What are the treatment options for osteoarthritis (OA) pain in the feet and ankles?

Treatment Options for Osteoarthritis Pain in the Feet and Ankles

A comprehensive approach combining physical activity, exercise, orthotics, weight management, and appropriate medications is the most effective strategy for managing osteoarthritis pain in the feet and ankles. 1

Non-Pharmacological Treatments (First-Line)

Physical Activity and Exercise

• General exercise programs show uniform positive effects on pain for foot/ankle osteoarthritis 1
• Strength and resistance training for lower limbs effectively reduces pain and improves physical function 1
• Aerobic exercise improves pain outcomes in osteoarthritis 1
• Initial instruction followed by integration into daily life is recommended, with 12 or more supervised sessions showing better outcomes 1
• Aquatic exercises in warm water (86°F) provide analgesia for painful joints while reducing joint loading 1

Orthotics and Footwear

• Appropriate footwear with shock-absorbing properties is essential for reducing joint pain 1, 2
• Orthotics show small but consistent positive effects on pain for foot/ankle osteoarthritis 1
• Knee orthoses (especially sleeves and elastic bandages) can help with associated knee osteoarthritis 1
• Shoes with shock-absorbing insoles have been shown to reduce pain and improve function 1

Weight Management

• Weight loss programs are strongly recommended if the patient is overweight or obese 2, 3
• Weight reduction reduces mechanical stress on weight-bearing joints 2
• Programs with explicit weight-loss goals show better results (mean changes of -4.0 kg) 1

Assistive Devices

• Walking aids, assistive technology, and adaptations at home/work should be systematically considered 1
• Canes and other walking aids can reduce joint load and improve mobility 3
• High satisfaction rates indicate these are important and useful for people with osteoarthritis 1

Other Non-Pharmacological Approaches

• Local heat or cold applications provide temporary pain relief 1, 3
• Transcutaneous electrical nerve stimulation (TENS) may help with pain management 1, 2
• Psychological interventions like cognitive behavioral therapy (CBT) and relaxation techniques show uniform positive effects on pain 1
• Patient education enhances understanding and counters misconceptions about osteoarthritis 1, 2

Pharmacological Treatment Algorithm

First-Line Medications

• Acetaminophen (paracetamol) is the preferred first-line pharmacological treatment for mild to moderate pain, up to 4 grams daily 1, 2
• Topical NSAIDs should be considered before oral NSAIDs, particularly for localized pain 1, 3

Second-Line Medications

• If acetaminophen and topical NSAIDs are insufficient, consider oral NSAIDs or COX-2 inhibitors 1, 3
• Use oral NSAIDs at the lowest effective dose for the shortest possible period 1
• When prescribing oral NSAIDs/COX-2 inhibitors, add a proton pump inhibitor for gastroprotection, especially in elderly patients 1, 3

Third-Line Medications

• For persistent pain, consider opioid analgesics as adjuncts to or replacements for other analgesics 1
• Intra-articular corticosteroid injections may provide short-term pain relief during disease flares 3, 4
• Viscosupplementation with hyaluronic acid has shown to be safe and efficacious for ankle osteoarthritis 5

Important Considerations and Pitfalls

• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs, especially in patients over 50 1, 3
• Elderly persons are at high risk for side effects of NSAIDs, including GI, platelet, and nephrotoxic effects 1
• High-impact aerobic training should be avoided as it involves rapid application of loads across joint structures 1
• Glucosamine and chondroitin products are not recommended based on current evidence 1, 2
• The disease course and patient's needs often change over time, requiring periodic review and adjustment of therapy 1, 6
• Early stages of ankle osteoarthritis should be treated with non-surgical methods before considering surgical options 5