and 57% report foot and ankle pain in
the first year (Riskowski et al., 2011). Disease severity is not
the only factor that affects disability. Other contributing
factors may include socio-economic factors, depression, and
access to appropriate medical care and supportive resources,
which all contribute to the quality of patient care and patient
compliance with recommended treatments (Jones, Halbert,
Crotty, Shanahan & Batterham, 2003).
Growing evidence shows that early diagnosis and treatment
offers the best chance of limiting the disabling effects of RA
on joints and damage to organs (Breedveld & Combe, 2011;
Rheumatoid Arthritis, 2011). For patients who are referred
for pedorthic treatment complaining of bilateral joint pain
in the metatarsophalangeal and/or interphalangeal joints but
have not been diagnosed with rheumatoid arthritis, the
clinician should look for the cardinal signs of articular
inflammation. These signs include warmth, joint line
tenderness, pain on motion particularly at end range, and
intra-articular swelling or effusion. The history should also
include questions regarding other joints in the body, mode
of onset of pain, quality of pain and general health of the
patient. Episodic swelling, stiffness, weakness, and more
generalized symptoms are warning signs of a possible
rheumatic condition. A thorough history and assessment of
the painful joints may elicit responses that indicate a referral
back to the physician is necessary. If the physician suspects
RA an immediate referral to a rheumatologist will speed
appropriate treatment. With respect to non-pharmacological
treatment, research suggests that pedorthic treatment of the
foot in RA using foot orthoses and specific shoe types that
reduce plantar pressures and redistribute forces may play a
significant role in the treatment of the RA foot (Riskowski
et al., 2011; Williams et al., 2011; Woodburn, Barker &
Helliwell, 2002). Other health care professionals are integral
to the team treating the RA patient and may include
rheumatologist, physiotherapist, occupational therapist,
dietician, alternative therapists, social worker, and other
complementary professionals.
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Pathology
In rheumatoid arthritis, the immune system attacks the
synovium in particular, a thin layer of tissue that lines the
joints. People with RA experience “flares” or intermittent
active phases of the disease where joints may become hot,
red, inflamed, and painful. The initial trigger for the
autoimmune reaction that leads to rheumatoid arthritis is
unknown but viral infection, bacterial infection, stress,
hormones, environmental factors, and smoking have all been
suggested as possible triggers (Carty, Snowden & Silman,
2003; Söderli, Bergsten & Svensson, 2011). As a result of the
immune response that attacks the synovium, a host of
inflammatory cells infiltrate the joint flooding it with
A reference manual of best practice in pedorthic care
inflammatory chemicals that damage cartilage, subchondral
bone, articular capsule, and ligaments. Synovial fluid builds
up within the joint leading to swelling and pain in the joint.
The synovium thickens and develops into a granular tissue
called a pannus, which releases inflammatory mediators,
eroding the cartilage particularly but also the bone
underneath. Once a pannus has formed, scar tissue can
develop which can eventually ankylose, fusing the bone ends
together. Not all cases of RA progress to the ankylosis stage,
but joint erosion, subluxation and subsequent deformity are
common in RA (Marieb & Hoehn, 2010). The pattern of
joints affected can help in differentiating rheumatoid
arthritis from other conditions. Symmetrical involvement of
the small joints of the hands and feet is a hallmark of RA.
RA can on occasion begin as a sudden onset polyarthritis, or
a transient episode of single joint or polyarthritis lasting only
a few days or weeks, but this is not the standard presentation
(Tehlirian & Bathon, 2008). RA tends to affect joints
symmetrically in the body as opposed to other arthritic
diseases such as osteoarthritis which may act asymmetrically,
targeting one or more individual joints. The progression of
RA is highly variable among individuals with the disease.
There are certain biological markers and clinical indicators
that can identify individuals who are at high risk of rapid
disease progression.
