Best Practice & Research Clinical Rheumatology 26 (2012) 409422

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Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevier.com/locate/berh

Gait deviations in individuals with inammatory joint

diseases and osteoarthritis and the usage of threedimensional gait analysis
Eva W. Brostrm, PT, PhD a, *, Anna-Clara Esbjrnsson, PT, MSc a,
Johan von Heideken, MD a, Maura D. Iversen, PT, MPH, DPT, SD b, c
a

Department of Womens and Childrens Health, Karolinska Institutet, Karolinska University Hospital, Solna,
SE 171 77 Stockholm, Sweden
b
Department of Physical Therapy, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA
c
The Division of Rheumatology, Immunology, and Allergy, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, USA

Keywords:
Rheumatoid arthritis
Osteoarthritis
Gait analysis
Kinematic
Kinetic

This chapter describes three-dimensional gait analysis and

common gait deviations in adults with rheumatoid arthritis (RA)
and osteoarthritis (OA). Furthermore, we describe changes in gait
deviations following surgical and non-surgical interventions. Gait
analysis is used to dene gait deviations and to evaluate varying
surgical approaches, types of surgeries and non-pharmacologic
interventions. Most studies examine gait in adults with knee OA.
Limitations of existing studies include small samples, poor selection of controls, sample heterogenecity, lack of baseline gait
assessments and inconsistency in measurement. Across studies,
time and distance parameters are generally used to provide
a global measure of gait deviations. Individuals with RA and OA in
the lower extremities exhibit reduced walking speed/cadence and
decreased motion and moments in relation to healthy subjects.
Future research should include larger sample sizes, the use of
proper controls, pre- and post-assessments and identify gait
abnormalities early in the disease process to minimise long-term
consequences.
2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 46 8 51774400; fax: 46 8 51772695.

E-mail address: eva.brostrom@ki.se (E.W. Brostrm).
1521-6942/$ see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.berh.2012.05.007

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Introduction
Joint diseases are an umbrella term used to describe several diagnostic categories of which rheumatoid arthritis (RA) and osteoarthritis (OA) are among the most common. Approximately 0.51% of
the population of North America is diagnosed with RA and the prevalence worldwide is slightly lower
[1]. RA and OA are major causes of work disability, diminished function and loss of independence.
Physical therapy is among the rst line of treatment options in OA and RA, yet, there is no agreement
about which physical therapy training programmes are most effective and how these interventions
impact the biomechanics of affected joints [2]. Medical treatments target pain and inammation to
improve joint function. However, severe pain associated with structural joint changes may require
surgical interventions such as osteotomies, arthrodesis or joint replacement [3,4]. In 2003, 202,500
primary total hip replacements (THRs) and 402,100 primary total knee replacements (TKRs) were
performed in the United States [3]. The worldwide prevalence of total hip and knee replacements has
escalated dramatically in persons with OA while surgery is decreasing in RA due to the implementation
of biologic therapies [3,5]. The costs of medical therapy, conservative treatment and associated indirect
costs such as disability combine to produce high societal costs [6].
While pathophysiology differs between these two diseases, both result in musculoskeletal
impairments, reduced aerobic capacity, pain, limitations in function and, in some cases, joint deformity.
This could lead to alterations in gait such as reduced walking speed [710]. This chapter describes gait
analysis, with an emphasis on three-dimensional (3D) gait analysis with respect to joint rotations
(kinematics) and joint reactions (kinetics). This chapter also reviews common gait deviations in adults
with RA and OA and describes changes in gait following surgical and non-surgical interventions.
Search strategy
On 2 February 2012, following databases were searched for abstracts: Pubmed, Cinahl, Embase,
Medline and Web of Science. Using the terms Gait AND (Kinematic OR Kinetic) AND (Arthritis OR
Rheumatic disease), 641 abstracts were found and read. Thereafter, hand searches of articles in
reference lists were performed. Articles were included in the review based on (1) including kinematic
and kinetic parameters from 3D gait analysis, (2) diagnosis of hip, knee or ankle OA evaluating
treatment and (3) diagnosis of RA. Articles should be in English and of full length. However, due to the
large body of literature regarding OA, and since the aim of this review was to discuss the usage of 3D
gait analysis in individuals with OA and RA and not to provide a complete review of existing literature,
the most relevant articles were selected.
Gait analysis
Denitions of gait and phases of the gait cycle
Gait is described in terms of strides. A stride is dened as the distance between one heel strike and
next heel strike of the same foot and consists of a stance phase and a swing phase. Stance can be
divided into ve phases, starting with initial contact as the heel strikes the ground, loading response,
mid-stance, terminal stance and pre-swing. Swing phase is commonly divided into initial swing, mid
swing and terminal swing (Fig. 1). For efcient gait, an individual needs to achieve stability in stance,
appropriate pre-position of the foot in swing, foot clearance during swing and adequate step length to
conserve energy [11].
What is gait analysis and when is gait analysis indicated?
Clinical gait analysis is the study of human walking and includes measurement of movement quality
and the identication of potential causes of abnormalities to develop treatment recommendations. A
motion analysis laboratory contains specialised equipment operated by a team of multidisciplinary
personnel, for example, physiotherapists, orthopaedic surgeons, podiatrists and engineers. Motion
analysis begins with a comprehensive physical examination consisting of assessments of joint range of

