Available online at www.sciencedirect.

com

Gait & Posture 28 (2008) 574580 www.elsevier.com/locate/gaitpost

Characterising the clinical and biomechanical features of severely deformed feet in rheumatoid arthritis
Deborah E. Turner *, James Woodburn
School of Health & Social Care and HealthQWest, Glasgow Caledonian University, Glasgow, UK Received 30 October 2007; received in revised form 3 April 2008; accepted 6 April 2008

Abstract Purpose: 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-specic 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. Methods: 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 footspecic disease activity were determined using the Leeds Foot Impact Scale and clinical examination respectively. Comparison was made against a normative control group (n = 53). Results: 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. Conclusions: Abnormal gait patterns were identied and were distinguishable among those patients with predominantly forefoot, rearfoot or combined foot deformity. # 2008 Elsevier B.V. All rights reserved.
Keywords: Rheumatoid arthritis; Foot; Gait analysis; Foot pressure; Disability; Impairments

1. Introduction Foot deformities such as hallux valgus, claw toe and pes planovalgus are some of the most striking features in patients with rheumatoid arthritis (RA) [1] Radiographic studies have shown that the development of foot deformity increases with longer disease duration and is accelerated in the presence of more severe disease [2,3]. This nding is true both for deformity localised to the forefoot and in the rear and midfoot [3,4]. Factors associated with deformity such as pain, functional loss and disability have been studied extensively but the mechanisms of how these may be related are still unclear
* Corresponding author. Tel.: +44 141 3318718; fax: +44 141 3318112. E-mail addresses: debbie.turner@gcal.ac.uk (D.E. Turner), Jim.Woodburn@gcal.ac.uk (J. Woodburn). 0966-6362/$ see front matter # 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.gaitpost.2008.04.004

[25]. Deformity, especially in its severest form, may be troublesome for patients, in terms of obtaining comfortable footwear but is not always painful. After adjusting for disease duration and severity, foot deformity in a heterogenous population of RA patients was found to have no predictive value for foot-related impairment or disability [6]. Indeed, only in RA cohorts who are well dened by disease duration or severity, or by localisation of impairments to the rear- or forefoot can this association be found [2,5,7]. Foot pain probably has the strongest inuence on functional ability regardless of disease duration [57]. Foot joints which are stiff and deformed may also play an important role but this is less clear. Semi-quantitative functional indices correlate poorly with foot deformity whereas objective measurements such as gait analysis indicate a relationship albeit weaker than pain [4,5,7]. The recent pursuit of objective gait data has yielded a better

D.E. Turner, J. Woodburn / Gait & Posture 28 (2008) 574580

575

understanding of foot impairments in RA. Thus RA patients with foot deformity will shorten their stride length and walk slower, particularly if the rearfoot is involved [5]. Deformity alters the shape of the foot and changes the distribution of pressure on the plantar surface. Elevated focal pressures in the forefoot increase with disease duration and are associated with pain during walking and gait adaptations [810]. These parameters, as well as any accompanying gait compensations can now be successfully quantied using increasingly sophisticated three-dimensional (3D) gait models of the foot and ankle [1115]. Investigating well-dened RA subpopulations is helpful in understanding the pathway leading from underlying disease processes to localised impairment and to enable the development of disease-staged targeted treatment. We have previously undertaken this approach in early RA detecting clinically important functional changes in the foot within 2 years from disease onset [16]. At the opposite end of the disease spectrum this present study investigates RA patients with the most severe forms of foot deformity since these represent an important clinical challenge for both conservative and surgical management. More precisely, the aim of this study was to characterise the clinical and biomechanical features of well-established severe foot deformity in patients with RA grouped by location of deformity in comparison with normative data.
2. Methods 2.1. Patients Patients with conrmed diagnosis of RA, based on the American College of Rheumatology criteria [17] and symptomatic foot deformity based on an impairment/footwear subscale of the Leeds Foot Impact Scale (LFISIF) !4 were recruited [18]. One foot was randomly selected for assessment. Fore- and rearfoot deformities were quantied using the Structural Index (SI) score, which considers hallux valgus, metatarsal phalangeal (MTP) subluxation, 5th MTP exostosis, and claw/hammer toe deformities for the forefoot (range 012) and calcaneus valgus/varus angle, ankle range of motion and pes planus/cavus deformities for the rearfoot (range 0 7) [5]. Patients were sub-classied by the localised severity of foot deformity. Those with a forefoot SI score of !10 were assigned to the forefoot (FF group), those with a rearfoot SI score !4 to the rearfoot (RF group) and those with scores exceeding both minimum criterion for fore- and rearfoot to the combined foot deformity group (COMB group) [5]. Community dwelling adults with no history of inammatory arthritis or musculoskeletal disease involving the lower limb and foot were recruited for comparison. Local Research Ethics Committee approval was obtained for this study. In total 28 patients were recruited into the study, 12, 10 and 6 were assigned to the FF, RF and COMB groups respectively. All gait and clinical data were collected on the same day. 2.2. Demography, disease and clinical data Age, gender, body mass index, disease duration and disease activity (using the 28 joint count) were recorded for each patient.