The complications of RA are many. In long-standing disease
extra-articular symptoms occur in approximately 40% of RA
patients and may include the formation of firm, fibrous
rheumatoid nodules on elbows, Achilles tendon, metatarsal
heads and fingers; shortness of breath or chest pain due to
pulmonary fibrosis, pleural effusion; pain and redness
around the eyes due to scleritis; dry eyes and dry mouth;
congestive heart failure as a result of pericarditis; bleeding
stomach ulcers; and skin ulcers and infections due to
rheumatic vasculitis (Tehlirian & Bathon, 2008). AviñaZubieta et al., in a review of cardiovascular mortality in RA
patients, reported most studies found a 30–50% increase in
mortality rates due to cardiovascular disease in RA patients
as compared to the general population. However, more
recent studies indicate improvements to mortality rates from
cardiovascular disease for RA patients and the authors
suggest that earlier diagnosis and the use of more aggressive
and newer antirheumatic treatment regimens have improved
survival rates (Aviña-Zubieta et al., 2008). The key to
achieving long-term disease control is to reduce
inflammation promptly and effectively therefore early
therapeutic intervention with appropriate medications
reduces long-term disability and joint and organ damage
(Breedveld & Combe, 2011; Rheumatoid Arthritis, 2011;
Winston, 2011) .
Common Testing and Differential
Diagnosis
There is no single test for RA, rather it is a diagnosis reached
after combining the results of a thorough patient history,
physical examination, blood tests, and diagnostic imaging.
A careful examination of musculoskeletal complaints by a
physician will determine the direction of the clinical exam
and the appropriate lab tests and diagnostic imaging that is
This is an excerpt from “Clinical Practice Guidelines: A reference manual of best
practice in pedorthic care.” – © The Pedorthic Association of Canada, 2012
Pedorthic Association of Canada Clinical Practice Guidelines
required. Polyarthritis of the hands and feet is also a
common feature of other rheumatic diseases as are the
constitutional symptoms of fever, weight loss, loss of
appetite, swollen glands, anemia, and myalgias. Polyarthritis
associated with RA needs to be differentiated from similar
rheumatic diseases such as systemic lupus erythematosus
(SLE), systemic sclerosis (scleroderma), psoriatic arthritis,
rheumatic fever, reactive arthritis, infectious arthritis and
Sjorgren syndrome. Blood tests are used to determine levels
of inflammation, identify antibodies and other markers that
will help determine a diagnosis of RA. Rheumatoid factor
(RF) is an antibody that is not normally present in healthy
individuals, but 70–80% of individuals with RA have high
levels of rheumatoid factor; however, destructive arthritis
can still occur in the absence of RF. A positive anti-cyclic
citrullinated peptide (CCP) antibody test, in combination
with elevated erythrocyte sedimentation rate (ESR) and Creactive protein (CRP) rates and a positive RF supports a
diagnosis of RA (Rheumatoid Arthritis, 2011; Tehlirian &
Bathon, 2008). However, high levels of RF may also be
present in other autoimmune diseases including Sjogren’s
syndrome, systemic lupus erythematosus, scleroderma,
polymyositis, and dermatomyositis. Radiographs for RA
diagnosis may reveal joint space narrowing, bone erosions,
deformities or periarticular osteoporosis (Tehlirian &
Bathon, 2008). MRI and ultrasound may be more sensitive
tests in early disease when some blood tests may not yet be
positive.
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Contraindications
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The patient may complain of callus formation under high
pressure areas, pain from nodules, lesions on high friction
areas from footwear irritation. The development of
subcutaneous nodules occurs in approximately 30% of
patients and can further complicate already painful joints.
Inflammation alters pain perception, lowering the threshold
for pain (Hodge, Bach & Carter, 1999) so higher plantar
pressures associated with joint changes is not the only factor
at play in the painful RA foot. Dorsal subluxation of the
lesser MTP joints can occur exposing the distal end of the
metatarsals to increased pressure leading to callosities and
possible ulceration of overlying skin under the metatarsal
heads as well as over clawed and hammer toes (Magalhaes
et al., 2006). Common foot deformities in RA include hallux
valgus, hallux rigidus, splaying of the forefoot, metatarsal
subluxation, clawing of lesser toes, rearfoot valgus and
damage to the ankle joint (Baan et al., 2011; Goksel Karatepe
et al., 2010).