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411

Fig. 1. Normal gait cycle dened from initial heel contact to heel contact with the same limb.

motion (ROM), muscular contracture, muscle strength/tone, bony deformity and examination of the
neurosensory system. Gait analysis can be performed either barefoot or shod or with/without walking
aids. Videotape recordings provide an overall impression of the smoothness and uidity of gait. Closeup views also help identify joint deformities.
During 3D gait analysis, a person is instructed to walk back and forth on an established pathway,
approximately 10 m in length, while measures of kinematics and joint reactions kinetics are obtained
using 3D cameras and force plates [12,13]. Kinematics is dened as the relative motion between two
adjacent bones, but does not account for the cause of that motion. Thus, kinematics describes the range
and patterns of motion during walking. Kinetics is the study of gravitational forces, not visible to the
eye, that act on the body. These forces are obtained through the use of force plates. Forces are
commonly normalised to weight to allow to compare data across different weights and are described
either as internal (the forces from muscles, ligaments and tendons that act on a joint) or external
(gravitational forces acting on the body). The joint moments and segmental angular velocity is
calculated to extract the power, classied as either absorbing power (eccentric contraction) or
generating power (concentric contraction). Simultaneously, information about walking speed, time
and distance parameters, for example, walking speed, stride length, step length and limb support time
can be obtained [11].
Gait analysis uses and limitations
Gait analysis provides detailed information about joint rotation and forces to further delineate the
relationship between joint disease, joint impairments and compensatory gait strategies adopted to
overcome painful and disabling deformities. The limitations of gait analysis include the time needed to
capture and process data, the associated equipment costs, the need for trained personnel, challenges
inherent in comparing data between labs and the variability in placements of markers. However, gait
analysis can provide key parameters such as peak values or timing of the peak values to identify
abnormalities and assess the impact of interventions in a more objective manner [11].
Time and distance parameters and the effect of speed
Gait pathology in individuals with RA and OA is commonly evaluated using time and distance
parameters. These parameters are often affected in individuals with arthritis and described as reduced

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E.W. Brostrm et al. / Best Practice & Research Clinical Rheumatology 26 (2012) 409422