The impact of the disease localised to the feet was measured using the LFIS, which has two subscales to measure impairment/footwear (LFIFIF) and activity limitation/participation restriction (LFISAP) [18]. A single clinician recorded swollen (SJC) and tender (TJC) joint scores in the foot for the ankle, subtalar, calcaneocuboid, talonavicular, MTP, interphalangeal joint of the hallux and proximal interphalangeal joints of the lesser toes (range 014). The number of patient reported painful (PJC) joint sites was also recorded (range 014). 2.3. Gait analysis An instrumented walkway (GAITrite, CIR systems, Clifton, NJ, USA) was used to capture spatial and temporal gait parameters. Plantar foot pressures were measured using the EMED-ST platform (Novel GmbH, Munich, Germany). A six-camera 60 Hz videobased motion analysis system (Falcon System, Motion Analysis Corporation, Santa Rosa, CA, USA) was used to track the motion of 22 spherical reective targets placed on the shank and foot [6,13]. Visual3D software (C-motion, Inc., Rockville, MD, USA) was used to build segmented foot models which comprised of the shank, rearfoot, forefoot, and hallux. Marker placement and segment models were based on those described by Carson et al. [19]. Spatial and temporal parameters were collected from two passes along the walkway. Kinematic and plantar pressure variables were collected simultaneously from ve barefoot walking trials (except in ve cases where foot pain limited two patients to four trials and three patients to three trials). A pre-determined core set of foot biomechanical variables was extracted from an average of the walking trials. These included walking speed and double-support as objective measures of global function [6,12,13]. Intersegment kinematics and plantar pressures represented intrinsic foot function. Rearfoot motion was expressed in the shank coordinate reference system as dorsiexion (+)/plantarexion (), inversion (+)/eversion () and internal (+)/external () in the sagittal, frontal and transverse planes respectively. Forefoot motion was expressed in the coordinate reference system for the rearfoot as dorsiexion (+)/ plantarexion (), inversion (+)/eversion (), and adduction (+)/abduction (+). The motion of the hallux was measured in the sagittal plane only, expressed in the coordinate reference system for the forefoot as dorsiexion (+)/plantarexion (). The rise and fall of the medial longitudinal arch during stance was measured vertical (z) coordinate of a single motion tracking marker placed over the navicular. Peak pressures in the forefoot and contact area for the toes (dened using automated software) were used as metrics to capture functional changes associated with MTP deformity. Off-loading the forefoot (a characteristic gait compensation strategy) was measured by recording the time (as a % of stance) when the centre-ofpressure (COP) reached 50% of foot length [10]. Contact area in the midfoot was used to assess collapse of the medial longitudinal arch [6,12]. 2.4. Statistical analysis The mean motion pattern of intersegment kinematics normalised in the time domain (0100% stance), was displayed graphically for each group. On these graphs, a colour-coded reference scale was used to show RA subgroup variation from normal in S.D. multiples (3 to +3) during each % of the stance phase [20]. Phases

