What is the appropriate management for a patient with mild hallux valgus, minimal first metatarsophalangeal joint osteoarthrosis, and a plantar calcaneal spur?

Management of Mild Hallux Valgus with First MTP Joint Osteoarthrosis and Plantar Calcaneal Spur

Conservative management is the first-line approach for mild hallux valgus (25°) with minimal first metatarsophalangeal joint osteoarthrosis and plantar calcaneal spur, focusing on orthoses, exercise, and topical treatments before considering surgical intervention.

Non-Pharmacological Management

Orthoses and Footwear

• Custom-made orthosis that includes both wrist and thumb support is recommended as first-line treatment 1
• Full splints (covering both thumb base and wrist) provide significantly better pain relief than half splints 1
• For hallux valgus specifically:
  • Medial wedge insoles for biomechanical correction of the valgus deformity 2
  • Footwear with adequate toe box width to reduce pressure on the first MTP joint
  • Consider custom orthotic devices that redistribute pressure away from the first MTP joint and plantar calcaneal spur

Exercise Program

• Range of motion exercises for the first MTP joint to maintain mobility 1
• Strengthening exercises for intrinsic foot muscles to improve stability 1
• Regular practice to improve function and reduce pain 1
• Aerobic, aquatic, and/or resistance exercises are strongly recommended 2

Additional Non-Pharmacological Approaches

• Local heat or cold applications to manage pain 2
• Joint protection techniques and activity pacing to avoid overuse 1
• Weight loss if the patient is overweight or obese 2
• Consider kinesiotaping as an alternative when range of motion is needed 1

Pharmacological Management

Topical Treatments

• Topical NSAIDs (particularly diclofenac gel) as first-line pharmacological treatment 1
• Apply directly to the affected first MTP joint and calcaneal area 1
• Topical capsaicin is conditionally recommended for pain relief 2

Oral Medications (if topical treatments are insufficient)

1. Oral paracetamol (up to 4g/day) as second-line treatment 1
2. Oral NSAIDs at lowest effective dose and shortest duration if inadequate response to paracetamol 1
3. Consider tramadol for patients with inadequate response to initial therapy 2

Advanced Interventions (for persistent symptoms)

Injections

• Intra-articular corticosteroid injections may be considered for the first MTP joint if other treatments fail 2
• Generally not first-line for hallux valgus but may provide temporary relief 1

Surgical Considerations

• Surgery should be considered only when conservative treatments have failed to provide adequate pain relief 1
• For mild hallux valgus (25°), joint-preserving procedures such as osteotomy would be preferred over arthrodesis if surgery becomes necessary 3
• Success rates for surgical treatment of hallux valgus range from 80% to 95%, with complication rates of 10-30% 3

Management Algorithm

1. First-line: Custom orthoses + appropriate footwear + exercise program
2. Second-line: Add topical NSAIDs and/or topical capsaicin
3. Third-line: Add oral paracetamol if needed
4. Fourth-line: Consider oral NSAIDs at lowest effective dose for shortest duration
5. Fifth-line: Consider intra-articular injections for persistent symptoms
6. Sixth-line: Surgical referral if conservative measures fail after 6-12 months

Follow-Up and Monitoring

• Regular assessment of pain levels, function, and treatment response 1
• Reassessment after 12 months of treatment (or earlier if condition worsens) 1
• Monitor for gastrointestinal side effects with NSAID use 1
• Evaluate range of motion, pain levels, and functional improvement regularly 1

Cautions and Considerations

• Avoid prolonged use of oral NSAIDs due to gastrointestinal, cardiovascular, and renal risks
• The plantar calcaneal spur may require additional attention with cushioned heel cups or specialized orthoses
• Minimal first MTP joint osteoarthrosis suggests early intervention may prevent progression
• The presence of os peronei and os tibiale externum are normal variants and don't require specific treatment