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 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 [1–3]. These include rheumatoid arthritis (RA), spondyloarthropathy (SpA)—comprising psoriatic arthritis (PsA), axial spondylitis (ankylosing spondylitis), reactive arthritis, enteropathic arthritis and undifferentiated SpA—and juvenile idiopathic arthritis (JIA). Clinical manifestations of RA in the foot include synovitis, deformity, tendon dysfunction, peripheral arthritis, and subluxation and dislocation of the metatarsophalangeal (MTP) joints. SpA also causes dactylitis and enthesitis, with the Achilles tendon, plantar fascia and tibialis posterior tendon insertions commonly affected. Synovitis, deformity and enthesitis are prevalent in JIA. Extra-articular features of IA, including peripheral neuropathy and entrapment neuropathies, can also manifest in the foot, and the risk of peripheral arterial disease (PAD) is increased [4]. Long-term steroid use can contribute to poor tissue viability in the foot; when combined with joint deformity and poor vascular supply, the risk of tissue breakdown is significantly increased. Foot ulcers are an important consideration in IA and immunosuppression increases risk of potentially serious infection [5, 6]. Foot involvement often persists despite significant advances in the pharmacological management of IA, resulting in pain, functional impairments, reduced health-related quality of life and increased healthcare costs. Existing guidance in this area includes the Arthritis and Musculoskeletal Alliance (ARMA) Standards of Care for people with musculoskeletal foot health problems, published in 2008, the British Society of Paediatric and Adolescent Rheumatology (BSPAR) Standards of Care for children and young people with JIA (2010) [7], and the North West Podiatry Services Clinical Effectiveness Group Guidelines for the management of foot health for people with RA (2014) [8]. Considering the advances in the management of IA over the past decade, these guidelines are now outdated. The National Institute for Health and Care Excellence (NICE) guideline for managing RA in adults (2018) highlights the need to identify foot problems but does not make recommendations about specific aspects of clinical management [9]. This guideline aims to provide patient-focused, evidence-based, expert recommendations for the management of foot health in IA in the UK. This guideline was developed to assist health professionals who treat and manage people with foot problems and IA. The target audience includes 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 settings, and secondary and tertiary care. This guideline will also provide a helpful resource for people living with foot problems in IA and their carers and be relevant for those responsible for commissioning care for people with IA and foot involvement in the National Health Service (NHS). This guideline does not cover: surgical management treatment of injuries systemic drug therapies. This guideline was produced by a multidisciplinary guideline working group (GWG) of rheumatologists (E.R., P.S.H.), a paediatric rheumatologist (G.C.), orthopaedic foot and ankle surgeons (R.Re., A.L.), a specialist rheumatology nurse (S.R.), podiatrists (M.R.B., L.S.C., L.C., H.J.S., H.M., L.S., J.W.), a paediatric podiatrist (R.F.), a physiotherapist (L.B.), an orthotist (R.Ro), a general practitioner (L.W.) and people with experience of living with or caring for someone with IA (A.R., S.V., J.D.). An additional lay member withdrew from the guideline development process due to personal circumstances. Guideline development was led by E.R., who chaired the GWG. M.R.B. was the deputy chair. L.S.C. led the preparation of the written guideline. The systematic literature review was conducted by two researchers with evidence synthesis expertise (N.C., D.vd.W.). This guideline was developed in line with the British Society for Rheumatology (BSR) Guidelines Protocol (version 5.4, November 2023) using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to determine certainty in the evidence for each guideline question. The guideline covers foot problems (including pain, deformity, nail and skin pathologies, ulceration, PAD and neuropathy) in people with RA, SpA and JIA. The full guideline scope was published previously [10]. Nineteen key clinical questions (Table 1) were developed through consensus among GWG members to guide a systematic literature review. 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) and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) [11] (Supplementary Table S1, available at Rheumatology online). An information specialist (N.C.) designed and conducted systematic searches across nine bibliographic databases (MEDLINE, EMBASE, HMIC, AMED, EMCARE [all OVID]; CINHALPlus [EBSCO]; Cochrane Library; Epistemonikos and Pedro) from database inception to 21 September 2022. A broad search was completed using both subject headings and text word searching, combining terms for IA and foot/ankle (see Supplementary Table S2, available at Rheumatology online, for all database searches). This enabled a single search to be carried out in each database to cover all guideline research questions. No date or language restrictions were applied. In addition, the reference lists of relevant systematic reviews identified during screening were checked, and conference abstracts from the BSR, European Alliance of Associations for Rheumatology (EULAR), American College of Rheumatology and the Royal College of Podiatry were hand searched for 2021 and 2022 to identify relevant emerging evidence. The results of each search were downloaded into Endnote™ 20 (reference management software; Clarivate Analytics, available at www.endnote.com) to facilitate deduplication, and the resulting unique records imported into Rayyan [12], available