576

D.E. Turner, J. Woodburn / Gait & Posture 28 (2008) 574580

Table 1 Demographic, disease, and clinical characteristics of the control subjects and RA groups Variable Group Control (n = 53) Age (years) Gender (F:M) BMI Disease duration (years) Disease Activity Score LFISIF (range 021) LFISAP (range 030) Swollen joint count (range 014) Tender joint count (range 014) Painful joint count (range 014) Forefoot Structural Index (range 012) Rearfoot Structural Index (07) Weight bearing heel alignment angle (8) 55.2 (11.7) 33/20 26.3 (4.4) 2 (3) 1 (3) 0 (1) 0 (1) 0 (0) 1 (1) 0 (0) 3 (3) FF (n = 12) 57.8 (9.3) 7:5 23.5 (3.6) 15.8 (7.8) 3.69 (1.22) 11 (4) 13 (9) 2 (3) 4 (3) 3 (3) 11 (1) 1 (1) 6 (4) RF (n = 10) 53.8 (13.2) 8:2 26.1 (3.7) 15.7 (13.7) 4.44 (1.50) 12 (4) 20 (7) 2 (3) 6 (3) 3 (2) 5 (3) 5 (1) 14 (5) COMB (n = 6) 64.7 (6.9) 4:2 24.9 (3.1) 20.2 (11.7) 3.08 (1.55) 13 (3) 22 (4) 1 (1) 7 (5) 3 (3) 11 (1) 4 (1) 12 (3)

FF group, severe forefoot deformity group; RF group, severe rearfoot deformity group; COMB group, severe fore- and rearfoot deformity group; BMI, body mass index; LFISIF, Leeds Foot Impact impairment/footwear score; LFISAP, Leeds Foot Impact activity limitation/participation restriction score. Values are mean standard deviation.

where the deviation >2S.D.s were visually identied and conrmed from the descriptive statistics. From this abnormal phase a single variable (either the peak or the value from a standardised time point such as mid- or terminal stance) was then selected for comparison against normal reference ranges. This process enabled reduction of the kinematic data to a manageable core set. To compare the biomechanical differences between the RA patients and control subjects, the mean difference and associated condence intervals were calculated using the t distribution.

3. Results 3.1. Demographic, clinical features and disease characteristics Demographic and disease characteristics (presented as means and standard deviations) are summarised in Table 1. Disease activity lay within the medium reference range of >3.2 to 5 for both the FF and RF groups, whilst low disease activity of <3.2 was found in the COMB group [21]. The LFISIF score was comparable across all three RA subgroups but was elevated in comparison with the normative control group (Table 1). In contrast, between group differences in the LFISAP scores were identied with the RF and COMB groups showing markedly higher scores. All three RA groups had comparable levels of swollen, tender and painful foot joints. The mean weight bearing heel alignment angle was valgus in all of the study groups but was markedly more severe in both the RF and COMB groups (Table 1). 3.2. Gait analysis Walking speed was reduced and double limb support times increased in all three RA groups compared to normal

values (Table 2). Those in the COMB group walked slower and the double-support time was longer in the RF and COMB groups. From the analysis of the intersegment kinematics, six key variables were identied where the motion pattern varied from normal by !2/+2S.D.s (Fig. 1, Table 2). In the rearfoot, all three RA subgroups showed a marked reduction of plantarexion in terminal stance. In the frontal plane both the RF and COMB groups demonstrated excessive eversion at mid-stance in comparison with controls. The inverted position of the forefoot at mid-stance was excessive for all three RA groups but only exceeded >2S.D.s in the RF group. In comparison with normal values the forefoot was more abducted in the RF group around heel lift but the peak value remained within normal limits. By contrast, there was marked forefoot abduction in the COMB group (Table 2, Fig. 1). The lowest vertical height of the navicular was excessively low (at approximately 50% of the normal vertical height) in the RA groups with the exception of the FF group where it remained within normal limits. All three RA groups showed a marked reduction of peak hallux dorsiexion during terminal stance in comparison to the control group (Table 2, Fig. 2). Delay in the forward progression of the centre-ofpressure was observed in both the RF and FF groups but not in the COMB group (Table 2). Large reductions in the lesser toe contact area was observed for all three RA groups in comparison with controls but was most marked in the FF and COMB groups. In contrast the midfoot contact area was comparable with controls in the FF group but distinctly increased in both the RF and COMB groups. Peak pressure in the forefoot was only marginally increased in the RF group but markedly higher in the FF and COMB groups (Table 2). A representative peak pressure prole for each RA group is shown in Fig. 2.

