What is the diagnosis and recommended management for a 51‑year‑old overweight woman with early osteoarthritis of the right ankle/foot, painful calcaneal pressure point, severe hypertension on presentation, currently taking a 7‑day course of etoricoxib (COX‑2 inhibitor) and tramadol with modest pain relief?

Diagnosis and Management Plan

This patient has early osteoarthritis of the right calcaneus with severe hypertension (180/100 mmHg), and the current etoricoxib 120 mg must be discontinued immediately due to its cardiovascular and renal toxicity, particularly given her uncontrolled blood pressure. 1

Primary Diagnoses

1. Early osteoarthritis of the right ankle/foot (calcaneus) – confirmed by X-ray findings and clinical presentation 1
2. Stage 2 hypertension (180/100 mmHg) – requires urgent management regardless of work stress 1
3. Overweight (BMI 27.01) – contributing factor to both conditions 1

Immediate Action Required: Discontinue Etoricoxib

Stop etoricoxib 120 mg immediately. The NICE guidelines explicitly state that all oral NSAIDs and COX-2 inhibitors carry significant cardiovascular, renal, and hepatic toxicity, and individual risk factors—particularly uncontrolled hypertension—must be carefully assessed before prescribing these agents 1. Etoricoxib at 120 mg is specifically mentioned as having higher cardiovascular risk 2, 3, and this patient's blood pressure of 180/100 mmHg represents a clear contraindication to continued COX-2 inhibitor therapy 1.

Revised Pain Management Strategy

First-Line: Switch to Acetaminophen

• Prescribe acetaminophen (paracetamol) 1000 mg three times daily (3000 mg total) as scheduled dosing, not as-needed 1, 4
• This is the safest first-line pharmacologic treatment for osteoarthritis pain and should have been tried before etoricoxib 1, 4
• Maximum daily dose is 4000 mg, but limiting to 3000 mg in a 51-year-old woman reduces hepatotoxicity risk 4, 5
• Regular scheduled dosing provides more consistent pain relief than PRN use 4, 5

Second-Line: Add Topical NSAID

• If acetaminophen alone provides insufficient relief after 1-2 weeks, add topical diclofenac or ketoprofen gel to the calcaneal area 1, 4
• Topical NSAIDs have minimal systemic absorption and markedly lower cardiovascular, renal, and gastrointestinal risk compared to oral NSAIDs 4, 6
• Ketoprofen gel achieves 63% response rate versus 48% with placebo over 6-12 weeks 4, 6

Tramadol Continuation

• Continue tramadol 50 mg every 8 hours as needed for breakthrough pain only 1, 7
• Tramadol is appropriate as adjunctive therapy but should not be the primary analgesic 1, 7
• It does not aggravate hypertension or cause gastrointestinal bleeding, making it safer than NSAIDs in this patient 8, 7

Essential Core Non-Pharmacologic Treatments (Must Implement)

These are mandatory components of osteoarthritis management and must be started immediately alongside medication changes 1:

Weight Loss Program

• Target 5-10% body weight reduction (3.5-7 kg loss from current 70 kg) 1
• Weight loss of ≥5% produces clinically important improvements in pain and function, with benefits increasing progressively up to 20% weight loss 1
• This directly reduces mechanical load on the calcaneus 1

Structured Exercise Program

• Prescribe local muscle strengthening exercises for the foot/ankle plus general aerobic fitness training 1
• Supervised exercise programs are more effective than home-based programs 1
• Balance exercises should be included to reduce fall risk 1

Footwear Modification

• Recommend shock-absorbing shoes or insoles immediately 1
• This is specifically indicated for calcaneal osteoarthritis to reduce impact loading 1

Patient Education

• Provide written and oral information countering the misconception that osteoarthritis is inevitably progressive and untreatable 1, 4
• Emphasize that proper management can significantly improve symptoms 1

Hypertension Management

Urgent blood pressure control is required before considering any future oral NSAID or COX-2 inhibitor therapy 1:

• Recheck blood pressure in a controlled setting (not after night shift) within 3-7 days 1
• If persistently ≥140/90 mmHg, initiate antihypertensive therapy or refer to primary care for management 1
• Document baseline blood pressure before any future NSAID consideration 1

Additional Adjunctive Options if Above Measures Fail

Intra-articular Corticosteroid Injection

• Consider a single intra-articular corticosteroid injection into the subtalar or ankle joint if pain remains moderate-to-severe after 4-6 weeks of the above regimen 1, 4
• This provides short-term relief (1-3 weeks) and is appropriate when oral NSAIDs are contraindicated 4, 6

Physical Therapy Modalities

• Local heat or cold applications to the calcaneus 1
• TENS (transcutaneous electrical nerve stimulation) 1
• Manual therapy, manipulation and stretching 1

Assistive Devices

• Consider a walking stick or cane if gait is significantly affected 1

Critical Pitfalls to Avoid

1. Never restart oral NSAIDs or COX-2 inhibitors without first achieving blood pressure control <140/90 mmHg 1, 4
2. If oral NSAIDs become necessary in the future, always co-prescribe a proton pump inhibitor for gastroprotection 1, 4
3. Do not exceed 4000 mg acetaminophen daily; strongly prefer 3000 mg limit in this 51-year-old patient 4, 5, 6
4. Do not prescribe glucosamine or chondroitin—these are not recommended due to lack of efficacy 1, 6
5. Avoid prolonged high-dose NSAID use in the future, as this patient is approaching the age group with substantially higher adverse event rates 1, 4

Follow-Up Plan

• Reassess pain level in 2 weeks after acetaminophen initiation 1
• Recheck blood pressure within 1 week in a rested state 1
• Evaluate weight loss progress and exercise adherence at 4-6 weeks 1
• Consider referral to physical therapy for supervised exercise program 1
• If symptoms remain refractory after 6-8 weeks of comprehensive management, consider podiatric foot and ankle surgery referral 1