Executive Summary: The British Society for Rheumatology guideline for the management of foot health in inflammatory arthritis

The guideline was developed in line with the British Society for Rheumatology (BSR) Guidelines Protocol (version 5.4, November 2023). A lay summary of this guideline can be found in Supplementary File S1, available at Rheumatology online. Foot problems are highly prevalent in adults, children and young people with inflammatory arthritis (IA), an umbrella term encompassing a range of chronic, autoimmune conditions characterized by joint inflammation. These include rheumatoid arthritis (RA), spondyloarthritis (SpA)—comprising psoriatic arthritis (PsA), axial SpA (ankylosing spondylitis), reactive arthritis, enteropathic arthritis and undifferentiated SpA—and juvenile idiopathic arthritis (JIA). Existing guidelines relevant to foot health in IA are outdated or lack specific guidance for treatments [1–3]. This guideline aims to provide patient-focused, evidence-based, expert recommendations for the management of foot health in IA in the UK. Rheumatologists, general practitioners, orthopaedic surgeons, allied health professionals (such as podiatrists, orthotists, physiotherapists and occupational therapists) and specialist rheumatology nurses involved in the management of people with foot problems in IA, in primary care and community, secondary and tertiary care settings. People living with foot problems in IA and their carers. Clinical commissioners. Surgical management. Treatment of traumatic foot injuries. Systemic drug therapies. Nineteen clinical questions (Table 1) were developed through consensus between GWG members to guide a systematic literature review, as published previously [1]. The guideline covers foot problems (including pain, deformity, nail and skin pathologies, ulceration, peripheral arterial disease and neuropathy) in people with RA, SpA and JIA. Throughout the guideline, the terms ‘foot health’ and ‘foot problems’ refer to the entire foot and ankle complex. Key clinical questions Key clinical questions The systematic review underpinning the guideline was registered in PROSPERO (ID CRD42023423109). The search strategy is included in Supplementary Table S1, available at Rheumatology online. Guideline development followed the BSR Guidelines protocol using GRADE methodology to determine certainty in the evidence and strength of recommendation (SOR). The level of certainty in evidence (LOE) was determined as high (A), moderate (B) or low/very low (C), reflecting the confidence in the estimates of benefits or harm. Recommendations were categorized as strong (1) and in favour of an intervention when the benefits clearly outweigh the risks (or vice versa for recommendations against), or weak (2) when risks and benefits are more closely balanced or where they are more uncertain. The wording of each recommendation was agreed by all members and subjected to a vote for strength of agreement (SOA) on a scale of 1–100 (no to complete agreement). Evidence tables are presented in Supplementary Tables S2–S19, available at Rheumatology online. The guideline is expected to be updated after five years. 1. In adults, children and young people with suspected or confirmed IA, questions relating to foot symptoms should be asked at each visit and, if appropriate, clinical examination of the foot should be undertaken, including disease activity, deformities, foot posture, musculoskeletal function, gait assessment, footwear, range of motion, vascular and neurological status, and skin and nail pathologies. SOR: 1; LOE: B/C; SOA: 92. The SOR is based on cross-sectional studies and expert consensus. Clinical assessment should be patient-centred and guided by symptoms and concerns; foot symptoms should prompt a detailed assessment of disease activity, including palpation of the foot joints for localized swelling and tenderness. There is weak evidence from cross-sectional studies for the specificity of the MTP joint squeeze test to identify synovitis in patients with suspected IA, but the test has been shown to lack sensitivity [4–6]. Foot posture, deformities, gait, range of motion, skin, toenails, and neurological and vascular status should be assessed, and footwear/insoles physically examined. In children and young people with IA specifically, age and developmental stage should be considered. Foot joints should be assessed as part of Juvenile Arthritis Disease Activity Score-71 (JADAS-71) [7] and paediatric Gait Arms Legs and SPine (pGALS) screening [8]. 2. Health professionals managing adults, children and young people with suspected or confirmed IA should have access to appropriate imaging (including X-ray, ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI)) to assess foot health, to inform clinical management. SOR: 1; LOE: B/C; SOA: 99. The SOR is based on cross-sectional, cohort and case-control studies, and expert opinion. X-ray, CT, US or MRI may be most appropriate depending on the clinical scenario. MRI is considered the reference standard modality for imaging synovitis and tenosynovitis in IA, and is more sensitive than conventional radiographs for the detection of inflammation [9]. To assess foot health specifically, there is weak evidence for the use of MRI and US [10–12]. Anyone who performs US should undertake a recognized formal training programme [13]. Recommendations relating to imaging in other IA guidelines should be considered [3, 14–16]. 