Most patients with involvement of the rearfoot complain of
ill-defined ankle pain, lateral ankle pain associated with
valgus deformity and lateral impingement (Li, 2007), plantar
heel pain, generalized foot pain and difficulty walking on
uneven ground and difficulty finding footwear. Changes to
ankle stability and talar position may result in damage to the
tibialis posterior tendon which further contributes to foot
deformity (Magalhaes et al., 2006). Suspected dysfunction
of the tibialis posterior tendon can be confirmed by an
inability to perform a single heel raise or by a lack of
inversion of the rearfoot during heel raise.
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Maintaining a healthy lifestyle can benefit RA patients
including cessation of smoking, appropriate exercise,
maintaining a normal weight, healthy diet, and utilizing aids
for daily living where necessary. Appropriate referrals for
these issues are necessary. Some medications used to alter
the disease process or treat symptoms may be
contraindicated in some patients due to co-morbidity,
intolerance, and other factors. For patients taking biologic
therapy an immediate referral to their rheumatologist or
family physician is necessary if they develop foot or leg
ulcerations. Do not try pressure-relieving orthotics or
footwear as a first line treatment for ulcers if the patient has
not consulted with their doctor or rheumatologist for
possible medication-related issues first. In addition to drug
therapies, patient tolerance for conservative or alternative
therapies may also dictate the nature of the treatment plan
for each individual.
The Patient Perspective
Bone and joint erosion caused by RA is particularly evident
in the feet. 16–19% of RA patients initially present with foot
complaints (Goksel Karatepe et al., 2010) and 20% already
have radiological damage at diagnosis (Baan, DrossaersBakker, Dubbeldam & van de Laar, 2011). Otter et al. (2010)
found women reported significantly higher scores for foot
pain than men. Patients initially may report forefoot pain.
The metatarsophalangeal joints (MTP) is one of the most
common complaints especially in early RA (Magalhaes,
Davitt, Filho, Battistella & Bertolo, 2006; Otter et al., 2010).
This is an excerpt from “Clinical Practice Guidelines: A reference manual of best
practice in pedorthic care.” – © The Pedorthic Association of Canada, 2012
Patients report a decreased tolerance for walking and
standing (Cho et al., 2009). Joint damage and foot
deformities cause functional impairment disrupting normal
gait patterns and restricting activities of daily living (Baan
et al., 2011; Clark et al., 2006; Woodburn, Helliwell & Barker,
2003). They may have generalized foot pain on weightbearing, joint damage that causes pain on weight-bearing,
pressure sensitive areas of the foot which limit standing and
walking activities.
In addition to pain, patients report numbness, stiffness,
weakness and decreased range of motion in the joints.
Limited mobility has far reaching implications for the
lifestyle of rheumatoid arthritis sufferers. Not only do
patients suffer from pain, stiffness and deformity of the feet,
these complications have severe consequences for
independence, employment and maintaining social
integration (Otter et al., 2010). In RA deformity and pain
have an impact on functional ability but it also has
detrimental effects on how the body looks, the perceptions
of an individual’s body image, moods, and general quality
of life (Goksel Karatepe et al., 2010; Williams & Nester,
2006).
