2025 BSR Guideline: Management of Foot‑Health in Inflammatory Arthritis

Rheumatology (Oxford), March 2025, DOI: 10.1093/rheumatology/keaf071 British Society for Rheumatology；multidisciplinary task‑force: rheumatologists, podiatrists, orthotists, physiotherapists, patient‑lived‑experience representatives；recommendation‑grading SOR 1 / SOR 2；level‑of‑evidence LOE B‑C；statement‑overall‑agreement 96‑99 %Oxford Aca...

Abstract

Objective This is the first standalone BSR full‑guideline dedicated to foot‑health for inflammatory‑arthritis (IA). It covers adults, children and young‑people with rheumatoid arthritis (RA), spondyloarthritis (psoriatic arthritis, axSpA, enteropathic‑arthritis) and juvenile idiopathic arthritis (JIA). Foot‑related pain, deformity, skin‑nail damage, pressure‑ulcer‑risk are frequently under‑recognised in routine rheumatology clinics. This guideline delivers evidence‑based baseline assessment, multidisciplinary‑pathway, conservative‑care, orthoses‑footwear, skin‑nail‑care, injection‑therapy, rehabilitation, high‑risk‑foot stratification and surgical‑referral thresholdsOxford Aca....

Methods Systematic‑literature‑review; modified‑Delphi‑expert‑voting; developed following formal BSR guideline‑development protocol; includes patient‑public‑involvement. Covers primary‑community through secondary‑tertiary‑rheumatology servicesBritish So....

Conclusion Routine foot‑examination must be integrated into standard rheumatology consultation at diagnosis and follow‑up. Multidisciplinary podiatry‑led pathway is core‑standard‑of‑care. Custom‑orthoses, appropriate‑footwear, tailored‑exercise and skin‑nail‑care are foundational conservative‑interventions. Optimised systemic‑DMARD / biologic‑targeted‑therapy is essential alongside local foot‑care. Surgical‑referral is reserved for severe refractory deformity after exhausting full‑conservative‑packageOxford Aca....

Keywords: inflammatory‑arthritis; foot‑pain; foot‑deformity; podiatry; orthoses; footwear; wound‑care; juvenile‑idiopathic‑arthritis; BSR‑guideline

Overarching‑principles

1. Foot‑pathology is highly‑prevalent across all IA‑subtypes; foot‑assessment must‑not‑be omitted in routine‑rheumatology visits.
2. Person‑centred shared‑decision‑making: incorporate patient‑pain‑experience, mobility‑goals, footwear‑preference, occupation‑and‑daily‑living‑requirements.
3. Multidisciplinary‑team (MDT): rheumatology, podiatry‑chiropody, orthotist, physiotherapy; orthopaedic‑foot‑surgeon when‑indicated.
4. Systemic inflammatory‑disease‑control is fundamental; optimise DMARD / b/tsDMARD therapy simultaneously with local‑foot‑interventions.
5. Children, young‑people and high‑risk‑foot‑patients require intensified‑surveillance and age‑adapted‑care‑plans.

1 Baseline and ongoing foot‑assessment

1. Perform comprehensive foot‑examination at the time of IA‑diagnosis. Re‑assess feet at every routine‑follow‑up, or whenever patient reports foot‑pain, walking‑difficulty or footwear‑fitting‑problemsOxford Aca....
2. Full‑examination‑items:
   • Skin: dryness, fissures, callus/hyperkeratosis, erythema, blister, break‑in‑skin, pre‑ulcerative‑changes
   • Nails: thickening, onycholysis, ingrown‑toenail, fungal‑nail‑disease
   • Musculoskeletal: toe‑deformities (hallux‑valgus, hammer‑toe, claw‑toe), synovitis/swelling, enthesitis, tenderness, range‑of‑motion
   • Vascular‑neurological: peripheral‑pulses, capillary‑refill, light‑touch‑/‑vibration‑sensation‑screening
3. Document foot‑pain‑score, mobility‑restriction, footwear‑difficulties, ulcer‑/pressure‑injury‑risk‑stratum.
4. Prompt‑referral to specialist‑podiatry‑service when foot‑symptoms impair activities‑of‑daily‑living, work‑participation or quality‑of‑life (SOR 1)Medscape R....

2 Conservative non‑pharmacological management

2.1 Orthoses & footwear

1. Patients with IA‑related foot‑symptoms should receive access to customised‑foot‑orthoses: either fully‑bespoke devices OR clinician‑modified‑prefabricated‑insoles (SOR 1, SOA 99 %). Goal: reduce abnormal plantar‑pressure, relieve pain, improve gait‑pattern and mobilityOxford Aca....
2. Footwear‑evaluation is integral: adequate toe‑box width‑and‑depth to accommodate bony‑deformity; supportive‑mid‑sole; stable‑heel‑counter. Avoid narrow‑pointed‑toe‑box, high‑heeled‑shoes.
3. Orthoses and footwear need periodic‑re‑review, adjustment or replacement as foot‑shape and disease‑status change over‑time.

