Sixteen studies (n=609) were included.
The evidence from 4 studies was classed as grade A, seven as grade B, two as grade C and three as grade D. The majority of the studies were small in size with most having fewer than 40 participants; only 5 studies had more than 80 participants.
Foot orthoses (3 RCTs, 1 clinical trial, 2 repeated measure studies and 1 case report).
All of the studies used different designs and types of foot orthoses; different outcome measures were also used. Three RCTs (all grade A) compared rigid custom-made foot orthoses with placebo foot orthoses. One RCT reported a significant improvement in Foot Function Index scores for the intervention group compared with the control group (P=0.026), but no significant differences in global pain score, Disease Activity Score, Health Assessment Questionnaire and Larsen radiological scores for hands and feet. Another RCT reported that intervention participants were 73% less likely to experience progression of hallux valgus (P=0.04). However, both this study and the third RCT reported little or no significant differences in measures of pain, disability and function.
Significantly reduced foot pressures and foot pain were also observed with different foot orthoses (as compared with regular shoes) in the repeated measures study (grade B). Similarly, pain, step length, stride length and physiological cost index were significantly improved with custom-made orthoses (compared with no orthoses) in one study (grade B). One repeated measures study (grade B) measuring velocity, cadence and stride, showed that only the level of change reported for stride was significantly improved (P<0.05) for the foot orthoses group in comparison with regular shoes. Finally, a case study (grade D) reported that a patient experienced substantial pain relief immediately and 22 months after having custom-formed leg/hindfoot orthoses fitted; increased in velocity, cadence, stride length and single limb stance were also reported (significance not assessed).
Footwear (1 RCT with repeated measures and 2 questionnaires).
One small RCT (grade B) showed that participants in the intervention group (extra-depth shoes for 2 months) showed significant improvements in the following outcomes when compared with a no treatment control group: physical function (P=0.0001), walk pain (P=0.0002), stair pain (P=0.0001) and pain-free walk time (P=0.0007). There was no increase in the use of arthritis medication or walking aids when compared with the control group. The 2 studies using questionnaires reported that, overall, most patients were satisfied with the intervention footwear (78.8%), but women were more dissatisfied with the style of the footwear (P=0.0004). Participants also reported problems with the weight of the footwear (28%), calefaction (heat) (49%) and comfort (42%).
Foot orthoses in combination with footwear (1 RCT and 1 prevalence study).
The prevalence study (grade B) showed that of the 99 participants, 95 had no special shoes or inserts, 1 had an orthotic insert and 3 had custom-made shoes. The RCT (grade A) showed that pain scores were improved in patients who wore semi-rigid insoles in extra depth shoes for 12 weeks in comparison with extra depth shoes alone. However, there was no difference in pain scores when soft insoles in extra depth shoes were compared with extra depth shoes alone. Both interventions were associated with significant material compression (P<0.002) and neither intervention had a significant effect on synovitis or function. Just over half of the participants showed a preference for semi-rigid over soft orthoses.
Foot orthoses, footwear and physical therapy (2 case reports).
The specific details of the interventions varied between the 2 studies (both grade D). However, both studies reported that patients had improvements in gait (significance not assessed) and complete pain relief.
Padded hosiery (1 RCT with repeated measures).
Improvements in pressure relief (P<0.001) were reported for the 2 intervention groups (medium- and high-density padded hosiery) in comparison with bare feet (grade B). Painful symptoms (P<0.01) also decreased in the intervention groups in comparison with the patients' own socks. The participants indicated that they were satisfied with the interventions and would continue to wear them.
Callus debridement (1 clinical trial).
This grade B study reported significant reduction in forefoot pain immediately post-treatment. Peak pressures, peak forces and contact times on the painful forefoot were also reduced after callus removal, but the differences were not statistically significant. There was no change in global arthritis pain and the treatment effects were reported to disappear 7 days post-treatment.
Referral to podiatrists as the source of footwear interventions (1 questionnaire).
One Dutch questionnaire (grade C) reported that orthopaedists and rehabilitation practitioners strongly agreed with the prescription of orthopaedic footwear being considered for RA patients. The rate of prescription appeared to be related to beliefs about the advantages or disadvantages and satisfaction of the intervention, and not the desirability of prescription.