What are the treatment options for a patient with arthritis in the big toe joint and a bone spur on the heel who cannot take Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Treatment Options for Arthritis in the Big Toe Joint and Heel Bone Spur Without NSAIDs

For a patient unable to take NSAIDs with big toe arthritis and heel bone spur, acetaminophen up to 4 grams daily should be the first-line oral analgesic, combined with physical therapy, appropriate footwear modifications, and intra-articular corticosteroid injections for acute flares. 1

First-Line Pharmacologic Management

Acetaminophen (up to 4 grams daily in divided doses, maximum 3 grams if long-term use) is the preferred initial oral analgesic when NSAIDs are contraindicated, despite modest effect sizes in clinical trials. 1 While the American College of Rheumatology acknowledges that acetaminophen may be ineffective for many patients and has very small effect sizes in meta-analyses, it remains appropriate for those with limited pharmacologic options due to NSAID intolerance or contraindications. 1 Regular monitoring for hepatotoxicity is required, particularly at maximum dosage. 1

Non-Pharmacologic Interventions (Strongly Recommended)

Exercise therapy is strongly recommended as a core treatment and should be initiated immediately alongside pharmacologic management. 1, 2 This includes:

• Land-based or aquatic exercises tailored to the patient's functional capacity 1, 2
• Physical therapy referral for instruction in proper exercise techniques, self-management training, and thermal therapies 1
• Weight reduction if overweight or obese, as even modest weight loss significantly improves symptoms 1, 2

Assistive devices and footwear modifications are conditionally recommended and particularly relevant for foot pathology:

• Walking aids to reduce weight-bearing stress 1, 2
• Appropriate footwear with cushioning for heel bone spurs 1
• Orthotic insoles may provide mechanical relief 1

Second-Line Pharmacologic Options

If acetaminophen provides inadequate relief after an appropriate trial (at least 2-4 weeks at adequate doses):

Duloxetine is conditionally recommended as the next-line pharmacological treatment for osteoarthritis pain when acetaminophen fails. 1, 2 While studied primarily in knee OA, its effects are expected to be similar for other joints including the foot. 1 Duloxetine has proven efficacy in reducing pain and improving function with an acceptable safety profile, though tolerability and side effects must be considered. 1, 2

Tramadol is conditionally recommended for patients with contraindications to NSAIDs who find other therapies inadequate. 1, 2 However, tramadol should not be used long-term due to modest benefits in long-term pain management (3 months to 1 year) and risk of dependence. 1, 2

Interventional Options for Acute Flares

Intra-articular corticosteroid injections are strongly recommended for acute pain exacerbations, particularly when joint effusion is present. 1, 2 For the big toe joint (first metatarsophalangeal joint), ultrasound or fluoroscopic guidance may improve accuracy of injection, though not absolutely required for peripheral joints. 1 These injections demonstrate short-term efficacy and are appropriate for episodic use. 1, 2

Topical Alternatives

Topical capsaicin is conditionally recommended for localized chronic pain, though the American College of Rheumatology recommendation is conditional against it while other guidelines suggest it as an option. 1, 2 This may be considered for the heel bone spur as a localized treatment. 1

Treatment Algorithm

1. Initiate acetaminophen at 2-4 grams daily (divided doses) and assess response after 2-4 weeks 1
2. Simultaneously begin exercise therapy and physical therapy referral 1, 2
3. Implement footwear modifications and consider orthotic insoles for mechanical relief 1
4. If acetaminophen inadequate, add duloxetine starting at low dose 1, 2
5. Consider tramadol if duloxetine ineffective or not tolerated, but avoid long-term use 1, 2
6. Use intra-articular corticosteroid injections for acute flares in the big toe joint 1, 2
7. Consider surgical consultation if conservative measures fail and pain remains severe with radiographic evidence of structural damage 1, 2

Important Caveats

Avoid long-term opioid use beyond tramadol unless the patient is not a surgical candidate and has failed all other medical therapies. 1 The evidence for long-term opioid benefit in non-cancer pain is very modest. 1

Do not use glucosamine, chondroitin, or other supplements as these lack proven efficacy and are not recommended by current guidelines. 2

Monitor acetaminophen hepatotoxicity with regular liver function tests if using maximum doses chronically, and reduce to 3 grams daily maximum for long-term use. 1