2.2 Exercise & rehabilitation

1. Offer individually‑tailored foot‑and‑ankle‑targeted‑exercise‑programme after holistic‑assessment: strengthen intrinsic‑foot‑muscles, improve ankle‑range‑of‑motion, balance‑and‑gait‑stability (SOR 1, LOE C)Oxford Aca....
2. Routine extracorporeal‑shock‑wave‑therapy, low‑level‑laser‑therapy are NOT recommended as‑standard‑care; evidence‑insufficient for routine‑clinical‑use.

2.3 Skin, nail and wound‑care

1. Emollients are recommended for dry‑foot‑skin to reduce fissuring risk (SOR 1)Oxford Aca....
2. Callus / hyperkeratosis:
   • Without suspected‑ulceration: do‑not‑offer isolated sharp‑debridement alone; combine with orthoses‑footwear‑and‑self‑management‑education.
   • If underlying‑ulceration is suspected: specialist‑trained‑podiatrist performs sharp‑debridement to expose wound‑base.
3. Personalised‑nail‑care‑advice for all IA‑patients: recognise ingrown‑toenail, infection‑signs; clear‑pathway to access‑specialist‑foot‑service for complications (SOR 2)Oxford Aca....
4. Foot‑ulcer‑management‑core‑principles:
   • Pressure‑off‑loading is first‑priority‑intervention
   • Optimise peripheral‑perfusion
   • Appropriate local‑wound‑dressing‑regimen
   • Treat secondary‑bacterial‑infection
   • MDT‑podiatry‑wound‑team‑co‑management

3 Local‑injectable therapy

• Intra‑articular / peri‑articular glucocorticoid‑injections for acute localised foot‑synovitis (MTP‑joints, subtalar, ankle joints) for short‑term‑pain‑relief.
• Adjunct‑therapy only; not for repeated long‑term‑monotherapy. Continue optimal‑systemic‑disease‑modifying‑treatment.

4 Imaging‑utilisation in foot‑disease

• Ultrasound (preferred first‑line imaging): detect synovitis, tenosynovitis, bursitis, enthesitis, early‑erosive‑change; good for monitoring inflammatory‑activity.
• MRI: for complex‑cases when ultrasound‑findings are inconclusive; evaluate bone‑marrow‑oedema, occult‑stress‑fracture. ‑ Plain‑radiographs: better for established‑structural‑bony‑damage, late‑stage erosions‑and‑deformity.

5 Special‑populations

5.1 Children & young‑people (JIA)

• Early‑podiatry‑involvement from diagnosis; regular foot‑surveillance alongside skeletal‑growth‑and‑maturation.
• Age‑and‑weight‑adapted orthoses‑and‑footwear‑modifications. ‑ Transition‑planning from paediatric‑to‑adult‑rheumatology‑foot‑services.

5.2 High‑risk‑foot‑phenotype

High‑risk‑stratum: combined bony‑deformity + reduced‑peripheral‑perfusion + neuropathy + previous‑foot‑ulcer‑history. ‑ Require intensified‑frequency‑podiatry‑review; aggressive‑pressure‑off‑loading‑strategy; avoid‑delay‑in‑intervention.

6 Surgical‑referral criteria

Consider orthopaedic‑foot‑surgical‑opinion only when all maximal‑conservative‑measures have been optimised and failed:

1. Severe persistent disabling foot‑pain unresponsive‑to‑medical‑and‑podiatry‑care
2. Fixed‑bony‑deformity severely‑impairing‑walking‑and‑daily‑function
3. Recurrent, non‑healing pressure‑ulcers caused by prominent‑bony‑protrusion

Surgery is NOT‑first‑line‑therapy. Systemic‑disease‑activity should‑be‑well‑controlled pre‑operatively.

7 Patient‑education & self‑management

Deliver culturally‑adapted, individualised foot‑health‑education at‑diagnosis and reinforce‑at‑follow‑up: ‑ How inflammatory‑arthritis affects foot‑joints, skin‑and‑nails ‑ Footwear‑selection‑principles ‑ Self‑monitor for pain, swelling, redness, skin‑break‑down ‑ Clear‑care‑path: when‑and‑how‑to‑access‑podiatry‑specialist‑services ‑ Self‑pacing‑and‑activity‑advice

8 Key‑guideline highlights

1. First‑full‑BSR‑guideline‑focused‑entirely‑upon IA‑foot‑health; mandates foot‑examination as‑standard‑rheumatology‑assessment.
2. Emphasise‑early‑podiatry‑access, rather‑than‑waiting‑until‑severe‑deformity‑develops.
3. Custom‑orthoses and appropriate‑footwear are‑central‑conservative‑treatment.
4. Multimodal‑package: orthoses +‑footwear +‑exercise +‑skin‑nail‑care +‑optimised‑systemic‑therapy.
5. Imaging‑matrix: ultrasound as‑first‑line for inflammatory‑foot‑lesions.
6. Well‑defined thresholds for surgical‑referral after full‑conservative‑failure.