2025 BSR Guideline: Foot‑Health‑Management in Inflammatory Arthritis (Summary)

Rheumatology (Oxford), May 2025；DOI:10.1093/rheumatology/keaf071 First‑ever dedicated BSR foot‑health guideline for inflammatory‑arthritis(IA); multidisciplinary task‑force: rheumatologists, podiatrists, physiotherapists, orthotists, patient‑representatives；statement‑agreement ≥ 96 %‑99 %Oxford Aca...

Abstract

Objective This is the first BSR‑specific guideline addressing foot‑involvement across inflammatory‑arthritis including rheumatoid‑arthritis(RA), spondyloarthritis(SpA, psoriatic‑arthritis, axial‑SpA) and juvenile‑idiopathic‑arthritis(JIA) for adults, children and young‑peopleOxford Aca.... Foot symptoms (pain, deformity, skin‑nail lesions, ulceration, neuropathy‑ischaemia) are frequently under‑assessed in routine rheumatology practice. The guideline delivers holistic assessment, multidisciplinary‑pathway, conservative‑interventions, footwear‑orthoses, self‑management and criteria for surgical‑referral.

Methods Systematic‑literature‑review; modified‑Delphi‑consensus‑voting；two‑tier‑strength‑of‑recommendation (SOR 1 / SOR 2); covers primary‑community‑care through‑to‑secondary‑tertiary‑rheumatology‑servicesPMC.

Conclusion Foot‑screening must‑form‑part‑of‑standard rheumatology‑assessment at diagnosis and follow‑up. Multidisciplinary‑podiatry‑led care‑pathway is core. Custom‑orthoses, appropriate‑footwear, targeted‑exercise, skin‑nail‑care and patient‑education are foundational‑conservative‑measures. Surgical‑opinion should‑be‑considered for persistent‑severe‑deformity refractory‑to‑maximal‑non‑operative‑therapy.

Keywords: inflammatory‑arthritis; foot‑pain; foot‑deformity; podiatry; orthoses; footwear; BSR‑guideline

Overarching‑principles

1. Foot‑problems are common‑and‑disabling across all‑IA‑subtypes; foot‑assessment should‑not‑be‑omitted‑in‑routine‑rheumatology‑consultationsMedscape R....
2. Person‑centred‑shared‑decision‑making: integrate‑patient‑pain‑experience, mobility‑goals, footwear‑preference, work‑and‑daily‑living‑needs.
3. Multidisciplinary‑team‑(MDT)‑model: rheumatology, podiatry‑chiropody, orthotist, physiotherapy, orthopaedic‑foot‑surgeon where‑required.
4. Systemic‑disease‑control remains‑fundamental; optimise‑DMARD / biologic‑targeted‑therapy alongside‑local‑foot‑interventions.

1. Baseline‑and‑ongoing‑foot‑assessment

• Mandatory‑baseline‑foot‑examination at‑diagnosis of‑IA: inspect skin, nails, callus/hyperkeratosis, toe‑deformities, swelling‑synovitis, plantar‑pressure‑points, pulses‑capillary‑refill, neurological‑sensation‑screeningMedscape R....
• Re‑assess feet at‑every‑routine‑rheumatology‑review, or whenever‑patient‑reports‑foot‑pain, walking‑difficulty or‑footwear‑fitting‑problems.
• Document: pain‑score, mobility‑limitation, footwear‑difficulties, ulcer‑/pressure‑sore‑risk.
• Prompt‑referral‑to‑specialist‑podiatry‑service when‑foot‑symptoms‑impact‑activities‑of‑daily‑living.

2. Conservative non‑pharmacological core‑interventions

2.1 Orthoses & footwear

1. All‑patients‑with‑IA‑related‑foot‑symptoms should‑gain‑access‑to customised‑foot‑orthoses (bespoke fully‑customised OR clinician‑modified‑prefabricated‑insoles). Purpose: reduce‑plantar‑pressure, relieve‑pain, improve‑gait‑and‑mobilityOxford Aca....
2. Footwear‑assessment‑is‑integral: adequate‑width‑depth‑to‑accommodate‑deformed‑feet; supportive‑soles; avoid‑narrow‑pointed‑shoes, high‑heels.
3. Orthoses‑and‑footwear‑require‑periodic‑re‑review‑and‑replacement as‑foot‑shape‑changes‑over‑disease‑course.

