What is the best course of action for a 58-year-old male patient with chronic pain and left foot deformity, who has been taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Tylenol (acetaminophen) since 2020, and has difficulty with ambulation due to a deformity of the 4th and 5th toes with absent 4th metatarsal?

Management of Chronic Foot Pain with Deformity in a 58-Year-Old Male

For a 58-year-old male with chronic pain and left foot deformity due to absent 4th metatarsal and deformity of the 4th and 5th toes, the most appropriate management includes referral to orthopedics, prescription of custom orthotics (Apex X520M with gel insoles), and consideration of alternative pain management options beyond NSAIDs and acetaminophen which he has been taking since 2020.

Assessment of Current Situation

• Patient has completed physical therapy without adequate pain relief
• Long-term use of NSAIDs and acetaminophen since 2020 (approximately 4 years)
• Left foot deformity characterized by:
  • Absent 4th metatarsal
  • Deformity of 4th and 5th toes
  • No erythema or blistering
  • Difficulty with ambulation

Recommended Management Plan

1. Orthotic Management

• The prescription of Apex X520M shoes with gel insoles (size 10.5) is appropriate and evidence-based
• Custom orthotics are strongly recommended for patients with foot deformities to redistribute plantar pressure and improve ambulation 1, 2
• Below-knee customized devices provide optimal protection for patients with foot deformities 1

2. Pain Management Alternatives

• Long-term NSAID use (since 2020) raises concerns about potential gastrointestinal, renal, and cardiovascular adverse effects, particularly in a 58-year-old patient 1, 3
• Consider transitioning from NSAIDs to:
  • Acetaminophen alone as first-line therapy if pain is mild to moderate 1, 3
  • Tramadol as an alternative for patients who don't receive adequate pain relief from acetaminophen and are at risk for NSAID-related side effects 3
  • Topical agents (such as capsaicin) for localized pain 3

3. Specialist Referral

• Referral to orthopedics is appropriate given:
  • Failure of conservative management (completed physical therapy without adequate relief)
  • Structural foot deformity affecting ambulation
  • Chronic pain despite long-term analgesic use
• The American Family Physician and other guidelines support referral to foot specialists when there is no improvement after conservative treatment 2

4. Additional Considerations

Footwear Recommendations

• Shoes should be 1-2 cm longer than the foot with adequate width at metatarsal phalangeal joints 2
• Open-backed shoes can help reduce pressure on painful areas 2
• The prescribed Apex X520M with gel insoles addresses these requirements

Monitoring and Follow-up

• Regular assessment every 4-6 weeks to evaluate response to treatment 2
• Monitor for proper orthotic fit and footwear compliance
• Assess for any signs of skin breakdown or pressure points, especially at the deformity sites

Potential Pitfalls and Caveats

1. Long-term NSAID use: Continued use of NSAIDs since 2020 increases risk of gastrointestinal bleeding, renal dysfunction, and cardiovascular events. Consider gastroprotection with proton pump inhibitors if NSAIDs must be continued 1.

2. Orthotic adjustment period: Patient should be informed that adaptation to new orthotics may take 1-2 weeks, and initial discomfort doesn't necessarily indicate treatment failure.

3. Monitoring for diabetic complications: Although not mentioned in the case, given the patient's age and foot deformity, screening for diabetes would be prudent, as diabetic neuropathy can complicate foot conditions 1.

4. Expectations management: Conservative treatment with orthotics and appropriate footwear can improve symptoms in approximately 90% of patients, but complete pain resolution may not be achievable in all cases 2.