D.E. Turner, J. Woodburn / Gait & Posture 28 (2008) 574580 FF group, severe forefoot deformity group; RF group, severe rearfoot deformity group; COMB group, severe fore- and rearfoot deformity group; RF, rearfoot; FF, forefoot; COP, centre-of-pressure. Values are mean standard deviation. a Kinematic variables selected as abnormal based on a deviation >2S.D. from the normal motion pattern at pre-determined phases of stance for one or more of the RA groups (as indicated by ^) in comparison with control subjects (see Fig. 2).
RA and control group comparisons; mean difference (95% condence interval) 0.42 (0.68, 0.16) 5.7 (0.6, 10.7) Combined and control 11.5 (3.4, 19.5) 14.5 (18.4, 10.6) 8.0 (3.1, 12.9) 11.4 (20.6, 2.3) 15.3 (21.6, 9.0) 17.1 (32.5, 1.7)

577

1.7 (6.4, 9.7) 7.1 (8.8, 5.4) 4.9 (24.4, 34.2) 452 (156, 748)

4. Discussion In this study, RA patients with severe foot deformity were characterised by long-standing disease, moderate levels of disease activity and moderate-high levels of foot-related impairment and disability. In order to understand impact of deformity more fully, gait analysis was undertaken. Consistent with the ndings of other groups we identied adapted and degraded gait patterns [716]. When grouped by predominant location of deformity, 3D gait analysis detected both common features and distinctly different subgroup patterns of disrupted foot function which mapped closely to the localised structural impairments. Across the RA groups, patients tended towards a shufing gait style characterised by slow walking speed and prolonged double-support. These common features may represent global functional adaptation [6] or compensated gait for pain and deformity in both the forefoot [7] and rearfoot [12]. Sagittal plane kinematic data showed a delay in heel rise and a marked reduction in the magnitude of plantarexion in terminal stance in all three RA groups in comparison to normative data, which suggests that the normal rocker function at the ankle and forefoot is lost. The FF group typically displayed avoidance of load transfer to the forefoot (evidenced by increased time taken for COP to reach 50% of foot length) in response to pain [10] and all three groups showed loss of third rocker function in terminal stance, emphasising the universal involvement of the forefoot [6,7,13,14]. Excessive eversion of the rearfoot coupled with excessive internal rotation of the shank has been reported in the pronated foot type [22] and in RA patients with pes planovalgus deformity [23]. All of the RA groups demonstrated abnormal eversion of the rearfoot at heelstrike and excessive eversion through the entire stance phase of gait compared to normal data. However, those with rearfoot deformity were markedly more everted for a longer period of the stance phase making it possible to differentiate between those with rearfoot and forefoot deformities. In contrast to previous studies the pattern and range of rearfoot internal and external rotation in all the RA groups was within normal limits, suggesting that the normal coupling motion between the rearfoot and shank was not established. This coupling motion was previously reported in a group of RA patients with early disease and correctable pes planovalgus deformity [23]. Lack of coupling may be a consequence of severe deformity accompanied with some disruption of the soft tissue structures and changes in joint geometry. However, imaging data would be required to validate this inference. Patients with rearfoot deformity had a substantially higher number of abnormal kinematic features and appreciably greater levels of foot-related disability. This suggests that persistent synovitis and damage to the joints and soft tissue in the peri-talar complex has severe functional consequences and may partly explain worsening

0.36 (0.55, 0.16) 5.4 (0, 10.9)