walking speed and cadence, shorter stride and step length and prolonged double limb support time
[4,710,1417]. In healthy individuals, joint rotations and joint reactions are inuenced by walking
speed, such that slower walking speed results in reduced ranges of motion and reduced joint reactions
[18,19]. Hence, the question arises whether gait pathology in RA and OA, described as kinematics and
kinetics, is an effect of slower walking speed, disease pathology or both. In general, while there is
limited research, kinematic, kinetic and stride parameters data might be affected by both walking
speed and disease pathology, hence walking speed should always be considered in assessments and
conclusions drawn with care [7,20]. From a clinical standpoint, self-paced gait is the most relevant as
everyday activities will be affected and gait abnormalities during self-paced gait are likely to lead to
long-term consequences.
Typical gait deviations in patients with hip OA
OA is the end stage of a number of different diseases leading to cartilage degeneration. While OA can
exist in any joint, the primary joints affected are the large weight-bearing joints (hips and knees),
ankle, spine and hands. This process results in joint swelling, stiffness, instability, bone deformity and
muscle hypotrophy and is often associated with pain. These impairments greatly impact activities of
daily living and gait [6]. Analysis of the biomechanical consequences of OA is a prerequisite for evaluation of interventions intended to improve joint function.
Hip OA can result in a decreased ROM due to soft-tissue stiffness and structural joint changes
[21,22]. Patients with hip OA modify their gait to minimise pain, adjust to decreased hip ROM and
muscle weakness. Using 3D gait analysis, these gait adaptations in adults with symptomatic hip OA are
readily distinguishable from gait patterns in healthy adults [13].
Kubota and colleagues summarised the gait characteristics of 12 patients with bilateral symptomatic hip OA, adjusting for walking speed. Data indicated patients ambulated with an increased
cadence and ankle power generation, maintained an anterior pelvic tilt throughout gait, a dropped
pelvis during stance, and demonstrated decreased step width, hip extension and abduction angles as
well as a lower hip abduction moment [23]. In two studies assessing gait in patients with unilateral hip
OA, gait discrepancies increased when patients walked at faster speeds [24,25]. This discrepancy is
probably due to decreasing muscle forces as an adaptation to pain [26].
Gait patterns in patients operated with a total hip replacement
Twenty intervention studies were found of which seven evaluated walking function both pre- and
post-surgical treatment, 13 studies evaluated function post-treatment only. These studies are summarised in Table 1. Despite good functional outcomes, gait patterns in adults with THRs do not return to
normal 1 year after surgery [27,28]. Walking velocity was reduced among the patients with THR
compared to healthy controls as a result of shorter stride length, decreased hip exion/extension and
abduction, and diminished peak hip sagittal extension moments [29]. These differences may be
attributed to: (a) pain-avoidance strategies adopted preoperatively, (b) to concerns regarding their new
prosthesis or (c) to trunk strategies used to compensate for weak hip abductors following surgery
[30,31]. Perron et al. concluded the decrease in gait speed and the persistence of abnormal gait patterns
1 year following THR surgery were associated with a decreased hip extensor force moment and
decreased range of hip extension, respectively [32]. Even young hip replacement patients do not attain
normal gait kinematics 10 years postoperatively, indicating muscle atrophy and remaining stiffness
may affect kinematics many years after surgery [33].
With respect to various types of hip replacements, no conclusive evidence of superiority in gait has
been shown [3436]. Gait analyses have also been used to examine the impact of surgical approaches
on gait. In summary, no studies have shown any difference between the anterolateral and posterior
approach [27,3739]. To determine the impact of minimally invasive surgery on gait, Krych et al.
compared gait in patients undergoing mini-posterior THR with the two-incision approach. Patients
with the mini-posterior THR demonstrated better function, including hip exor and internal rotator
muscle strength, hip exor internal moment and longer single-leg stance during level walking at 1 year
while another study showed no benet for patients who underwent a THR through a minimally

Table 1
Summarizing interventional studies including individuals with hip, knee and ankle OA and 3D gait analysis with respect to kinematic and kinetic parameters. Studies regarding hip OA are
included in the table if they include both a pre and post, or only post-treatment evaluation. Studies regarding knee and ankle OA are included in the table if they include both a pre and post
treatment evaluation.
Follow-upc

Controld

Kinematice

Kineticf

20
17

Surgery
Surgery

O
O

O
O

Bennett et al., 2008 [33]

Foucher et al., 2007 [28]
Foucher et al., 2009 [84]
Gtze et al., 2009 [34]
Hodge et al., 1991 [85]
Klausmeier et al., 2010 [37]
Krych et al., 2011 [40]
Loizeau et al., 1995 [86]
Madsen et al., 2004 [38]
Mont et al., 2007 [35]
Nankaku et al., 2007 [30]
Nantel et al., 2009 [87]
Perron et al., 2000 [32]
Petersen et al., 2011 [36]
Pospischill et al., 2010 [41]
Queen et al., 2011 [39]
Rsler and Perka et al.,
2000 [61]
Shrader et al., 2009 [88]
Knee OA
Bejek et al., 2011 [59]

