Background: Foot and ankle problems in people with rheumatoid arthritis (RA) are common and frequently cause persistent pain [1]. Systemic interventions are effective at reducing overall disease activity. However, continuing foot problems may still occur even after reaching clinical remission [2]. Therefore, non-pharmacological and surgical interventions are commonly utilised in conjunction with systemic management strategies [3]. With the recent advent of advanced clinical practice, the scope of conservative and surgical care for the rheumatoid foot and ankle has changed and warrants further investigation.

Objectives: To identify and critically appraise evidence for the effectiveness of non-pharmacological and surgical interventions for the rheumatoid foot and ankle.

Methods: Studies were identified in appropriate electronic databases (from 1950 to June 2010). Search terms of `rheumatoid arthritis', `foot', `ankle' and related terms were used in conjunction with treatment search terms. Studies were also identified by hand searching. Included studies were quantitative longitudinal studies (all in English) and included randomised controlled trials (RCTs), case-control studies (CCTs), cohort studies and case series studies. Outcome measures investigated were pain and forefoot plantar pressures. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for correct statistical analysis, sample population representativeness, and compliant intervention use and presence of co-interventions.

Results: The inclusion criteria were met by 32 studies. Two studies had high quality internal validity and 30 had low quality internal validity. Four studies had high quality external validity and 28 had low quality external validity. No study had high quality for both internal and external validity. Foot orthoses were found to reduce pain. However, evidence was weak and should be viewed cautiously as study results were dependent on orthoses design. Evidence for foot orthoses reducing forefoot plantar pressures was inconclusive. Shoes and hosiery may possibly reduce pain and forefoot plantar pressures. However, evidence was inconclusive due to the lack of conducted studies. Evidence for debridement reducing pain and forefoot plantar pressures was inconclusive. However, available studies showed debridement was ineffective long term. Forefoot surgery was found to reduce pain. However, evidence was weak and should be viewed cautiously as study results were dependent on the forefoot surgery conducted. Evidence for forefoot surgery reducing forefoot plantar pressures was inconclusive. Rearfoot surgery studies showed possible pain reductions. However, the lack of studies means the level of evidence was inconclusive.

Conclusions: Evidence shows foot orthoses and forefoot surgery may be beneficial for reducing pain. All other areas of evidence were inconclusive. This was due to a lack of studies completed in this area and the low quality of those conducted. More RCTs for both non-pharmacological and surgical interventions have been conducted recently. However, more high quality research studies are still needed in all areas of non-pharmacological and surgical management of the rheumatoid foot and ankle.

Disclosure of Interest: None Declared