at www.rayyan.ai for title screening, and then Covidence systematic review software (Veritas Health Innovation, available at www.covidence.org) for abstract and full text screening. Studies were included if they concerned adults, children or young people with suspected or confirmed IA. Recent secondary evidence (2018 onwards), i.e. meta-analyses, systematic reviews, and umbrella reviews were included, as well as primary research: randomized controlled trials (RCTs) of any design; secondary, post-hoc, and sub-group analyses of individual RCTs, and RCT extension studies. were for or were not i.e. for questions to or controlled and were In addition, published conference abstracts of primary or secondary research from 2021 with and clinical were including trials records and were as well as full in any language an A of and is in Supplementary Table available at Rheumatology online. were and then full were by with by a to were by a A was and to for were the healthcare and of the of the of and were were the reference target and of or was by and by a for and were by a if Cochrane of was to risk of for and controlled clinical and relevant were from the In Studies were for each guideline in Supplementary available at Rheumatology online. evidence was or were of relevant was to evidence across for each guideline and for each of or for adults or and for each was to risk of or guidance for evidence was for evidence of and for or of and (see Supplementary Table available at Rheumatology online). of the GWG to review and determine The of evidence of and certainty in the evidence (GRADE) the of the but including and to treatment or and the A of was for each by working group members in at the the specific was The for each was as or A in of an was when the the or for all or when and are or they are the the of recommendations was to the full GWG for review. in the was by all members and to a to of a of to using the GWG members then each the and the was to an The of each was all members a of at members they not clinical to specific recommendations 20 or they with each they not to each and not contribute to the for The guideline is to be each by the literature provide the recommendations by the or of evidence or and the across the GWG The of a summary of the evidence the In adults, children and young people with suspected or confirmed IA, questions to foot be at each if clinical of the foot be including disease foot musculoskeletal range of vascular and and skin and nail The is evidence from and expert Clinical be and by and Foot a clinical an of disease including of the foot for and is evidence from for the of the joint to identify in with suspected IA, but the to Foot and be and any be for also be for and and The of and range of in the and be in to the quality of this and be for pathologies, including skin disease and An of vascular to for and be the increased risk of vascular disease and peripheral neuropathy in IA. can be with if (see The questions to foot be at each was in to evidence people with IA are about their In children and young people with IA and be into consideration when foot The foot be as of the Arthritis and the paediatric and screening The is when are of disease and includes an of and foot Health professionals managing adults, children and young people with suspected or confirmed IA to (including and to foot to clinical This is evidence from and and by expert can and of foot health in IA in the of clinical and a full foot health in adults, children and young people with IA, consideration be to provide additional information with clinical The of for foot health in IA is is or be the clinical In the and in IA, and are for in disease is the reference for and in IA and is for the of inflammation foot health is evidence for the use of and In adults with RA, and can be to inflammation and In a children with JIA was to potentially the of clinical of the with clinical be to the of to and is and is who a to in IA guidelines be including guidelines for the and management of RA and Rheumatology European Society to for the use of in the and management of JIA in clinical In adults with suspected RA and synovitis, of the of foot In adults with confirmed RA, of the and is to are these were to [9]. The guideline for the and management of in over of be for suspected and of the and and suspected enthesitis be if a be from guidelines for SpA when peripheral SpA is or be to peripheral enthesitis, peripheral arthritis, and and to disease and in peripheral clinical and In peripheral if the clinical of then is but provide additional In and are as in disease their increased over clinical and In adults, children and young people with foot problems in IA, to specialist foot be at any of the disease they of and quality of Foot problems include but are not to pain, joint deformity, risk of is evidence to to specialist for adults, children and young people with foot problems in this is expert and evidence from studies. In this specialist foot refer to foot with experience of managing foot problems in people with IA as or orthopaedic specialist people with IA are by health professionals with and with IA a to be in an to foot problems with foot problems in IA reported in foot with in to a and the need for to foot health and for be to adults, children and young people with IA, and their members and at and an and be by any member of the rheumatology multidisciplinary include IA and the about skin and nail and to additional of who to about foot problems, and the of podiatrists and These recommendations are by expert and evidence underpinning recommendations in this guideline. and for are key of care in conditions and are in the management of adults, children and young people with IA. The of foot health and in IA not RCT a for foot health care in any systemic conditions foot in the with In and adults with RA