3. In adults, children and young people with foot problems in IA, prompt referral to specialist foot services, e.g. podiatry, should be considered at any stage of the disease course where they impact on activities of daily living, participation and quality of life. Foot problems include but are not limited to pain, joint damage, deformity, risk of ulceration and/or footwear difficulties. SOR: 1; LOE: C; SOA: 98. In this context, specialist foot services refer to foot services with experience of managing foot problems in people with IA such as podiatry, orthotics or orthopaedic surgery. The SOR is based on expert opinion and indirect evidence from qualitative studies [17–19]. 4. Individually tailored, culturally sensitive foot health education and support for self-management should be offered to adults, children and young people with IA, and their family members and carers, at diagnosis and on an ongoing basis. SOR: 1; LOE: C; SOA: 97. 5. Education and self-management support could be offered by any member of the rheumatology MDT. SOR: 1; LOE: C; SOA: 95. 6. Information could include how IA and medications affect the feet, advice about skin and wounds, nail care, footwear and/or physical activity, exercise and pacing, self-management advice, signposting to additional sources of support, who to contact about foot problems, and the role of podiatrists and orthotists. SOR: 1; LOE: C; SOA: 99. The effectiveness of foot health education and self-management support in IA has not been formally assessed. One randomised controlled trial (RCT) comparing a self-management program for foot health against usual care in participants without any systemic conditions demonstrated better foot disability scores in the self-management group, with similar cost-effectiveness [20]. Qualitative studies and surveys [21–23] highlight a preference of people with IA for receiving foot health education shortly after diagnosis and insufficient provision of foot health education. Foot health advice and self-management support should be discussed at diagnosis and reinforced at follow-up appointment by any member of the rheumatology multidisciplinary team (MDT), following the NICE guideline for shared decision-making [24]. Additionally, health professionals should be sensitive to a person’s cultural identity or heritage and the beliefs and conventions that might be determined by this, when providing information [25]. 7. Adults, children and young people with foot problems in IA should have access to customized orthoses to reduce pain and improve function, recommended or prescribed by a health professional. A customized orthosis can comprise a fully bespoke device or a modified prefabricated orthosis tailored to meet the needs of the patient. SOR: 1; LOE: B/C; SOA: 99. The GWG agreed that a prefabricated orthosis is a device that has been mass-produced to a generic foot shape; this is in contrast to a custom-made or fully bespoke orthosis which is specifically manufactured to the shape of an individual’s foot. The customized orthosis referred to here is any device that has been tailored, adapted or modified to meet individual needs (including a prefabricated device that has been selected following assessment by a health professional with expertise). The SOR is based on systematic reviews and meta-analyses indicating that customized foot orthoses may be beneficial in reducing foot pain, improving function and decreasing plantar pressure in adults with RA [26–28]. NICE also recommended that functional orthoses should be available for adults with RA if indicated [3]. There is weak evidence for the effectiveness of foot orthoses for children with IA [29, 30]. Accessibility and cost should be considered. Prefabricated orthoses are readily available and can usually be provided instantly, whereas bespoke orthoses often require multiple visits. Limited data suggest prefabricated orthoses are more cost-effective [31]. 8. Therapeutic footwear may be effective at reducing pain and improving function in adults, children and young people with foot problems in IA. SOR: 2; LOE: C; SOA: 97. 9. The acceptability of therapeutic footwear for adults, children and young people with foot problems in IA should be taken into account. SOR: 1; LOE: C; SOA: 92. 10. A shared decision-making approach should be adopted to inform acceptability and may include factors such as comfort and fit, style, fastening mechanism, weight of the footwear, seasonality and cultural sensitivity. SOR: 1; LOE: C; SOA: 98. Two systematic reviews found limited evidence that therapeutic footwear, such as extra-depth and extra-width off-the-shelf shoes, or custom-made footwear, improves outcomes in people with RA [32, 33]. NICE guidance recommends therapeutic footwear should be available for adults with RA [3]. Adults, children and young people with IA without significant foot deformity should be supported to self-manage foot symptoms with appropriate commercially available footwear (e.g. footwear with adequate width and depth, arch support, a firm heel counter and a fastening mechanism). Acceptability of custom-made footwear can be limited by poor fit, aesthetics, shoe weight and comfort, which can be addressed by patient involvement in the design [34]. The NICE guideline for shared decision-making should be considered in the context of footwear provision and advice [24]; adults, children and young people with IA should be involved in decisions about therapeutic footwear, and choice of footwear should take into consideration their individual preferences, beliefs and values. 