Common Treatment
Early and aggressive treatment of RA is the overwhelming
recommendation of the rheumatology community
(Breedveld & Combe, 2011; Lacaille, 2000; Mäkinen,
Hannonen, & Sokka, 2006) to prevent joint destruction and
limit disease progression (Breedveld & Combe, 2011;
A reference manual of best practice in pedorthic care
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Pedorthic Association of Canada Clinical Practice Guidelines
Lacaille, 2000; Rheumatoid Arthritis, 2011). Primary
treatment of RA includes early intervention with drug
therapies, lifestyle changes, and patient education. Overall
treatment goals include reducing inflammation, preventing
damage to joints and organs, relieving pain, maintaining
mobility, and limiting harmful side-effects of medications
(Williams et al., 2011). There is no one single medication
that will address the complex progression of RA, but
standard treatment paradigms include the use of diseasemodifying antirheumatic drugs (DMARDs) (Jones et al.,
2003; Lacaille, 2000). DMARDs target biologic processes that
fuel inflammation in joints and have an effect on the
progression of the disease. They are often combined with
non-steroidal anti-inflammatories (NSAIDs) and/or steroids
which work to control symptoms of the disease. While
NSAIDs work quickly to relieve symptoms they do not have
an effect on the underlying disease and do not prevent
damage to the joints or organs. Steroids work quickly but
often have side effects so their use is often short-term. There
are a number of DMARDs available and depending on
patient response, more than one DMARD may be prescribed
or a combination of drugs including DMARDs and NSAIDs
or steroids. Patients need to be carefully monitored due to
possible toxicity of DMARD therapy.
The relatively small amount of research in the foot in RA is
disproportionate to the contribution of the foot to pain and
disability (Baan et al., 2011; Riskowski et al., 2011).
Inconsistencies in methodology, orthoses terminology,
orthoses fabrication techniques, trial quality, trial sizes, and
outcome measures have made evaluating the available
evidence and applying to clinical practice challenging (Clark
et al., 2006; Riskowski et al., 2011). In a review of studies of
foot orthoses in the RA foot, Clark et al. (2006) state that
there is strong evidence that foot orthoses do reduce foot
pain and improve functional ability, despite the range of
types of orthoses being assessed in the studies examined.
However, a Cochrane review of research on custom foot
orthoses for RA in the foot only awards foot orthoses a
A reference manual of best practice in pedorthic care
The purpose of providing orthoses is to relieve pain,
maintain or improve function and mobility, reduce plantar
pressures, prevent or minimize deformity, reduce ulceration
risk (Magalhaes et al., 2006; Williams, et al., 2011; Woodburn
& Helliwell, 1997). Several studies found that stabilizing
deformities and providing pain relief increased walking
tolerance and improved gait measures (Chalmers, Busby,
Goyert, Porter, & Schulzer, 2000; Cho et al., 2009; Woodburn
et al., 2003), however the mechanism by which orthoses and
footwear achieved these goals is not clear. While it is
commonly believed that orthoses have an effect on
kinematics and mechanical alignment these effects may be
small and may not be the primary influence of orthoses.
Other research provides alternative, or perhaps
complementary, explanations for the efficacy of foot
orthoses and specialized footwear. Orthoses may change
muscle activation patterns in the foot and leg (Nurse,
Hulliger, Wakeling, Nigg & Stefanyshyn, 2005; Nurse & Nigg,
2001) as well as gait pattern changes which may influence
joint loading, reducing stresses to the joints (Woodburn et
al., 2002). This may explain why orthoses of various
densities, designs, and materials have shown positive results
in a wide range of studies. There may be a variety of
influences at play to achieve improved results (Riskowski et
al., 2011). In a review, Egan supported the current practice
of recommending orthoses recognizing their potential to
provide pain relief at a relatively low cost (Egan, 2010).
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There has been a major shift in the treatment of RA in the past
decade as newer biologic agents have been developed which
have proven to be successful, preventing damage to the joints
and improving the quality of life and lifespan of RA patients,
even producing remission (Mäkinen et al., 2006; Winston,
2011). “In patients with well-established RA, biologic agents
have been shown to effectively improve clinical, functional
and radiographic outcomes and to retard radiographic
progression” (Breedveld & Combe, 2011). In more advanced
disease, orthopaedic surgery may be necessary due to joint or
soft tissue destruction or deformity. In a recent study, Shourt
et al. (2012) showed a marked decline in orthopaedic surgeries
for RA in a more recent cohort of patients compared to those
followed from 1980 to1994, suggesting that recent treatment
advances may be reducing the rate of disease progression and
therefore the need for as many surgeries (Shourt, Crowson,
Gabriel & Matteson, 2012). Treatment options for RA also
include conservative treatment including the use of analgesics,
physical therapy, occupational therapy, access to social
workers, patient education regarding lifestyle changes,
splinting, alternative therapies, specialty footwear, and foot
orthoses for foot pain relief.
