Management of Degenerative Arthritis of the Foot
Begin with a structured exercise program and weight loss (if overweight), then add topical NSAIDs for accessible joints or oral NSAIDs for polyarticular involvement, reserving intra-articular corticosteroid injections for acute flares or refractory symptoms. 1, 2
Core Non-Pharmacological Interventions (Start Here for All Patients)
Initiate these immediately—they are as important as medications:
Exercise programs should include strengthening exercises, aerobic activity (walking), and range of motion exercises performed daily. 3 Aquatic exercise provides an excellent alternative for patients with difficulty tolerating weight-bearing activities. 2
Weight loss is mandatory for overweight or obese patients, as even modest reduction (5-10% body weight) significantly improves symptoms and slows disease progression. 3, 1, 2 Combined weight loss and exercise programs are more effective than either alone. 2
Self-management education must be provided at the initial visit and reinforced at every encounter, covering the nature of osteoarthritis, activity pacing, and joint protection techniques. 3, 1, 2
Appropriate footwear should be recommended to reduce adverse mechanical factors, though specific evidence for foot OA is limited. 3
Assistive devices including walking aids should be considered to reduce joint load and improve mobility. 3, 1
Pharmacological Management Algorithm
First-Line Pharmacotherapy
For localized foot joint involvement: Start with topical NSAIDs as they provide effective pain relief with minimal systemic exposure. 1, 2 This is particularly appropriate for accessible joints like the first metatarsophalangeal joint.
For polyarticular involvement (multiple foot joints or foot plus other joints): Use oral NSAIDs (naproxen, ibuprofen) at the lowest effective dose for the shortest duration. 3, 2, 4 Always assess cardiovascular and gastrointestinal risk factors before prescribing. 3
Acetaminophen (up to 4,000 mg/day) can be used initially due to favorable safety profile, though efficacy is modest and likely inferior to NSAIDs. 3, 2, 4
Second-Line Options (If Inadequate Response)
Intra-articular corticosteroid injections provide short-term relief (weeks to months) for moderate to severe pain or acute flares in specific joints. 3, 1, 2, 4 Evidence for foot joints is limited but extrapolated from knee/hip data.
Topical capsaicin can be added as adjunctive therapy, though application may be challenging on foot surfaces. 3, 1
Duloxetine (30-60 mg/day) should be considered if inadequate response to NSAIDs or if comorbid depression exists. 3, 1, 2
Tramadol is reserved for refractory cases when other options have failed, but carries risks of dependence and side effects. 3, 1, 2, 4
Third-Line Considerations
- Intra-articular hyaluronic acid may provide short-term benefit for ankle OA specifically, though evidence is limited and controversial. 3, 5
Physical Modalities and Adjunctive Treatments
Local heat or cold applications can provide symptomatic relief as needed. 3, 1
Transcutaneous electrical nerve stimulation (TENS) may be used for pain relief. 3, 1
Manual therapy (manipulation and stretching) can be considered, though evidence is limited. 3, 1
Tai chi combines neuromotor exercise with balance training and is conditionally recommended. 3, 1, 2
Treatments NOT Recommended
Do not prescribe glucosamine or chondroitin despite patient requests—evidence shows lack of efficacy. 3, 1, 2
Avoid long-term opioids—evidence does not support their use and they carry significant harm. 3, 2
Electroacupuncture is not recommended. 3, 1 Standard acupuncture has insufficient evidence despite some trials. 3
Surgical Considerations
Arthroscopic debridement may provide interim relief in early arthritis with preserved range of motion, particularly for impinging osteophytes and loose bodies. 6 However, this is controversial and not routinely recommended.
Arthrodesis (fusion) of mid-tarsal, tarsometatarsal, or first metatarsophalangeal joints is the definitive surgical option for severe, refractory disease with established functional limitation. 6, 7 Success rates exceed 90% with high patient satisfaction. 7
Do not delay definitive surgical treatment once conservative management has clearly failed, as prolonged conservative therapy leads to established functional limitation and severe pain. 3, 4
Critical Pitfalls to Avoid
Do not delay exercise therapy while waiting for medications to work—exercise is equally important as pharmacotherapy and must be implemented immediately. 2
Do not focus solely on pharmacotherapy—the non-pharmacological interventions form the core management and must be prioritized. 3, 2
Do not use oral NSAIDs without assessing cardiovascular and gastrointestinal risk—implement gastroprotection with proton pump inhibitors when indicated. 3
Do not continue ineffective treatments—if a modality provides no benefit after an adequate trial (typically 2-4 weeks for medications, 6-8 weeks for exercise), discontinue it and move to the next option. 3
Special Considerations for Foot OA
The first metatarsophalangeal joint and midfoot are most commonly affected, with ankle involvement less frequent. 8, 5 Despite high prevalence, foot OA has been neglected by researchers, and most recommendations are extrapolated from knee and hip OA studies. 8, 5 Imaging with plain radiographs remains common due to lack of accepted clinical diagnostic criteria. 8, 5