Rheumatoid Arthritis Patient with Severe Forefoot Deformity and Limited Hand Function
A 64-year-old woman with seropositive rheumatoid arthritis (20-year history) presents with bilateral hallux valgus, lateral deviation of the lesser toes, and painful plantar calluses under the second and third metatarsal heads. She has had two metatarsal head resections on the right foot. Her wrists are fused in neutral, grip strength is poor, and she cannot reach her feet to don shoes or fasteners. She lives alone, uses a rollator, and has a 15-step flight to her apartment. Current footwear: slip-on canvas shoes with a worn-out sole. She reports forefoot pain at 4/10 at rest and 7/10 after 10 minutes of walking. She has tried off-the-shelf gel inserts without relief. Her rheumatologist has cleared her for orthotic management and wants to avoid further surgery if possible.
1. Design an orthotic and footwear plan that addresses her forefoot pain, deformity, and inability to don devices independently.
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The plan must solve three problems simultaneously: pressure relief at the metatarsal heads, accommodation of the deformed forefoot, and independent donning.
Pressure relief: A total-contact insert with a metatarsal pad placed proximal to the second and third metatarsal heads, plus a relief or recess under the resected areas. Because she has had metatarsal head resections on the right, the right insert needs a deeper accommodation zone to prevent the remaining bony prominences from bearing load. Use a semi-rigid shell (e.g., cork or EVA of appropriate density) so the foot does not sink into the relief and negate it. A rocker-bottom sole reduces demand on the forefoot during push-off.
Accommodation: Extra-depth shoes with a wide, high toe box to accommodate hallux valgus and lateral toe deviation. Soft, seam-free lining. The shoe must fit the deformed forefoot without pressure at the first MTP and the fifth toe.
Independent donning: This is the deciding constraint. She cannot reach her feet or manage laces or straps. Options: a shoe with a long-handled shoehorn and elastic laces, or a slip-on design with a rear pull tab; a flexible, wide-opening shoe. A custom device that requires precise placement she cannot achieve is a failed device. Consider a molded insert that stays in the shoe (not removable) so she only has to step in. If she cannot don even slip-ons, a home visit or OT referral for adaptive equipment (sock aid, long-handled shoehorn) is warranted.
Safety: The 15-step flight and rollator use mean the shoe must have a stable, non-slip sole and a secure fit; a loose slip-on is a fall risk. Follow up in 2 weeks to check skin and donning, then adjust.
2. She asks whether custom orthotics will "straighten her toes." How do you answer, and what outcome measures would you use to judge success?
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Answer to the patient: Custom orthotics will not straighten her toes or reverse the deformity. In rheumatoid arthritis, the hallux valgus and lateral toe deviation are driven by joint destruction, ligamentous laxity, and tendon imbalance; an insert cannot correct that. What orthotics and footwear can do is redistribute pressure away from painful metatarsal heads, accommodate the deformed shape so shoes do not press on prominences, and reduce pain with walking. Setting that expectation honestly prevents disappointment and supports adherence.
Outcome measures to judge success:
- Pain: numeric rating scale at rest and after a defined walk (e.g., 10 minutes), compared with her baseline 4/10 and 7/10.
- Function: distance or time walked before pain; ability to complete the 15-step flight and use the rollator comfortably.
- Skin: resolution or improvement of plantar calluses under the second and third metatarsal heads; no new lesions.
- Donning independence: can she put the shoes on and take them off alone, and how long does it take?
- Adherence: is she actually wearing them daily? A device she cannot don will show zero wear.
- Shoe fit: no redness at the first MTP or fifth toe after wear.
Reassess at 2 weeks and 6 weeks. If pain does not improve with a well-made insert and extra-depth shoe, refer back to rheumatology or orthopedics for consideration of further forefoot surgery, since orthotic management has limits in advanced RA deformity.