Foot Osteoarthritis (OA)

Foot osteoarthritis is a common cause of foot pain found in one in six people aged over 50, 69% of whom report disabling foot pain. Osteoarthritis is the wear and tear of the cartilage within a joint which can lead to reduced range of motion and pain. The big toe joint (MTP) is the most commonly affected joint in the foot, followed by the midfoot joints. 

Big toe joint osteoarthritis is pain located in the 1st toe. It is found more commonly in females, with increased age and lower socioeconomic classes. Structural factors associated with the condition include a flatter foot posture and longer and wider bones around the big toe joint.

Common symptoms of big toe joint osteoarthritis include pain and stiffness within the joint. Observations include a dorsal exostosis (extra growth of bone), swelling and redness. Clinical assessments used to diagnose this condition include pain on palpation, limited range of motion (<64 degrees), crepitus (creaking/crunching) and a hard-end feel. Big toe joint osteoarthritis can be diagnosed either clinically or with radiographs.

Midfoot Osteoarthritis

Midfoot osteoarthritis is pain at the highlighted red regions in the above foot image. It is more prevalent in individuals aged over 75 years, in women and those in routine occupations, and is associated with obesity, pain in other weight bearing joints and previous foot and ankle injuries. Structural factors associated with midfoot osteoarthritis include a flatter foot posture, greater mobility of the first metatarsal (bone attaching to the big toe joint), less range of motion in other foot joints, longer central metatarsals (long bones within the foot) and increased plantar pressures.

Common symptoms of midfoot osteoarthritis include tenderness across the midfoot, made worse by passively flattening the foot. Having a flatter foot posture appears to be a useful predictor of symptomatic midfoot osteoarthritis. Due to the complexity of the midfoot, it is inherently difficult to reliability measure the motion within these joints. Although there are measures of midfoot mobility, there are currently no valid clinical measures used to diagnose midfoot osteoarthritis. Therefore, currently midfoot osteoarthritis requires radiographs to confirm its diagnosis, as the current clinical assessments have either not been studied or are not strongly correlated with its diagnosis.

Big Toe Osteoarthritis

First line treatment options for foot osteoarthritis generally include NSAIDs (anti-inflammatory medication), strengthening of the foot and lower leg, footwear modifications, foot orthoses and intraarticular injections. If conservative measures fail, surgical options are considered. 

The treatment options for big toe joint osteoarthritis have only been researched in a handful of randomised controlled studies. From these studies there is some evidence for:

• Sesamoid (big toe) manipulation/mobilisation, flexor hallucis longus strengthening (isometric and isotonic contractions) and gait retraining (reinforcing the functional use of the hallux flexors)

• Arch contouring foot orthoses

• Rocker-sole footwear

• Carbon fibre shoe stiffening inserts

When looking at non randomised controlled studies, the evidence behind the treatment of big toe joint osteoarthritis suggest that people tend to respond well to conservative treatments. These studies found treatment options such as footwear education (wider toe box), foot orthoses and corticosteroids successfully reduced pain and returned patients to previous activity.  

Treatment options I find useful for big toe joint osteoarthritis within the clinic include footwear education (wider toe box/rocker sole), taping, physical therapy (foot/ankle mobilisations/dry needling), custom orthotics with any modification to encourage first ray propulsion or decrease load through the forefoot. In addition, increasing strength within the lower limb to increase the foots capacity to withstand load [variations of calf raises, toe yoga (hallux/flexor hallucis brevis push downs while lifting lesser toes and vice versa] and proximal strengthening to the hip where required).

Midfoot Osteoarthritis

The treatment options for midfoot osteoarthritis have only been researched in one randomised control study, which compared functional custom foot orthoses with sham orthoses. This study found significant biomechanical changes and greater improvement in pain and function at 12 weeks. When looking at non randomised control studies, there is evidence which found NSAIDS (anti-inflammatory medication), physical therapy, corticosteroids, foot orthoses, carbon fibre insoles and surgery beneficial in midfoot osteoarthritis. 

Treatment options I find useful for midfoot osteoarthritis within the clinic include footwear education (lacing techniques for the dorsal foot/encouraging less compression on the midfoot from tight footwear), custom orthotics designed to decrease the compressive forces in the midfoot and reduce plantar pressures in the heel and midfoot. As there is some evidence that people with midfoot osteoarthritis have more mobility within their first metatarsal, similarly to big toe joint osteoarthritis, strengthening the lower limb and muscles that insert into the foot may help stabilise the joints within the foot.

In addition, people with midfoot osteoarthritis have less range of motion in the big toe and subtalar joint – so any treatments to encourage the mobility within these joints may be of benefit (foot/ankle mobilisation/dry needling/stretching/strengthening). However future research is required to further our knowledge for the best treatment options for both big toe joint and midfoot osteoarthritis, as currently the evidence is extremely limited. 

If you have any questions on whether physio is the best option for you, or you have any questions about MVMNT in general, feel free to contact via email.

- Jay Towolawi, Specialist Sports Physiotherapist and MVMNT Founder.