a for of foot health the of of foot health for people with IA Foot health and be at and at by any member of the rheumatology The guideline for be into consideration during any adults, children and young people with foot problems in IA be to in their and to their and health professionals be to a or and the and be by this children and young people with foot problems in IA to to and or by a health A can a or a to the of the of of foot in the The GWG a to be a to a foot this is in to a or is to the of an The to is any or to individual (including a by a health with The is individual RCTs, systematic reviews and meta-analyses, foot be in foot pain, and plantar in adults with RA also functional be available for adults with RA if [9]. is evidence for the of foot for children with a systematic review of two found evidence of the of foot and quality of life in children with JIA but a RCT found foot be in and foot over in children with JIA the of the is to a RCT for of be with to and with or are available in and can be with often evidence the of of is available are be at and in adults, children and young people with foot problems in IA. The of for adults, children and young people with foot problems in IA be into A be to and include as and of the and systematic reviews the clinical of for adults with RA is evidence as and or foot pain, and and plantar guidance be available for adults with RA [9]. from the GWG was adults, children and young people with IA significant foot deformity be to foot with available with and a and a the of for adults with significant foot deformity in RA are well in with in terms of poor of the and of This often results in poor can among involvement during the process of can The guideline for be in the of and adults, children and young people with IA be involved in about and the of into consideration their individual and including be to adults, children and young people with foot problems in IA, if a (see The of for foot problems in IA in clinical studies. at risk of was reduced and and in adults with IA, but the GWG this of quality to their the is expert consensus A the of ankle range of and functional in children with JIA found significant is evidence for for adults, children and young people with foot in IA. included in in adults in RA is evidence to the use of and for adults, children and young people with foot problems in IA In or suspected ulceration, not be in additional and foot be The of of plantar in adults with RA in two and a In the RCTs, over for or functional and over a In the all reported with an in of but the treatment was by and not a significant The for and foot are in recommendations and this guideline. when be by with specialist No to of plantar in adults with of IA or children and young people with IA. of the GWG with expertise inflammatory in not be GWG members with experience to children and young people with IA reported they with In the of suspected ulceration, of be to the and of the for infection and is a risk for foot in people with and be are and and can be for the of skin the foot in IA. The of for foot health in IA not in clinical are for skin conditions and for skin the the of and for plantar for people with foot problems in are also for people with to and for the of the The is expert use of in and risk of be to problems by people with IA, as hand problems, make the of adults or children and young people with IA be nail care including to treat be when to foot for for and and to of disease is the of including joint disease and skin and nail disease in Foot skin and nail health be and in the of systemic In the of or surgical of can be are in the general and include and These can infection and additional in people with IA who are be to the of and when and to a specialist foot (see In are systemic treatment be and be for the treatment of nail disease in people with to be guidelines for psoriatic nail disease and and and systemic and can also be foot skin disease in guidelines when is area or foot is to a review of systemic disease with and and be for not or are to with care. infection is be and and be with from the rheumatology is evidence for of nail over in IA or be a children and young people with IA and foot be to an health of adults, children and young people with IA and foot include and disease in the of their IA, and their management include of of or or as treatment for infection IA disease be the of the guideline, the GWG a as any area of skin is or and as a for foot in IA are a found a of and an of is evidence for the management of foot in recommendations are evidence for managing foot and expert research people with RA foot to and and when to to in with or at risk of foot be and when to a health the health who a and the rheumatology with to is important to is not in Foot in RA the in the causes of foot in IA include and The of foot management include and of the often involved to of tissue treatment of treatment of and The management of foot infection in people with IA who are due to systemic drug treatment can be as of infection be of a can be infection is and in the of infection be with the rheumatology with guidance available in the guidelines for and and of of systemic can disease and with the rheumatology disease management is are and and can be as an for the of inflammation and in the foot in IA. guidance using or be and available if and young people be to general or in a paediatric are in clinical to inflammation and in the foot in IA, to or as a The is expert evidence for the of for adults with enthesitis, and in IA in a systematic review of trials and of for The GWG the of or and to and evidence are in the foot is the GWG the of including increased of are to and and to of the is not the by with systemic or clinical steroid or steroid is also evidence from for in and a clinical in the ankle and in children and young people