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“silver level” of evidence for their use, finding results of
clinical trials not strong enough to develop guidelines
(Hawke, Burns, Radford, & du Toit, 2008; Riskowski et al.,
2011). Regardless, repeated findings and clinical
observations in these studies may be helpful in making
treatment decisions regarding foot orthoses and footwear to
treat foot pain in RA.
Both rigid (carbon graphite) and semi-rigid (subortholene,
EVA) orthotic materials have been shown to reduce pain and
improve function in adults with RA (Chalmers et al., 2000; Cho
et al., 2009; Woodburn et al., 2002) and in children with JIA
(Powell, Seid, & Szer, 2005). In early disease, patients responded
well to harder orthoses, showing a reduction in metatarsal and
rearfoot pain, however, Woodburn et al. (2002) cautioned that
rigid devices should only be used in patients where the tarsal
joints are not affected by disease. Soft orthoses (plastazote and
polyurethane foam) did not produce as positive a reduction in
forefoot pain as semi-rigid or EVA orthoses with metatarsal
pads (Chalmers et al., 2000; Hodge et al., 1999). Magalhaes et
al. utilized EVA orthoses and found the orthoses effective in
reducing pain, perceived disability and activity limitation. Foot
type may also play a role in the selection of orthotic materials.
Lower arched or pronated feet generally respond well to harder
materials whereas rigid deformity and pes cavus foot types do
better with softer materials (Riskowski et al., 2011). As
Chalmers et al. (2000) found, too soft a material does not
produce a therapeutic effect.
Wearing time appears to have a dramatic effect on the
efficacy of custom foot orthoses with increased wearing time
resulting in decreased pain, disability, and deformity (Clark
et al., 2006). Other authors support the continuous use of
custom foot orthoses to reduce pain and improve function
This is an excerpt from “Clinical Practice Guidelines: A reference manual of best
practice in pedorthic care.” – © The Pedorthic Association of Canada, 2012
Pedorthic Association of Canada Clinical Practice Guidelines
(Woodburn et al., 2003; Clark et al., 2006), one suggesting
an average wearing time of six hours per day for optimal
treatment effect. Williams et al. found that patients who wore
their prescribed orthoses and footwear for longer periods of
time had better pain reduction than those who did not wear
them as often.
Foot orthoses have also been found to reduce plantar
pressures under the feet of RA patients. Li (2007) found that
orthoses provided greater pressure and loading stress relief
in RA patients than in control subjects with no foot
problems. Surprisingly Hodge et al. (1999) using in-shoe
pressure measurement found no relationship between foot
pain and plantar peak pressure, however a relationship was
found between average pressure and foot pain. They
postulate that pain perception in RA is not well understood
and that while peak pressures may be an important variable
in the insensate foot evaluating risk of ulceration, average
pressure appeared better correlated to pain in the RA foot.
In-shoe pressure-measuring systems can provide vital
information when working with patients at high risk of
ulceration, but according to Hodge et al. those using in-shoe
pressure systems as a clinical tool should look to average
pressure as the more important variable in the management
of foot pain in RA (Hodge et al., 1999).
be modified with Velcro closures, or alternative closures to
accommodate the needs of the individual and improve
compliance.