9.9 (5.7, 14.1) 13.1 (16.8, 9.4) 9.0 (4.2, 13.9) 5.8 (9.2, 2.3) 16.9 (27.3, 6.5) 16.1 (27.1, 5.2) 10.5 (5.2, 15.8) 9.0 (13.4, 4.5) 8.4 (3.4, 13.3) 3.0 (8.5, 2.5) 4.0 (9.2, 1.2) 18.3 (27.1, 9.4) (9.3)^ (4.3)^ (4.7) (8.8)^ (2.8)^ (16.8)^ (4.2)^ (4.8)^ (6.7)^ (4.6) (9.4)^ (12.3)^ (7.0)^ (5.9) (8.0) (8.5) (6.3) (13.6)^ (3.8) (6.4) (4.3) (5.2) (7.5) (7.6) Selected kinematic variables a RF terminal stance plantarexion (8) RF mid-stance eversion (8) FF mid-stance inversion (8) FF peak abduction (8) Lowest navicular height (mm) Peak hallux dorsiexion (8) 6.2 0.8 1.7 4.7 32.0 40.2 4.3 8.2 10.1 7.7 28.1 21.9 3.7 12.2 10.8 10.4 15.1 24.0 5.3 13.7 9.7 16.1 16.8 23.0

Rearfoot and control

Table 2 Spatiotemporal, kinematic and plantar pressure/footprint variables for healthy adult control subjects and three groups of RA patients dened by location of foot deformity

0.29 (0.43, 0.15) 2.8 (0.1, 5.6)

Forefoot and control

0.83 (0.24) 22.1 (4.8)

Combined (n = 6)

0.90 (0.27) 21.8 (7.5)

Control and RA groups; mean value (standard deviation)

Rearfoot (n = 10)

0.97 (0.21) 19.2 (4.5)

1.25 (0.15) 16.4 (3.0)

Pressure/footprint variables COP at 50% foot length (% stance) Lesser toe contact area (cm2) Midfoot contact area (cm2) Forefoot peak pressure (kPa)

Walking speed (m/s) Double-support time (% gait cycle)

Spatiotemporal parameters

42.0 (6.9) 8.6 (2.2) 23.4 (8.2) 556 (223)

Control (n = 53)

54.0 (16.1) 3.0 (2.7) 22.9 (9.5) 927 (403)

Forefoot (n = 12)

52.2 (13.1) 4.4 (3.2) 35.4 (11.5) 631 (519)

43.6 (6.6) 1.5 (1.4) 28.3 (23.7) 1008 (243)

12.1 (1.2, 23.0) 5.6 (7.5, 3.7) 0.5 (7.1, 6.2) 371 (96, 646)

10.2 (0.7, 21.2) 4.2 (6.9, 1.5) 12.0 (2.3, 21.8) 75 (360, 510)

578

D.E. Turner, J. Woodburn / Gait & Posture 28 (2008) 574580

Fig. 1. Stance phase gait data for RA patient groups (solid coloured line represents the mean curve for each group as indicated in the legend) and the healthy control subjects (shaded area representing mean 1 standard deviation). The corresponding colour-coded deviations between the RA patients in each group and healthy control subjects are presented under the abscissa for comparison. A reference scale (range 3 standard deviations) is also provided (after Manal and Stanhope [20]). (For interpretation of the references to colour in this gure legend, the reader is referred to the web version of the article.)

foot-related disability as evidenced by high LFISAP scores. Furthermore, clinical features such as valgus heel position and pes planus deformity matched closely to the kinematic features of excessive eversion and low navicular height respectively [6,1214]. Navicular height remained within normal limits in the FF group during the whole stance phase but was markedly reduced in those with rearfoot deformity making it easy to differentiate between those with rearfoot and forefoot deformities. In those with forefoot deformity, hallux valgus and lesser toe deformity mapped well to the disrupted pressure distribution parameters, primarily reduced lesser toe contact area and increased forefoot peak pressures. Whilst high forefoot plantar pressures commonly occur in RA, factors such as pain, plantar sensation and the eroded joints have

mediating effects [24,25]. Although we cannot account for potential confounding based on these factors, deformity leads to signicant increase in forefoot pressures since these were higher in the FF and COMB groups in comparison with patients with in the RF group. Additionally $50% reduction in hallux dorsiexion during terminal stance was observed in all RA groups compared to normative data which is consistent with hallux valgus and 1st MTP joint damage. This nding, in combination with the reduced rearfoot plantarexion in terminal stance suggests a complete breakdown of sagittal rocker function and the windlass mechanism necessary for load acceptance, as well as decreased stability through stance and forward propulsion. The ndings of this study should be interpreted with caution. Since the sample sizes were small, no attempt was

