Available literature and quality of the evidence

A single systematic review of levels I–IV evidence (level IV) summarizes the vast majority of evidence on nonoperative treatment of 1st MTP OA. King et al. reviewed 11 studies on this topic, including one randomized controlled trial (RCT), two level II studies, and one level IV study.³ The review included a total of 1600 patients. The modalities included in this review were intra‐articular injections, manipulation and physical therapy, and orthotics and footwear modifications. There is no clinical evidence for the use of oral NSAIDs in 1st MTP OA; in fact, a recent review on this topic extrapolated from hip and knee OA evidence.⁴

Findings

The systematic review by King et al. found that, overall, the evidence was consistent in supporting the efficacy of physical therapy and footwear modification/orthoses, but more mixed when it came to intra‐articular injection in terms of treating 1st MTP OA.³

In terms of modification in footwear, insoles, and orthotics, there was only level III and IV evidence available. Success of orthoses was found to be 55% in a large study of 772 patients.¹ Similarly, 63% of patients in a longitudinal case series with over 14 years of follow‐up reported that they were satisfied with footwear modification as a first‐line therapy and would make the same decision again given the opportunity.⁵ Overall, King et al. made a Grade C recommendation (poor level evidence with consistent findings) for the use of orthotics or footwear modifications in the treatment of 1st MTP OA.³

Physical therapy is another mainstay in the treatment of most forms of OA. King et al. found two studies looking at the treatment of 1st MTP OA with physical therapy and/or manipulation.³ A downgraded RCT (level II) which used birthdates to randomize patients to physical therapy or control groups found that the intervention group had significantly better range of motion (42.7° ± 7.8° vs 14.4° ± 8.0°, p <0.001), flexor hallucis longus strength (3.5 ± 1.0 kg vs 0.7 ± 0.4 kg, p <0.001), and pain reduction (6.4 ± 1.3 vs 2.6 ± 1.1 kg, p <0.001).⁶ A small retrospective case series (level IV) found that duration of pain relief after manipulation was dependent on radiographic OA grade according to the Karasick and Wapner classification (Grades 1–3, 1 being least severe). Patients with Grade 1 OA had symptom relief for a median of six months, compared to only three months for Grade 2 and no relief for Grade 3.⁷ Overall, King et al. also assigned a Grade C recommendation (poor level evidence with consistent findings) for physical therapy/manipulation.³

There were six studies looking at various types of injectable therapies for 1st MTP OA. King et al. found that the higher‐quality evidence available for injection therapy (levels II and III) suggested either no benefit for injection, or a benefit that lasted three months or less.³ In their meta‐analysis of hyaluronic acid injection studies specifically, they did find that the standardized mean difference (SMD) showed a benefit for both rest pain (SMD = −0.52; 95% confidence interval [CI]: −0.77 to −0.28) and walking pain (SMD = −0.44; 95% CI: −0.83 to −0.05) with low heterogeneity (I² = 10.2%). Interestingly, despite the results of this meta‐analysis, King et al. made a Grade B recommendation (fair evidence with consistent findings) against injection as an effective treatment for hallux rigidus.³

Resolution of clinical scenario

• Overall, there is scarce, low‐quality evidence for nonoperative treatment of 1st MTP OA.
  
• Based on consistent findings among level II–IV evidence, physical therapy, footwear modification, and orthoses are effective in providing symptom relief in the treatment of 1st MTP OA. In addition, these therapies may be more effective in patients with milder disease.
  
• Evidence for injection therapy in 1st MTP OA is mixed, with some moderate‐quality evidence suggesting no benefit, especially beyond three months. Lower‐quality evidence suggests there may be a benefit, particularly when it comes to hyaluronic acid injection.