Treatment of Resistant Flexion of the First MTP Joint with Minimal Erythema
For resistant flexion deformity of the first MTP joint with minimal erythema, initiate conservative management with long-term orthoses (worn for at least 3 months) combined with topical NSAIDs as first-line pharmacological treatment, reserving arthrodesis for cases where conservative treatment fails to adequately relieve pain. 1, 2
Initial Conservative Management Algorithm
First-Line Pharmacological Treatment
- Topical NSAIDs are the preferred initial pharmacological intervention due to their superior safety profile compared to systemic options, with topical diclofenac gel showing small but meaningful improvements in pain and function after 8 weeks 1, 2
- Oral NSAIDs should be reserved for limited duration when topical therapy provides insufficient relief, particularly when multiple joints are affected 1, 2
Orthotic Management
- Custom-made orthoses for the first MTP joint should be prescribed for prolonged use (minimum 3 months) to achieve symptom relief, as shorter periods show no benefit 1, 2
- The orthosis should be fitted by a specialized health professional to improve compliance and prevent complications such as pressure sores 1, 2
- Long-term use is specifically advocated, with evidence supporting either custom-made thermoplast long orthoses worn during activities of daily living or custom-made neoprene long orthoses worn at night 1
Exercise Therapy
- Implement exercises aimed at improving joint mobility, muscle strength, and thumb base stability (principles applicable to first MTP joint) 1, 2
- Exercise regimens should be tailored to the specific joint involved, as first CMC joint exercises differ from interphalangeal joint protocols 1
Additional Conservative Options
Intra-articular Corticosteroid Injection
- May be considered for painful joints when initial conservative measures provide inadequate relief 2
- This represents a second-line option before considering surgical intervention 2
Patient Education
- Provide education on disease nature, course, and self-management principles 2
- Train patients in ergonomic principles, pacing of activity, and use of assistive devices 2
Surgical Intervention Criteria
When Conservative Treatment Fails
- Arthrodesis (fusion) of the first MTP joint is the gold standard surgical treatment for end-stage arthritis and severe deformity when other treatment modalities have not sufficiently relieved pain 2, 3, 4
- Surgery should only be considered for patients with structural abnormalities after conservative treatment failure 2
Specific Surgical Indications
- Arthrodesis is indicated for end-stage arthritis, severe deformity, and as a salvage procedure after failed previous operations 3
- Joint arthroplasty is specifically indicated for hallux ulcers (in diabetic patients) with limited range of motion of the first MTP joint 1, 2
- Arthroscopic release may be considered for arthrofibrosis with functional limitation in patients who fail conservative treatment 5
Important Clinical Caveats
The presence of minimal erythema suggests early inflammatory changes rather than advanced arthritis, making conservative management particularly appropriate as the initial approach. The resistant flexion deformity indicates structural changes that may benefit from orthotic support to prevent progression 1, 2.
Management should be individualized based on joint severity and comorbidities, with optimal treatment typically requiring both non-pharmacological and pharmacological options 2. Long-term follow-up should be adapted to individual patient response to treatment 2.