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Table 8 Recommendations on conservative treatment

From: Multidisciplinary recommendations for diagnosis and treatment of foot problems in people with rheumatoid arthritis

  LoE Ref LoA
Technical adaptations to over-the-counter shoes can reduce pain and improve physical functioning.* These adaptations can be prescribed in patients with abnormal foot function, foot joint damage/deformity, or malalignment of the feet, provided that the feet fit in over-the-counter shoes.** *3**4b * [59] **n/a 9.3 (8–10)
Ready-made therapeutic shoes with extra depth, support, incorporated inlays, and optional technical adaptation can reduce forefoot plantar pressure and foot pain and improve gait characteristics, physical functioning, and health-related quality of life.* These ready-made shoes can be prescribed in patients with i) abnormal foot function, foot joint damage/deformity, or malalignment of the feet, and ii) feet that do not fit in over-the-counter shoes, but for whom custom-made shoes are not indicated.** *3 **4b * [46, 60,61,62,63,64] **n/a 9.3 (7–10)
Custom-made therapeutic shoes can reduce pain and improve physical functioning.* These custom-made shoes can be prescribed in patients with i) abnormal foot function, foot joint damage/deformity, or malalignment of the feet, and ii) feet that do not fit in over-the-counter shoes or ready-made therapeutic shoes.** *3 **4b * [25] **n/a 9.5 (8–10)
Custom-made therapeutic shoes should be worn all day, after a habituation period. 3 [25] 8.5 (0–10)
Foot orthoses are recommended in patients with abnormal foot function, when adequate over-the-counter shoes are insufficient in reducing foot symptoms. 4a/b [27,28,29,30,31] 9.0 (2–10)
Foot orthoses in adequate shoes can reduce forefoot plantar pressure and pain. 1 [28, 30] 9.4 (7–10)
The function of foot orthoses should be assessed in relation to the patient’s footwear, due to the interaction between the two. 3 [60] 9.3 (8–10)
Rigid foot orthoses are recommended in feet with correctable malalignment, to control the position of the feet during weight-bearing. 4a [27, 29, 32, 33] 8.9 (7–10)
Total contact foot orthoses are recommended in feet with uncorrectable malalignment or fragile skin. The material used for the production of total contact foot orthoses depends on the required characteristics of the foot orthoses. 4a/b [29, 32] 9.0 (6–10)
General exercise therapy is recommended according to the Dutch KNGF Guideline for Physical Therapy in Patients with Rheumatoid Arthritis. 1 [34] 9.1 (7–10)
Exercise therapy specific to the foot and ankle can include i) strengthening exercises for the intrinsic foot muscles and M. tibialis posterior; ii) active stretch exercises for the plantar fascia, achilles-tendon, and peroneal muscles; and iii) active exercises to improve joint mobility. 4a [33] 8.8 (7–10)
A silicone toe orthosis can be used in the treatment of malalignment of toes and secondary pain or high pressure. 3 [65] 9.2 (7–10)
In the prescription of a silicone toe orthosis, the following factors should be considered: i) a sensibility disorder or peripheral artery disease; ii) a skin defect on the foot of interest; and iii) sufficient room in the shoe for wearing the toe orthosis. 4a/b [36] 9.3 (8–10)
A toenail brace can be used in the treatment of an ingrowing or ingrown toenail. ^ 2 [66, 67] 8.8 (5–10)
In the prescription of a toenail brace, the following factors should be considered: i) a sensibility disorder or peripheral artery disease; ii) a skin defect, inflammation, or onycholysis on the toe of interest; and iii) the use of biologicals. 4a/b [36] 9.3 (7–10)
When a fungal nail or mycosis of the skin is detected, treatment should be started to prevent ulcers and secondary bacterial infections. 4a/b [32] 9.0 (7–10)
Pressure and shearing forces should be normalised in feet with hyperkeratotic lesions. For normalisation of pressure and shearing forces, i) an individual shoe- and sock advice can be given; or ii) foot orthoses, silicone toe orthosis, technical adaptations to over-the-counter shoes, ready- or custom-made therapeutic shoes, or a provisional therapy (e.g., felt padding or taping) can be prescribed. 4a/b [32, 36] 9.0 (6–10)
Excessive hyperkeratotic lesions should be treated. During the treatment the following factors should be considered: i) a sensibility disorder or peripheral artery disease, and ii) fragile skin, plantar bursa, and prominent metatarsal heads on the foot of interest. 4a/b [32, 36] 9.1 (7–10)
When an (pre-)ulcer or infection is detected, the treating physician should be consulted. 4a/b [32] 9.2 (6–10)
In wound-care, a provisional therapy (e.g., felt padding) can be applied to reduce pressure. When material with an adhesive layer is used, fragile skin should be taken into consideration. 4a [32] 8.8 (7–10)
  1. LoE Level of Evidence for the recommendations: (1) research of level A1 or at least 2 independently conducted studies of level A2, (2) 1 study of level A2 or at least 2 independently conducted studies of level B, (3) 1 study of level B or C, (4a) expert opinion described in the literature, (4b) opinion of the expert group. Ref. references. LoA Level of Agreement for the recommendations: Numeric Rating Scale from 0 (total disagreement) to 10 (total agreement) reported as mean (range). n/a not applicable. ^ based on literature not specific for RA. * refers to the first part of the recommendation with corresponding level of agreement and references. ** refers to the second part of the recommendation with corresponding level of agreement and references