11. Individually tailored exercises should be offered to adults, children and young people with foot problems in IA, if indicated after a comprehensive holistic assessment (see Recommendation 1). SOR: 1; LOE: C; SOA: 96. The role of targeted exercises for foot problems in IA has rarely been formally evaluated in clinical studies [35]. The SOR is based on expert consensus. There is currently insufficient evidence to recommend the use of electrophysical therapies (e.g. extracorporeal shockwave therapy, low level laser therapy) for adults, children and young people with foot problems in IA. 12. In patients without diabetes or suspected ulceration, callus debridement should not be routinely offered in isolation; additional treatments (e.g. education and self-management advice, foot orthoses, footwear, emollients) should be used. SOR: 1 (against); LOE: C; SOA: 98. Two RCTs concluded that sharp scalpel debridement had no benefits over sham debridement in adults with IA [36, 37]. In a small prospective cohort study (n = 8), treatment effect was lost by seven days [38]. The rationale for adjunctive treatments are discussed under Recommendations 4–10 and 13. No studies have been undertaken in adults with other types of IA, or children and young people with IA. GWG members with podiatric expertise agreed that inflammatory callus margins in PsA should not be debrided. In the case of suspected ulceration, and in people with diabetes, sharp scalpel debridement of overlying callus should be performed to reveal the size and nature of the ulcer, assess for infection and promote healing [39]. Additionally, callus is a risk factor for foot ulceration in people with diabetes, and sharp scalpel debridement should be performed [40]. Sharp debridement, when required, should only be undertaken by competent practitioners with specialist training. 13. Emollients are safe and effective, and can be offered for the relief of dry skin affecting the foot in IA. SOR: 1; LOE: C; SOA: 96. The effectiveness of emollients for foot health in IA has not been formally evaluated in clinical studies. Emollients are widely recommended for other conditions (e.g. in eczema and diabetes) [41], and risk of harm is low. Consideration should be given to other physical problems experienced by some people with IA, such as hand problems, which could make the application of emollients difficult. 14. All adults or children and young people with IA should be offered personalized nail care advice, including footwear advice, to help prevent and/or treat common toenail pathologies. People should be advised when to access foot health care, e.g. for ingrowing toenails, wounds and infections, and how to do this. SOR: 2; LOE: C; SOA: 99. 15. Systemic control of disease activity is the aim of treatment, including joint disease and extra-articular manifestations, e.g. skin and nail disease in psoriatic arthritis. Foot skin and nail health should be assessed and managed in the context of systemic disease. SOR: 1; LOE: C; SOA: 98. 16. In the presence of recurrent pain or infection, surgical removal of nails can be considered. SOR: 2; LOE: C; SOA: 96. Consideration should be given to the appropriateness of self-management of toenail pathologies, and when and how to access specialist foot services (see Recommendation 3). In PsA, where multiple nails are pathological, systemic rather than local treatment should be considered and dermatology input should be sought. Widespread psoriasis, or foot psoriasis that is unresponsive to topical treatment, should prompt a review of systemic disease management [42]. Nail surgery should be considered for toenail pathologies that do not or are thought unlikely to resolve with conservative care. When infection is present, antibiotics should be considered and DMARD/biologic therapy suspended [43, 44], with input from the rheumatology MDT. There is no evidence for one type of nail avulsion surgery procedure over another in IA or generally [45]; matrixectomy should therefore be considered on a case-by-case basis. 17. Adults, children and young people with IA and foot ulceration should be able to access an appropriate health professional(s) promptly. SOR: 2; LOE: C; SOA: 99. 18. Assessment of adults, children and young people with IA and foot ulceration should include causation, infection, wound severity and disease activity, in the context of their IA, comorbidities and their treatment. SOR: 2; LOE: C; SOA: 99. 19. Wound management could include wound cleansing, removal of devitalized tissue, application of topical medicinal products or dressings, or offloading, as appropriate. Systemic treatment for infection and/or IA disease activity should be considered. SOR: 2; LOE: C; SOA: 98. Recommendations are based on evidence for managing foot ulceration generally and expert opinion. Patients with or at high risk of foot ulceration should be advised how and when to access a health professional. Patient education regarding how to access a health professional is pertinent. Timely communication between the health professional who first identifies a wound and the rheumatology MDT ensures ulceration is not managed in isolation. Foot ulcer management principles include offloading, restoration of tissue perfusion, treatment of infection, treatment of comorbidities, local ulcer care, patient education and ulcer prevention [46]. Collection of a wound sample can be considered where infection is clinically suspected. Stopping conventional synthetic DMARDs (csDMARDs) and biologic DMARDs (bDMARDs) in the presence of infection should be discussed with the rheumatology MDT, with further guidance available in the BSR guidelines for bDMARD safety [43] and prescribing and monitoring of non-biologic DMARDs [44]. 20. Local corticosteroid injections are safe and effective, and can be offered as an adjunct for the relief of inflammation and pain in the foot in IA. Image guidance using radiology or ultrasound should be considered and available if needed. SOR: 1; LOE: C; SOA: 98. 