134
28
28
40
20
23
21
4
20
40
15
20
18
22
40
35
26

Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery

11 mo post
Pre and 2 days, 42 days
post
10 yrs post
Pre and 1 yr post
1 yr post
4 yrs post
30 mo post
Pre and 6, 16 w post
Pre and 2 mo, 1 yr post
4 yrs post
6 mo post
12 mo Post
4 w post
6 mo post
46 w post
6 w, 12 w post
Pre and 10 days, 12 w
Pre and 6 w post
14 w, 28 w post

O
O

O
O

O
O

O
O
O

14

Surgery

45

Surgery

Birmingham et al., 2009 [60]

Briem et al., 2009 [52]
Gaudreault et al., 2011 [50]
Haim et al., 2012 [89]
Hateld et al., 2011 [55]
Hinman et al., 2009 [48]
Kean et al., 2011 [51]
Liebensteiner et al.,
2008 [90]
Mandeville et al., 2008 [91]

128
27
29
25
42
20
14
30

Hip OA
Beaulieu et al., 2010 [31]
Bennett et al., 2006 [83]

Sample
sizea

21

Stride
parameterg

Pre and 3 mo post

Surgery
Injection
Training
Training
Surgery
Insole
Training
Surgery

Pre and
post
Pre and
Pre and
Pre and
Pre and
Pre and
Pre and
Pre and
Pre and

Surgery

Pre and 6 mo post

3, 6, 9, 12 mo
2 yrs post
3 w, 6 mo post
12 w post
3 mo, 9 mo post
1 yrs post
1 mo post
6 mo post
3 mo post

Radiographj

O
O
O
O
O

O
O
O
O
O

O
O
O

O
O
O
O
O
O
O
O

O
O
O
O
O
O
O
O
O
O

O
O
O

Self-reported
functioni

O
O
O
O
O
O
O
O
O
O
O
O
O
O

O
O

Painh

O
O
O
O
O

O
O

O
O
O
O
O
O
O
O

O
O
O
O
O
O
O
O

O
O
O
O
O
O
O

O
O
O
O
O
O
O
O

O
O
O
O
O
O
O
O

O
O
O
O
O
O
O
O

O
413

(continued on next page)

E.W. Brostrm et al. / Best Practice & Research Clinical Rheumatology 26 (2012) 409422

Interventionb

Author (yr)

Author (yr)

414

Table 1 (continued )
Sample
sizea

Follow-upc

Controld

Kinematice

Kineticf

Stride
parameterg

Pre
Pre
Pre
Pre

O
O

O
O
O
O

O
O
O
O

O
O
O

O
O
O

O
O

O
O
O

Quellet et al., 2002 [10]

Ramsey et al., 2007 [44]
Ramsey et al., 2007 [92]
Skwara et al., 2009 [53]

16
15
16
35

Sled et al., 2010 [49]

Smith et al., 2004 [93]
Smith et al., 2006 [94]
Ankle OA
Brodsky e al., 2011 [62]
Dyrby et al., 2004 [67]
Valderrabano et al., 2007 [66]

40
34
34

Surgery
Surgery
Brace
Injection,
RCT
Training
Surgery
Surgery

50
9
15

Surgery
Surgery
Surgery

and
and
and
and

2 mo post
1 yrs post
2 w post
12 w post

Pre and 8 w post

Pre and 1218 mo post
Pre and 1218 mo post

Painh

Self-reported
functioni

Radiographj

O
O
O
O

O
O
O

O
O
O

O
O
O

O
O
O

O
O
O

O
O
O

O
O
O

Number of participants included in the analysis.

b
Indicated if intervention is surgical, medical or conservative.
c
Indicated if evaluation is included pre and post or post only.
d
Healthy controls included.
e
Kinematic data included.
f
Kinetic data included.
g
Stride parameters included.
h
Pain score included, either to describe study population and/or as outcome measurement. Pain could be rated either as a separate measure, e.g. VAS, or as a separate dimension in
a measurement e.g. Harris hip score.
i
Self-reported function included, either to describe study population and/or as outcome measurement.
j
Radiographs included.