D.E. Turner, J. Woodburn / Gait & Posture 28 (2008) 574580

579

Fig. 2. Representative peak plantar pressure distribution maps for each of the three RA subgroups. In (A) a patient from the severe forefoot deformity group shows normal heel and midfoot pressure distributions with the footprint indicating normal medial longitudinal arch prole. In the forefoot, sharp peaks of pressure are localised to the 1st3rd metatarsal heads, accompanied by reduced contact area and peak pressure at the hallux and lesser toes. In (B) a patient from the severe rearfoot deformity group shows collapse of the medial longitudinal arch with contact over the navicular-medial cuneiform-base of 1st metatarsal region as well as the cuboid. Pressure in the forefoot is reduced laterally with a small elevated peak at the 1st metatarsal head. In (C) a patient with severe deformity of both the fore- and rearfoot regions shows, increased foot contact in the medial longitudinal arch and elevated peak pressure in the medial region of the heel. In the forefoot sharp peaks of pressure are located at the 1st4th metatarsal heads and also absent/reduced contact of the hallux and the 2nd4th toes.

made to undertake inferential statistical analysis. It was advantageous that the RA groups were homogenous for deformity features. This study employed a clinical index rather than radiographic images to characterise and quantify foot deformity which was favourable as it avoided unnecessary exposure to ionising radiation but introduced a subjective scoring system. However, it must be noted that all the measurements were taken by one experienced clinician and the interpretation and measurement of foot deformity from radiographic images can be difcult especially in cases of severe foot deformity. The strength of this study was the interpretation of gait data in light of a comprehensive clinical data set identifying key factors such as disease severity, impairments such as pain and deformity, and synovitis localised to the foot. In these cohorts of RA patients, severe foot deformity was associated with clinically important levels of impairment and disability. It is important to note that appreciably greater levels of foot-related disability were found in patients if the ankle/rearfoot were severely deformed and a greater number of abnormal kinematic features identied compared to those with severe forefoot deformity in isolation suggesting that treatments in early disease should be directed towards prevention of rearfoot deformity. Conict of interest The author(s) declare that they have no competing interests. Dr Deborah Turner is funded by the Arthritis Research Campaign.

References
[1] Michelson J, Easley M, Wigley FM, Hellman D. Foot and ankle problems in rheumatoid arthritis. Foot Ankle Intl 1994;15: 60813. [2] Shi K, Tomita T, Hayashida K, Owaki H, Ochi T. Foot deformities in rheumatoid arthritis and relevance to disease severity. J Rheumatol 2000;27:849. [3] Bouysset M, Bonvoisin B, Lejeune E, Bouvier M. Flattening of the rheumatoid foot in tarsal arthritis on X-ray. Scand J Rheumatol 1987;16:12733. [4] Bal A, Aydog E, Aydog ST, Cakci A. Foot deformities in rheumatoid arthritis and relevance of foot function index. Clin Rheumatol 2006;25:6715. [5] Platto MJ, OConnell PG, Hicks JE, Gerber LH. The relationship of pain and deformity of the rheumatoid foot to gait and an index of functional limitation. J Rheumatol 1991;18:3843. [6] Turner DE, Helliwell PS, Lohmann Siegel K, Woodburn J. Biomechanics of the foot in rheumatoid arthritis: identifying abnormal function and the factors associated with localised disease impact. Clin Biomech 2008;23:93101. [7] OConnell PG, Siegel KL, Kepple TM, Stanhope SJ, Gerber LH. Forefoot deformity, pain, and mobility in rheumatoid and nonarthritic subjects. J Rheumatol 1998;25:16819. [8] van der Leeden M, Steultjens M, Dekker JHM, Prins APA, Dekker J. Forefoot joint damage, pain and disability in rheumatoid arthritis patients with foot complaints: the role of plantar pressure and gait characteristics. Rheumatology 2006;45:4659. [9] van der Leeden M, Steuldjens M, Dekker JH, Prins AP, Dekker J. The relationship of disease duration to foot function, pain and disability in rheumatoid arthritis patients with foot complaints. Clin Exp Rheumatol 2007;25:27580. [10] Semple R, Turner DE, Helliwell PS, Woodburn J. Regionalised centre of pressure analysis in patients with rheumatoid arthritis. Clin Biomech 2007;22:1279.

