What is the appropriate management and discussion plan for a patient with mild to moderate osteoarthritis (OA) of the 1st metatarsophalangeal (MTP) joint on the left foot, diagnosed via X-ray, considering their current symptoms and medical history?

Management of Mild to Moderate Osteoarthritis of the Left 1st MTP Joint

You should call the patient to assess their current symptoms, functional limitations, and impact on daily activities, then initiate a comprehensive treatment plan centered on exercise, appropriate footwear, and topical NSAIDs as first-line therapy. 1

What to Ask During the Phone Call

Symptom Assessment

• Pain characteristics: Ask about pain severity (0-10 scale), timing (morning stiffness, pain with walking, end-of-day pain), and what activities provoke symptoms 1
• Functional impact: Specifically inquire about difficulty with walking, stair climbing, standing from sitting, and ability to wear desired footwear 1
• Quality of life effects: Ask how the condition affects their occupation, leisure activities, mood, and relationships 1
• Current footwear: Determine what types of shoes they typically wear, as improper footwear can exacerbate first MTP joint OA 1, 2

Medical History Relevant to Treatment Selection

• Comorbidities: Document cardiovascular disease, hypertension, gastrointestinal bleeding history, chronic kidney disease, liver disease, and diabetes, as these affect medication choices 1
• Current medications: Specifically ask about over-the-counter NSAIDs, acetaminophen-containing products, anticoagulants, and antihypertensives 1
• Weight status: Assess if patient is overweight or obese, as weight loss is a core treatment 1

Management Plan

Core Non-Pharmacological Treatments (Mandatory for All Patients)

Exercise and activity modification should be the cornerstone of treatment 1:

• Prescribe local muscle strengthening exercises for the foot and ankle 1
• Recommend general aerobic fitness activities (walking, swimming, cycling) for at least 30 minutes most days 1
• Advise on activity pacing to avoid "peaks and troughs" of activity that exacerbate symptoms 1

Footwear modification is critical for first MTP joint OA 1, 2:

• Recommend shoes with shock-absorbing properties, wide toe box, and adequate support 1, 3
• Avoid high heels, narrow toe boxes, and rigid-soled shoes 2

Weight loss if BMI >25 kg/m²: Target 5-10% body weight reduction through combined diet and exercise 1, 3, 4

Patient education about the condition, emphasizing that OA is treatable and not inevitably progressive 1

Adjunct Non-Pharmacological Treatments

Foot orthoses are strongly recommended for first MTP joint OA 1, 5, 2:

• Custom or prefabricated contoured foot orthoses can reduce pain and improve function 5, 2
• Podiatry referral may be beneficial for proper fitting and prescription 2

Local heat or cold applications can provide symptomatic relief 1

Assistive devices: Consider a cane if ambulation is significantly affected, though this is more relevant for hip/knee OA 1

Pharmacological Management Algorithm

First-line: Topical NSAIDs (e.g., diclofenac gel 2%) applied twice daily to the affected joint 1, 3, 4:

• Lower systemic exposure and fewer side effects compared to oral NSAIDs 3, 4
• Particularly appropriate given the superficial location of the first MTP joint 3

Second-line: Acetaminophen up to 3,000-4,000 mg/day in divided doses 1, 3, 4:

• Ensure patient is not taking other acetaminophen-containing products 3, 4
• Efficacy is modest but safety profile is favorable 1, 6

Third-line: Oral NSAIDs only if topical NSAIDs and acetaminophen are insufficient 1:

• Use lowest effective dose for shortest duration 1, 4
• Consider COX-2 selective NSAID (celecoxib) or standard NSAID with proton pump inhibitor 1
• Monitor blood pressure if patient has hypertension 4, 6
• Assess cardiovascular, gastrointestinal, and renal risk factors before prescribing 1

Avoid: Glucosamine, chondroitin, and opioids (including tramadol) are not recommended 1, 4

When to Consider Advanced Interventions

Intra-articular corticosteroid injections are not typically used for first MTP joint OA but may be considered for acute flares with effusion 3, 4, 6:

• Limit to 3-4 injections per year 3, 4, 6
• Monitor glucose in diabetic patients 3, 4

Surgical referral should be considered if conservative management fails after 3-6 months 3, 7:

• Options include cheilectomy (debridement of dorsal osteophytes) for mild-moderate disease 7
• Arthrodesis for advanced disease in active individuals 7
• Synthetic cartilage implant (Cartiva) as motion-sparing alternative to fusion 8

Follow-Up Schedule

Short-term (2-4 weeks): Assess initial response to footwear changes and topical NSAIDs 3

Medium-term (6-12 weeks): Evaluate adherence to exercise program, need for orthoses, and whether pharmacological escalation is needed 3, 5

Long-term (3-6 months): Determine if symptoms are adequately controlled or if surgical consultation is warranted 3

Common Pitfalls to Avoid

• Do not prescribe oral NSAIDs as first-line therapy when topical NSAIDs are appropriate for this superficial joint 1, 3
• Do not recommend glucosamine or chondroitin supplements, as evidence does not support their use 1
• Do not prescribe opioids or tramadol, as they have poor risk-benefit profiles for OA 4
• Do not neglect the core non-pharmacological treatments (exercise, footwear, weight loss), as these are the foundation of OA management 1
• Do not forget to assess for medication interactions, particularly with over-the-counter NSAIDs and acetaminophen-containing products 1