What is the best course of treatment for a 27-year-old male patient with chronic bilateral foot pain and ankle pain, particularly at the base of the big toe, with worn-out shoes and no family history of gout?

Management of Chronic Bilateral Foot and Ankle Pain in a 27-Year-Old Male

Begin with bilateral foot and ankle radiographs as the initial diagnostic step, followed by targeted conservative treatment based on the clinical presentation of first metatarsophalangeal joint pain and lateral shoe wear pattern suggesting biomechanical abnormalities. 1

Initial Diagnostic Approach

Imaging Strategy

• Obtain standard three-view radiographs of both feet and ankles immediately (anteroposterior, oblique, and lateral views) as this is the most appropriate initial imaging study for chronic foot and ankle pain of unknown etiology 1
• Radiography can reveal osteoarthritis, osteochondral abnormalities, stress fractures, accessory ossicles, or evidence of prior trauma that may explain the chronic symptoms 1
• The lateral shoe wear pattern suggests supination during gait, which can contribute to lateral ankle instability and stress on the first metatarsophalangeal joint 1

Clinical Assessment Priorities

• The base of the big toe pain (first metatarsophalangeal joint) in a 27-year-old male warrants consideration of several diagnoses, including hallux rigidus (early degenerative joint disease), sesamoiditis, turf toe injury, or inflammatory arthropathy, though gout remains less likely given the absence of family history and chronic rather than acute presentation 2, 3, 4, 5
• The bilateral nature and chronic course (years of symptoms) suggests a biomechanical or structural etiology rather than acute inflammatory or infectious process 1, 6
• Evaluate for point tenderness, swelling, deformity, range of motion limitations at the first metatarsophalangeal joints, and assess the entire gait pattern 7

Treatment Algorithm Based on Clinical Presentation

Initial Conservative Management (First 6-8 Weeks)

For First Metatarsophalangeal Joint Pain:

• Rest and activity modification to avoid aggravating movements 6
• NSAIDs for pain and inflammation control 6, 2
• Proper footwear with adequate width and cushioning is essential—the worn-out shoes must be replaced immediately 7
• Orthotic devices or arch supports to correct the supination pattern evident from lateral shoe wear 6, 7
• Weight loss if indicated (excess weight increases pressure on forefoot structures) 6, 8

For Ankle Pain (Particularly Left Ankle):

• If radiographs show degenerative changes, consider image-guided anesthetic injection, MRI without contrast, or CT without contrast as next steps 1
• If radiographs are normal but pain persists, MRI of the ankle without IV contrast should be ordered to evaluate for ligament abnormalities, tendon pathology, osteochondral lesions, or impingement syndromes 1
• Physical therapy focusing on ankle stabilization exercises and addressing the biomechanical abnormalities suggested by shoe wear 6

Advanced Imaging Indications

If radiographs are negative or equivocal and symptoms persist:

• MRI of the foot without IV contrast is the most appropriate next study to globally evaluate all anatomic structures including bone marrow, ligaments, tendons, and cartilage 1
• MRI is highly accurate for evaluation of ligament, tendon, and osteochondral abnormalities that may not be visible on plain radiographs 1
• Ultrasound may be useful for focal soft-tissue abnormalities and has the benefit of dynamic evaluation during specific movements 1

When to Refer to Specialist

Refer to orthopedic surgery or podiatry if:

• No improvement after 6-8 weeks of appropriate conservative treatment 6, 7
• Radiographs reveal significant structural abnormalities requiring surgical consideration 6, 7
• Advanced imaging demonstrates pathology requiring subspecialist management (significant osteochondral lesions, complete ligament tears, etc.) 1, 6
• Pain becomes severe or is accompanied by inability to bear weight 8

Critical Pitfalls to Avoid

• Do not overlook small avulsion fractures or stress fractures on initial radiographs—these are commonly missed in young active patients 7
• Failing to obtain weight-bearing views when indicated can miss significant pathology 7
• Underestimating the impact of proper footwear is a major error—the lateral shoe wear pattern indicates ongoing biomechanical stress that will perpetuate symptoms regardless of other treatments 7
• Do not assume gout based solely on first metatarsophalangeal joint involvement in a young patient without acute inflammatory presentation, family history, or risk factors 2, 3, 4, 5
• Corticosteroid injections should be used judiciously and are contraindicated near the Achilles tendon 6

Specific Considerations for This Patient

The combination of bilateral first metatarsophalangeal joint pain, bilateral ankle pain (worse on left), lateral shoe wear, and years of untreated symptoms strongly suggests a biomechanical etiology with secondary degenerative changes rather than inflammatory arthropathy 1, 6. The lateral shoe wear indicates supination during gait, which increases stress on lateral ankle structures and can alter forefoot mechanics, contributing to first metatarsophalangeal joint pathology 1, 7.

The priority is obtaining bilateral foot and ankle radiographs immediately, replacing inadequate footwear, initiating orthotic support to correct the supination pattern, and beginning NSAIDs with activity modification 1, 6, 7. If symptoms persist beyond 6-8 weeks despite these interventions, proceed with MRI evaluation and subspecialist referral 1, 6.