with JIA about of joint with in people with but is evidence in people with IA. recommendations for in the joint the of evidence to this as and of and during and can be when in children and young people with IA be in children or those are well and serious are include and of No serious during the or for all included in the systematic review of the A of reported a during the and developed at the of the of is also in in IA with evidence from for in joint disease and is evidence to any specific over in the foot In adults, children and young people with IA, the of inflammatory foot pain, or suspected the of systemic disease and a review of systemic disease The ankle and foot are to in IA. In the of evidence for systemic disease in the foot, this is expert and evidence for systemic disease reviews in IA The of inflammatory foot pain, or suspected are of poor disease of the of inflammation are and by children and young people with IA be who to if they about and to about this of for a rheumatology line or In foot the to or treatment be in the of the In adults or children and young people with foot problems in IA, surgical be is pain, risk of ulceration, joint deformity at the or and when multidisciplinary care or is to be is evidence when to surgical this is expert management is for people with IA. for surgical be in is significant or deformity and the is to a into commissioning and to also be an for In children and young people with foot problems in IA, the for surgical is and the range of surgical is a surgical and to the be at the of the and an includes surgical and the and of each be The cover an the be information the and and for systemic IA be (see and in not at In specialist foot include a this can surgical at an No specific recommendations were in foot and ankle including nail Existing guidelines for and and of be and from the rheumatology can be The guideline the need to the of by the the risk of a to when at the specific and to the when is all and are and is evidence of The guideline not be in the be for guidelines are to are specific guidelines for children and young people with for foot and ankle surgical in children and young people with IA be a In the of nail consideration be to the of Existing guidelines and be in the of serious infection but can be the infection In adults, children and young people with confirmed IA, questions to foot be at each if clinical of the foot be including disease foot musculoskeletal range of vascular and and skin and nail The for this is to be about foot at by any member of the and as In young people with IA who from paediatric to a multidisciplinary to foot health be a of the is evidence for the of foot health in the is expert care is as the process of a young healthcare from a to an care the and of young the young people with IA be to information and to foot health and of to foot health at each and recommendations for the care of young people with and National into and recommendations be or children and young people with foot problems in IA be and to guidelines for people with IA. This include and management of foot health including or children and young people with foot problems in IA be and to or children and young people with foot problems in IA be and to is evidence for or in to foot health in IA. from literature for IA in general is and and pain, and quality of and potentially disease recommendations for in people with IA and for and to of and musculoskeletal and guidelines for management and RA management be and as of the need for the of is for a and is in to adults, children and young people with foot in IA, be during a systemic The management of foot among people who are to be using a or the use of and management of foot health will people to their The of inflammation and disease in IA are well is a risk for PAD the risk of is in people with IA The guideline to and is for people with foot in IA The to also is among children and young people and is with foot in the general The of inflammation and disease and the of is well in IA can in IA people with IA for a and those who are or with health professionals to controlled and through and increased This guideline a to clinical with any guideline, individual can clinical health professionals to with to make about care. to to this guideline not be to these recommendations a a of to of the guideline in the are the GWG to including in to the to specialist foot is the is and to these specialist will rheumatology expertise in specialist foot and foot and ankle expertise in surgical and clinical commissioning will also in also to guideline the to refer to surgeons or scope practitioners, and care need to be designed to the of of the foot health in IA (Supplementary File available at Rheumatology with a of to a or is to with the guideline. in this guideline are expert consensus and the of evidence. RCTs, with and are to determine the and of for adults, children and young people with foot problems in IA. The recommendations for by the are in Table research recommendations are in Supplementary Table available at Rheumatology online. for research are not in A or is to the of an for research are not in A or is to the of an Supplementary is available at Rheumatology online. are available in the guideline and No specific was from any in the or to out the in this The recommendations in this guideline were developed any or any L.S.C. is by a Health Institute for Health Clinical 1) from for from 1) from from from to an arthritis for Musculoskeletal Clinical is by Health The are those of the and not those of the or the of Health and from from for was for the 2022 guideline. The of The GWG and for their into the systematic review underpinning this guideline. A of Guideline Group members can be found in Supplementary File S2, available at Rheumatology online.

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