What is the recommended initial management for a patient with hallux valgus deformity and mild osteoarthritis of the first metatarsophalangeal joint?

Management of Hallux Valgus with Mild First MTP Joint Osteoarthritis

Begin with conservative non-surgical management including proper footwear modifications, orthoses, topical NSAIDs, and structured exercise programs, as these interventions provide symptom relief while avoiding surgical risks in mild disease. 1, 2

Initial Conservative Management Approach

Footwear and Orthotic Interventions

• Wide toe box shoes with stiff soles are essential to minimize first MTP joint motion and reduce pressure on the bunion deformity 2
• Rocker-bottom shoes decrease motion requirements at the first MTP joint and can significantly reduce pain 2
• Custom orthotic devices improve foot biomechanics and reduce pressure on the first MTP joint, though proper fitting is crucial to prevent pressure sores 2
• For patients with diabetes, meticulous attention to orthotic fitting is mandatory to prevent ulceration at bony prominences 2

Pharmacological Management

• Topical NSAIDs are the first-line pharmacological treatment due to their favorable safety profile compared to oral analgesics 1
• Oral NSAIDs (such as naproxen up to 1000 mg daily) can be used if topical agents are inadequate, particularly for patients with moderate pain 1, 3
• Paracetamol (up to 4 g/day) is appropriate for mild-moderate pain and is the preferred long-term oral analgesic when effective 1
• Intra-articular corticosteroid injections can be used for acute pain flares, though evidence for long-term benefit is limited 2

Exercise and Physical Therapy

• Structured hand and foot exercises should be prescribed to improve joint mobility, muscle strength, and reduce pain 1
• Exercise programs should aim at improving joint mobility and strengthening foot musculature 2
• Exercises have small but meaningful beneficial effects on pain, function, and joint stiffness 1

Activity Modification

• Reduce joint loading during painful activities while maintaining overall physical activity 2
• Patient education about the chronic nature of osteoarthritis and self-management strategies is essential 2

When Conservative Management Fails

Indications for Surgical Consideration

Surgery is indicated when pain persists despite adequate conservative treatment for 4-6 weeks 2, 4

The specific surgical approach depends on:

• Severity of deformity (mild vs. moderate/severe hallux valgus angle)
• Presence and degree of osteoarthritis in the first MTP joint
• Patient age and activity level
• Previous surgical history

Surgical Options by Clinical Scenario

For Mild Deformity with Mild OA (No Prior Surgery)

• Distal first metatarsal osteotomies (e.g., Chevron osteotomy) are the procedure of choice 4
• These provide good to very good outcomes in 85% of patients 4

For Moderate-Severe Deformity with Mild OA

• Proximal first metatarsal osteotomy combined with distal soft-tissue correction is the procedure of choice 5
• This approach provides adequate correction of the intermetatarsal angle while balancing the MTP joint 5

For Mild OA with Failed Previous Hallux Valgus Surgery

• First MTP joint arthrodesis is the most reliable option for revision after failed hallux valgus surgery 6
• Arthrodesis can address multiple failure modes including recurrence, hallux varus, cock-up deformity, and degenerative arthritis 6
• Patient satisfaction is excellent or good in 72% of cases, though outcomes are poorer than successful primary procedures 6

For Physically Active Patients with Progressive OA

• Arthrodesis of the first MTP joint should be performed rather than resection arthroplasty 1, 4
• This provides stable, pain-free function for active individuals 4

For Elderly or Low-Demand Patients with OA

• Resection arthroplasty is preferred over arthrodesis 4
• This option is particularly suitable for patients with significant comorbidities 1

Common Pitfalls to Avoid

• Do not use lateral or medial wedged insoles as they lack clear efficacy for hallux valgus or first MTP OA 1
• Avoid combining NSAIDs with aspirin, as aspirin increases naproxen excretion and the combination increases adverse events without additional benefit 3
• Do not delay surgical referral in patients with persistent pain despite 4-6 weeks of optimal conservative management 2
• Ensure proper soft-tissue balancing during any osteotomy procedure to prevent recurrence or hallux varus 5
• In patients with diabetes, never overlook proper orthotic fitting as this can lead to catastrophic ulceration 2

Monitoring and Reassessment

• Clinical reassessment should occur after 4-6 weeks of conservative management 2
• Follow-up radiographs are generally unnecessary unless symptoms significantly change or surgical intervention is being considered 2
• For patients undergoing surgery, full weight-bearing in a flat surgical shoe is typically permitted postoperatively 4