580

D.E. Turner, J. Woodburn / Gait & Posture 28 (2008) 574580 [19] Carson MC, Harrington ME, Thompson N, OConnor JJ, Theologis TN. Kinematic analysis of a multi-segment foot model for research and clinical applications: a repeatability analysis. J Biomech 2001;34:1299307. [20] Manal K, Stanhope SJ. A novel method for displaying gait and clinical movement analysis data. Gait Posture 2004;20: 2226. [21] van Gesel AM, Anderson JJ, van Riel PL, Boers M, Haagsma CJ, Rich B, et al. ACR and EULAR improvement criteria have comparable validity in rheumatoid arthritis trials. American College of Rheumatology European League of Associations for Rheumatology. J Rheumatol 1999;26:70511. [22] Nigg BM, Cole GK, Nauchbauer W. Effects of arch height of the foot on angular motion of the lower extremities in running. J Biomech 1993;26:90916. [23] Woodburn J, Helliwell PS, Barker S. Three-dimensional kinematics at the ankle joint complex in rheumatoid arthritis patients with painful valgus deformity of the rearfoot. Rheumatology (Oxford) 2002;41: 140612. [24] Tuna H, Birtane M, Tastekin N, Kokino S. Pedobarography and its relation to radiologic erosion scores in rheumatoid arthritis. Rheumatol Int 2005;26:427. [25] Rosenbaum D, Schmiegel A, Meermeier M, Gaubitz M. Plantar sensitivity, foot loading and walking pain in rheumatoid arthritis. Rheumatology 2006;45:2124.

[11] Siegel KL, Kepple TM, OConnell PG, Gerber LH, Stanhope SJ. A technique to evaluate foot function during the stance phase of gait. Foot Ankle 1995;16:76470. [12] Turner DE, Woodburn J, Helliwell PS, Cornwall ME, Emery P. Pes planovalgus in rheumatoid arthritis: a descriptive and analytical study of foot function determined by gait analysis. Musculoskelet Care 2003;1:2133. [13] Woodburn J, Nelson KM, Lohmann Siegel K, Kepple TM, Gerber LH. Multisegment foot motion during gait: proof of concept in rheumatoid arthritis. J Rheumatol 2004;31:191827. [14] Khazzam M, Long JT, Marks RM, Harris GF. Kinematic changes of the foot and ankle in patients with systemic rheumatoid arthritis and forefoot deformity. J Orthop Res 2007;25:31929. [15] Laroche D, Ornetti P, Thomas E, Ballay Y, Maillefert JF, Pozzo T. Kinematic adaptation of locomotor pattern in rheumatoid arthritis patients with forefoot impairment. Exp Brain Res 2007;176:8597. [16] Turner DE, Helliwell PS, Emery P, Woodburn J. The impact of rheumatoid arthritis on foot function in the early stages of disease: a clinical case series. BMC Musculoskelet Disord 2006;21:102. [17] Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classication of rheumatoid arthritis. Arthritis Rheum 1988;31:31524. [18] Helliwell PS, Allen N, Gilworth G, Redmond A, Slade A, Tennant A, et al. Development of a foot impact scale for rheumatoid arthritis. Arthritis Rheum 2005;53:41822.