E.W. Brostrm et al. / Best Practice & Research Clinical Rheumatology 26 (2012) 409422

Interventionb

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415

invasive WatsonJones approach compared with those who were managed with a posterolateral
approach [40,41].
Typical gait deviations in individuals with knee OA
The most common location of knee OA is in the medial compartment resulting in a varus deformity
and an increased adduction moment [9,42,43]. To reduce the load of the medial compartment, patients
tend to rotate the leg outward during gait and reduce their walking speed.
Forty-four intervention studies were identied. In 17 studies, walking function was evaluated both
pre-and post-treatment and these are summarised in Table 1. Of these 17 studies, 77% had a sample size
of 20 or greater and 41% used healthy controls as the comparison. Among the studies, 81% measured
kinematics, 88% kinetics and 65% was classied radiographically. Time and distance parameters were
included in all studies and 88% used self-reported functional outcomes (Table 1).
Non-surgical interventions in persons with knee OA and their impact on gait
Eight of the 17 interventions studies included in Table 1 were non-surgical including joint injections, perturbation stimuli, braces, insoles and orthotics. Brace, shoes, insoles or canes are used to
reduce the load in knee OA, thereby decreasing pain. The decreased knee adduction excursions could
potentially reduce gait asymmetry between the braced and contralateral legs during walking (e.g.
ground reaction force (GRF) and external knee exion moment) [4446]. However, current data does
not support the use of the insoles as a mechanism to alter knee adduction moment [47,48].
In a study that examined the inuence of a home training programme targeting hip abductors,
training resulted in small but not signicant reductions in knee adduction moments compared to
controls [49]. This result is contrary to the data from Gaudreault et al. and Kean which illustrated no
effects on kinematics or kinetics after a standardised training programme [50,51].
Intra-articular injection of hyaluronic acid (HA) and triamcinolone (TA), in treatment of knee OA,
was associated with decreased pain and increased knee joint load [52,53].
Gait patterns in patients operated with a TKR and other surgeries
In a review of 11 studies, the authors concluded that patients treated with TKR have a reduced knee
motion, especially less knee exion in swing compared with controls [54]. Hateld and co-workers
showed that 42 patients after TKR had a decreased knee adduction moment at mid-stance and an
increased knee exion moment at toe-off, which indicates biomechanical improvement. However, the
moments did not reach normal values [55]. Alnahdi et al. examined the gait patterns of 31 patients with
knee OA at 6 months and 1 year after TKR [56]. Two different prosthetic concepts (posterior stabilised
and cruciate retaining) were used. Patients were examined at 6 months and 24 patients after 1 year.
The data suggested that the operated knee of patients undergoing TKR did not differ in any biomechanical aspect compared to those of healthy subjects [56].
Benedetti et al. assessed nine patients 1.5 years after TKR and identied a stiff knee pattern in
patients. This pattern was characterised by slow walking speed, reduced stride length and knee exion
during the load absorption phase [57]. Saari et al. compared concave and at cemented TKR in 83
patients 12 years after surgery. Patients with posterior stabilised insert had a lower hip-and-knee
extension moment and a reduced extension compared to controls [58]. In another study, Bejek et al.
compared conventional, computer-assisted and minimally invasive techniques, and the gait analysis
showed that there was a faster recovery in the minimally invasive TKR but at 6 and 12 months, no
differences could be seen between the groups [59].
Medial OA high tibial osteotomy (HTO) is an alternative approach to TKR. The concept behind this
operation is to reduce the load in the medial knee compartment by changing leg alignment in the
frontal plane from varus towards valgus. Two studies have shown a reduction of the knee adduction
moment after HTO reecting decreased load in the medial knee compartment that was associated with
decreased knee pain and improved function [60,61].