2.2 Exercise‑and‑rehabilitation

• Offer individually‑tailored foot‑and‑ankle‑targeted‑exercise‑programmes after‑holistic‑assessment, to‑strengthen‑intrinsic‑foot‑muscles, improve‑balance‑and‑gait‑stability (expert‑consensus‑recommendation, low‑direct‑trial‑evidence‑base)Oxford Aca....
• Insufficient‑evidence‑to‑support‑routine‑use‑of‑extracorporeal‑shock‑wave‑therapy, low‑level‑laser‑therapy for‑IA‑foot‑disease; these‑modalities‑are‑not‑recommended‑as‑standard‑care.

2.3 Skin, nail‑and‑wound‑care

1. Personalised‑nail‑care‑advice for‑all‑IA‑patients: manage‑ingrown‑toenails, hyperkeratosis‑calluses, dry‑fissured‑skin; teach‑recognition‑of‑early‑signs‑of‑infection‑and‑ulcer‑formationOxford Aca....
2. Foot‑ulcer‑management‑core‑principles: pressure‑off‑loading is‑primary‑measure; local‑wound‑care; optimise‑perfusion; treat‑secondary‑infection; treat‑underlying‑vasculitis / neuropathy‑comorbidities; multidisciplinary‑podiatry‑wound‑team‑co‑management.

3. Local‑injection‑therapy

• Intra‑articular‑/‑peri‑articular‑corticosteroid‑injections for localised‑acute‑foot‑synovitis (MTP, ankle, subtalar‑joints) may‑be‑used‑for‑short‑term‑pain‑relief, as‑adjunct‑to‑systemic‑therapy. Not‑for‑long‑term‑repeated‑monotherapy.

4. Special‑populations

4.1 Children & young‑people (JIA)

• Early‑podiatry‑involvement; regular‑foot‑surveillance alongside‑growth‑and‑skeletal‑maturation; age‑appropriate‑orthoses‑and‑footwear‑adaptations.

4.2 High‑risk‑foot‑phenotypes

• High‑risk‑profile: combined‑deformity + neuropathy + reduced‑peripheral‑perfusion + recurrent‑ulcer‑history: intensified‑frequent‑podiatry‑surveillance.

5. Surgical‑referral‑criteria

Consider‑orthopaedic‑foot‑surgical‑opinion for patients with:

1. Severe‑persistent‑pain‑and‑functional‑disability
2. Significant‑bony‑deformity refractory‑to‑maximal‑conservative‑treatment (orthoses, footwear, exercise, optimal‑systemic‑disease‑control)
3. Recurrent‑non‑healing‑pressure‑ulcers secondary‑to‑bony‑prominence‑deformity

Surgery‑is‑not‑first‑line; all‑conservative‑options‑should‑be‑optimised‑prior‑to‑referral‑for‑surgical‑assessment.

6. Patient‑education & self‑management

• Deliver culturally‑adapted‑individual‑foot‑health‑education at‑diagnosis‑and‑re‑inforced‑at‑follow‑up:
  • How inflammatory‑arthritis affects‑foot‑structure‑and‑skin‑nails
  • Footwear‑selection‑principles
  • Self‑monitor‑for‑pain, redness, breaks‑in‑skin‑integrity
  • Clear‑care‑path‑for‑when‑and‑how‑to‑access‑podiatry‑servicesMedscape R...

7. Key‑guideline‑highlights

1. First‑official‑BSR‑guideline‑dedicated‑to‑IA‑foot‑health; mandates‑foot‑examination‑as‑standard‑part‑of‑IA‑assessment.
2. Emphasises‑early‑podiatry‑access‑rather‑than‑waiting‑until‑severe‑deformity‑develops.
3. Custom‑orthoses‑and‑appropriate‑footwear‑are‑central‑conservative‑treatment.
4. Exercise‑rehabilitation‑supported‑by‑expert‑consensus‑despite‑limited‑high‑quality‑trial‑data.
5. Clear‑threshold‑for‑surgical‑referral‑after‑failure‑of‑full‑conservative‑package.