In a study comparing running shoes to orthopaedic specialty
footwear, using a single blind comparison design, running
shoes were the preferred footwear for comfort and weight
(Hennessy, Burns & Penkala, 2007). Another footwear
condition that also showed a decrease in forefoot loading
was custom orthotics in combination footwear that had a
forefoot rocker (Cho et al., 2009). Shoes with a forefoot
rocker have been shown to reduce plantar pressures in the
forefoot independent of orthoses as well (Brown, Wersch,
Harris, Klein & Janisse, 2004) but studies repeatedly show
better results with a combination of orthoses and footwear
with a forefoot rocker.
There are several footwear modifications that are commonly
used to treat painful RA feet. To decrease pressure on the
forefoot, rocker soles, provided balance and gait parameters
permit the use of rocker soles. In-shoe accommodations can
be used to relieve pressure on specific painful metatarsal
heads, by physically removing material from the inside of
the footwear directly under the affected area. Modifications
to the shape of the shoe may be necessary in order to
accommodate foot deformity such as a splayed forefoot with
a narrow heel. The sole can be split and widened in the area
that impinges on the foot and the shoe can then be re-soled
to secure the modification and seal the bottom of the shoe.
In some cases of forefoot pain where extra depth footwear
was not suitable, heat mouldable footwear has been shown
to reduce forefoot pain (Riskowski et al., 2011). Due to the
extent of deformity of the foot in some cases, custom
orthopaedic footwear is the best treatment option.
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Several other authors found the combination of orthoses
and specific footwear to be the most successful at alleviating
foot pain (Cho et al., 2009; Li, 2007; Woodburn et al., 2002).
Orthoses and footwear cannot be easily separated in the
treatment of the rheumatoid foot. These devices should
work together to provide a more appropriate therapeutic
environment for the RA foot. Despite the need for orthoses
and footwear in the RA population, Otter et al. (2010) found
poor adherence with prescribed orthoses and footwear, with
footwear having poorer adherence than orthoses (de Boer et
al., 2009). Reasons for non-adherence to footwear include
poor patient education, poor fit of orthoses in shoes,
aesthetics, design, comfort, weight, and poor efficacy
(Williams & Nester, 2006; de Boer et al., 2009).
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The definitions of orthopaedic and therapeutic footwear in
the literature varies but most often includes footwear
features such as extra depth, increased volume in the toebox, heat mouldable uppers, rearfoot stability. Foot
deformity and pain obviously have a negative impact on
finding appropriate footwear to accommodate the structural
changes and pain relief demands. Difficulty in finding
footwear can lead to prolonged use of inappropriate
footwear which can be a major contributing factor to foot
impairment (Silvester, Williams, Dalbeth & Rome, 2010).
Patient involvement in the process of selecting and designing
orthotic and footwear choices may improve adherence to
treatment. Patients who perceive the footwear to “look
comfortable” are more likely to wear the footwear chosen
(Williams & Nester, 2006). Overall mobility needs to be
considered when selecting footwear. Limited hand function
may restrict closure choices for footwear, eliminating laces
as an option for example. Ease of donning and doffing
footwear is important in those with spinal or hip
involvement where impaired flexion at the hip and back
makes reaching the feet impossible. Footwear may need to
This is an excerpt from “Clinical Practice Guidelines: A reference manual of best
practice in pedorthic care.” – © The Pedorthic Association of Canada, 2012
The provision of specialized footwear and orthoses has
larger implications than simply accommodating the feet,
they also influence issues such as body image, moods, a sense
of well-being, and quality of life (Otter et al., 2010; Williams
& Nester, 2006). The Canadian certified pedorthist is
uniquely positioned to provide orthotic and footwear
treatment for the RA foot and participate as part of the
multidisciplinary team treating the patient. The ability to
design and dispense patient specific devices, and to adjust
and modify those devices in a timely manner is a powerful
tool in treating the painful RA foot.
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Breedveld, F.C. & Combe, B. (2011). Understanding emerging
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This is an excerpt from “Clinical Practice Guidelines: A reference manual of best
practice in pedorthic care.” – © The Pedorthic Association of Canada, 2012
A reference manual of best practice in pedorthic care