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Typical gait patterns in individuals with ankle and foot OA

Persons with ankle OA walk with slower self-selected speed, ranging from 0.75 to 1.10 m/s
compared to healthy subjects [6267]. Khazzam et al. reported that subjects with degenerative ankle
joint disease walk at a pace approximately 67% lower than that of healthy subjects [64]. Studies
examining cadence and stride length report varying results, but most studies demonstrate that adults
with ankle OA have signicantly fewer steps per minute and shorter stride length. Khazzam et al.
furthermore reported that patients with ankle OA demonstrated decreased dorsiexion ROM and loss
of the rst rocker also known as rapid plantar exion at loading response [64]. This alternation in gait
could be associated with ankle pain.
Adults suffering from ankle OA report low American Orthopaedic Foot and Ankle Society ankle
scores (AOFAS) and function scores (SF-36) which reect their pain, loss of motion, decreased walking
speed and limitations in activities of daily living [62,64,66].
Typical gait deviations in individuals with ankle and foot OA following surgery
Nine studies of ankle and foot OA were reviewed of which three studies evaluated walking function
pre- and post-treatment. These studies are summarised in Table 1. A study of gait in adults with ankle
OA who have undergone ankle arthrodesis or total ankle replacement (TAR) found improved temporal
spatial parameters post-TAR [62]. Houdijk et al. reported that patients post-TAR demonstrate signicantly slower walking speed [63]. Beyert et al. examined the impact of shoes in nine persons who
underwent TAR and who walked at self-selected speeds [68]. The result indicated no signicant
difference in gait patterns compared to healthy controls. However, when asked to walk fast, the
patients with OA walked slower than controls.
Valderrabano et al. showed that preoperatively movements were reduced compared to controls,
this was normalised after TAR except for the plantar exion movement and plantar exion moments
which reached 77% versus 89% of normal subjects [66]. Mechanical load, joint moments and joint
stiffness of the ankle during walking after TAR does not differ from the mechanical load for controls
[63]. Brodsky et al. evaluated gait after ankle arthrodesis noted TAR creates a more normalized gait
pattern, especially kinetics at intermediate follow-up [62]. Vertical GRFs appear to decrease in the
second peak during terminal stance after TAR and joint power is substantially lower [65,67]. Extension
dorsiexion moment is increased by 1.3% (of body weight) after TAR suggesting plantar exor muscle
function is an important outcome of surgery. Beyaert et al. in another study of gait following ankle
arthrodesis, reported that an ankle fused in a neutral position induces alterations of foot kinematics
and GRF progression during barefoot walking. These alterations can have an undesirable effect on the
joints located between the tibio-talar fusion and the metatarsal heads [68]. The use of shoes improved
greatly but did not normalize the abnormal foot dynamics. Heel height appeared to be an important
compensatory factor for patients with an ankle arthrodesis and OA.
Introduction to typical gait deviations in RA
Repeated episodes of synovitis weaken and eventually destroy joints, altering motion parameters.
These changes may be associated with laxity in early RA and stiffness and deformity later. Thus, RAassociated inammation, joint stiffness, derangement and pain may lead to gait deviations [8]. The
foot and ankle complex is highly involved in the disease process [69] and the foot also plays an
important role in weight acceptance and transfer, contributing to shock absorption, stability and equal
distribution of plantar pressure. Disruption of any of these functions impacts gait. Thus, the
predominant focus of gait analysis has been on the foot with 64% of the included studies using a foot
model or examining ankle movement [7,16,17,7074]. Fewer studies have examined the inuence of the
larger joints in the lower kinematic chain [4,8,14].
Gait deviations in RA
Seventeen studies of gait analysis in RA were identied which met the inclusion criteria for this
review. Of these, 11 studies (65%) were observational [7,8,1417,7074]. Six of the studies (34%) were