21. Children and young people undergoing local corticosteroid injection should be offered access to general anaesthesia or conscious sedation in a suitable paediatric environment. SOR: 1; LOE: C; SOA: 99. Weak evidence for the effectiveness of injections on foot pain in adults with IA has been demonstrated in a systematic review of and one trial The GWG the effectiveness of and injections to reduce pain and inflammation. evidence of the effectiveness of over injections in the foot is injections more injection of that are to access and of other RCTs at other joint do not that injections are more effective than systemic or corticosteroid injections or sham corticosteroid There is weak evidence from studies of outcomes following local corticosteroid ankle and joint injections in children and young people with sedation safe and effective relief of pain and injections and can be considered in children and young people with IA anaesthesia may be more suitable in (e.g. children or for multiple Local corticosteroid injections are are is standard in other joints in IA (e.g. with evidence from RCTs for outcomes In adults, children and young people with IA, the presence of inflammatory foot pain, or and/or suspected swelling should the of systemic disease and prompt a review of systemic disease SOR: 1; LOE: C; SOA: The ankle and foot joints are to in IA. The SOR is based on expert opinion and evidence for systemic disease control reviews in IA generally The presence of inflammatory foot pain, or and/or suspected swelling are of poor disease after and by activity the of inflammation. Adults, children and young people with IA should be advised who and how to contact if they have about In adults or children and young people with foot problems in IA, prompt surgical referral should be considered where there is pain, risk of ulceration, joint and/or deformity at the or and usually when multidisciplinary care has or is considered unlikely to be SOR: 2; LOE: C; SOA: 99. There is no evidence when to surgical conservative management is usually appropriate. referral for surgical opinion should be considered in e.g. significant pain or deformity, into that and to off-the-shelf footwear may also be considered an for surgery. In children and young people with foot problems in IA, surgical referral is No specific recommendations were regarding in patients foot and ankle including nail BSR guidelines [43, should be followed and advice from the rheumatology MDT can be sought. In adults, children and young people with confirmed IA, questions relating to foot symptoms should be asked at each visit and, if appropriate, clinical examination of the foot should be undertaken, including disease activity, deformities, foot posture, musculoskeletal function, footwear, gait, range of motion, vascular and neurological status, and skin and nail pathologies. SOR: 1; LOE: B/C; SOA: 92. Recommendation 1. In young people with IA who from paediatric to care, a multidisciplinary approach to foot health should be considered a of the SOR: 2; LOE: C; SOA: 98. There is no evidence for the of foot health in the SOR is based on expert opinion. To care, young people with IA should be to information relating to foot health, and of how to access foot health services, at each for for Rheumatology Rheumatology Society and into Patient and recommendations should be considered. or children and young people with foot problems in IA should be and supported to meet physical activity guidelines for people with IA. This may include assessment and management of foot health including appropriate SOR: 1; LOE: C; SOA: 98. or children and young people with foot problems in IA should be and supported to where appropriate. SOR: 1; LOE: C; SOA: 99. or children and young people with foot problems in IA should be and supported to weight where appropriate. SOR: 1; LOE: C; SOA: 99. There is no evidence for physical activity, or weight specifically in to foot health in IA. Evidence from literature for IA in general that physical activity is safe and and improves pain, function, and quality of and disease The management of foot pain people who are to more should be considered using a personalized e.g. physical activity or the use of customized assessment and management of foot health needs therefore help people to meet their activity The of and on inflammation and disease activity in IA are recommendations for physical activity in people with IA and for and participation to prevent of and musculoskeletal and NICE guidelines for weight management and RA management should be considered. The NICE guideline relating to and is also for people with foot symptoms in IA This guideline the lack of evidence available to inform the management of foot health in IA, with an of RCTs in most treatment Recommendations in this guideline are therefore based on expert consensus and studies. with adequate sample and are to determine the and cost-effectiveness of treatments for adults, children and young people with foot problems in IA (see recommendations for in Supplementary is available at Rheumatology online. are available in the guideline and No specific was from any in the or to the in this is by a Health Education for Health Clinical has (1) from (2) for from has (1) from (2) from has from to an on arthritis for Clinical is by Health Education The are of the and not of the or the of Health and has from has from for was for the NICE The have no of The GWG and for their input into the systematic review underpinning this A of British Society for Rheumatology Guideline members can be found in Supplementary File available at Rheumatology online.

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