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417

interventional including: surgical interventions in individuals with ankle joint arthritis, forefoot
arthritis and gait after treatment with disease-modifying anti rheumatic drugs (DMARDs) [4,69,75
77]. One study was a randomized control trial (RCT) and evaluated the effect of custom-made
orthoses for individuals with rear foot deformity. This study showed that custom-made orthoses
reduced excessive eversion and valgus deformity. Furthermore, at 12 and 30 months follow-up, the
reduced eversion movement was sustained during barefoot walking [78].
Among all studies, only 47% had a sample size of 20 or greater and 94% used a healthy control group.
With respect to outcomes, 88% reported kinematic data, 94% time and distance parameters and 59%
evaluated kinetic aspects of gait. Self-reported function was the most often reported clinical outcome
(76%) followed by pain (65%) and disease activity (53%). In 47% of the studies, the disease duration was
more than 5 years; however, in 29% the disease duration was not mentioned (Table 2).
RA patients typically adopt an antalgic gait including reduced walking speed, cadence and stride
length. These patients demonstrate longer weight-bearing periods between the feet and reduced
ranges of motions, joint moments and joint power [8,17,71,72]. Limiting joint rotations may be one
strategy to reduce joint load over painful and unstable joints. Gait analysis is, however, most often
performed barefoot which can accelerate the problems for individuals with RA. Laroche et al., 2006,
evaluated the effect of reduced dorsiexion of hallux joint on hip and knee kinematics and kinetics and
reported a strong relationship between reduced dorsiexion and increased hip and knee exion. These
data suggest that hallux mobility should have a higher treatment priority [14].
Deviations in foot kinematics can be summarised as including: reduced ankle plantar exion,
reduced and delayed heel rise in stance, decreased ankle plantar exor moments and powers and
valgus heel deformity [16,71,73,78].
Forefoot disease, commonly known as arthritis in the metatarsalphalangeal (MTP) joints, primarily
affects late stance and includes reduced hallux dorsiexion at terminal stance and pre-swing which
affects the windlass mechanism [64]. The windlass mechanism includes dorsiexion of the hallux and
tightening of the plantar fascia to aid in stabilising the foot arch during toe-off [11]. Hindfoot disease is
characterised by an excessive heel eversion, a valgus deformity, increased internal tibial rotation,
excessive forefoot inversion and lower navicular height [73]. Researchers have suggested that hindfoot
disease affects gait more than forefoot disease [73]. When comparing patients with mainly hindfoot
disease with those with mainly forefoot disease, the hindfoot group was more everted for a longer
period of stance and the navicular height was reduced when hindfoot was involved. This is an
important measure to distinguish between forefoot and hindfoot disease [73]. In a large review that
evaluated the clinimetric quality of 78 articles of walking function in individuals with RA, Baan et al.
concluded that there was a strong consensus regarding the interpretation of gait deviations in RA
despite varying methodology [12].
Limitations of gait analysis in patients with RA and OA
There is a wide variety of motion analysis variables used in the analysis of subjects with OA and RA
and this complicates the synthesis of data across different studies [12,27,29]. Establishing a unied set
of variables for gait analysis would enable researchers to compare and contrast outcomes for various
interventions. Many studies of gait analysis conducted in adults with OA and RA use relatively small
samples and limited trials per patient [9,4244,7982]. Thus, most are underpowered. Only one study
enrolled more than 100 subjects with OA (hip, knee and ankle). Thus, the potential risk for type II error
exists. In some trials, the patient sample is heterogeneous with analyses mixed for patients with OA
and RA or combining data on patients with hip, knee and ankle surgery. In addition, the inclusion
criteria are not consistently described.
Given the data available, we recommend future researchers establish a priori the sample size
calculation when conducting gait studies. Furthermore, most studies evaluate only kinematic
parameters. Including kinetic and electromyographic variables would provide information on the
forces producing the movements and abnormal muscle activation patterns [21]. To best synthesise the
data on gait outcomes in RA and OA, we recommend the inclusion of disease severity classication via
radiographic, for example, Kellgrens, Lawrence or other measures for examples of patient reported
outcome measures (PROMs). This will allow for stratication of analysis for specic subgroups of

418

Table 2
Summarizing table of observational and interventional studies including individuals with RA and 3D gait analysis with respect to kinematic and kinetic parameter.
Sample
sizea

Designb

Controlc

Kinematicd

Canesco et al., 2011 [76]

13

Dubbeldam et al., 2011 [18]

Grndal et al., 2006 [69]

21
12

O
O

Hamilton et al., 2001 [77]

24

Khazzam et al., 2006 [64]

Laroche et al., 2006 [14]
Laroche et al., 2007 [15]
Long et al., 2003 [75]

22
9
9
10

OConnell et al., 1998 [16]

Turner et al., 2006 [71]
Turner et al., 2008 [72]
Turner et al., 2008 [73]
Weiss et al., 2007 [4]

10
12
28
74
14

Weiss et al., 2008 [8]

Woodburn et al., 2002 [74]
Woodburn et al., 2003 [78]

50
50
98

Woodburn et al., 2004 [17]

11

Intervention/Surgical/
Pre and post
Observational
Intervention/surgical/
post
Intervention/medical/
pre and post
Observational
Observational
Observational
Intervention/surgical/
pre and post
Observational
Observational
Observational
Observational
Intervention/surgical/
pre and post
Observational
Observational
Intervention/
conservative, RCT/pre
and post
Observational

Kinetice

Stride
parameterf

Paing

Self-reported
functionh

Disease
activityi

Disease
durationj

Radiographsk

O
O

O
O
O
O

O
O

O
O
O

O
O

O
O

O
O
O
O

O
O
O
O

O
O
O
O
O

O
O
O
O
O

O
O
O
O
O

O
O
O
O
O

O
O
O
O
O

O
O
O
O
O

O
O
O
O

O
O
O
O

O
O
O

O
O
O

O
O

O
O

O
O
O

O
O

O
O
O

Number of participants included in the analysis.

Observational evaluation once, Interventional evaluation pre and post or post only.
Healthy controls included.
d
Kinematic data included.
e
Kinetic data included.
f
Stride parameters included.
g
Pain score included, either to describe study population and/or as outcome measurement. Pain could be rated either as a separate measure, e.g. VAS, or as a separate dimension in
a measurement e.g. Harris hip score.
h
Self-reported function included, either to describe study population and/or as outcome measurement.
i
Disease activity included, either to describe study population and/or as outcome measurement.
j
Disease duration included.
k
Radiographs included.
b
c

E.W. Brostrm et al. / Best Practice & Research Clinical Rheumatology 26 (2012) 409422

Author (yr)

E.W. Brostrm et al. / Best Practice & Research Clinical Rheumatology 26 (2012) 409422

419

patients. The literature is also lacking regarding 3D gait evaluation of non-surgical treatments for hip,
knee, ankle OA and RA.
Summary
This chapter describes 3D gait analysis, with a focus on joint rotations (kinematics) and joint
reactions (kinetic), reviews common gait deviations in adults with RA and OA and describes changes in
gait following surgical and non-surgical interventions. 3D gait analysis provides additional detailed
information on joint moments and movements not available with standard clinical approaches. Adults
with RA and OA exhibit alterations in gait often described as reduced walking speed and cadence, and
decreased ranges of motions and moments. More clinical studies of gait in adults with knee OA exist
than in other forms of OA or RA. With some exceptions, many studies are underpowered and there is
a great variability in methodology. We recommend researchers in this eld develop a consensus in
research methodology to identify core outcome measures and standardised analytic approaches
including a consistent agreement to adjustment for walking speed.

Practice points
3D gait analysis can be used to:





establish a baseline before treatment;

evaluate interventions, for example, surgical and conservative (orthotics and braces);
patient educational purposes;
improve providers clinical gait observation skills through a greater appreciation for phases of
gait, normal gait and abnormalities; and
 complement information obtained through self-reported outcomes.

Research agenda
 Evaluation of interventions using gait analysis should include pre- and post-gait assessments,
combined with valid and reliable self-reported measures
 At an individual level, gait analysis can be a tool to guide the orthopaedic surgeon in the
selection of surgical approaches and to measure the patients physical limitations postsurgery
 Ideally, gait analysis can also provide information on abnormalities early in the disease
process before habitual patterns develop
 Larger patient and control groups are needed to reduce the risk of type II error. Clear inclusion
and exclusion criteria are required and should include information regarding conrmation of
diagnosis, number of joints involved, age, body mass index (BMI) and severity of disease
 Standardized evaluation approaches and analytical approaches (such as adjustment for
walking speed) will enable comparisons across studies.

Conict of interest statement

The authors do not have any to disclose.
Funding
No grants or funding has been applied or given in direct connection with this chapter.

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