It can affect one or several joints: talonavicular, sub-talian and phalangeal metatarsus, the most frequent.
It usually appears because of a static problem of the foot or after a trauma. The best treatment is preventive: correction of static problems (use of corrective templates) and acquired or constitutional architectural vices, rapid treatment of eventual fractures.
There are no specific recommendations for its treatment, which does not differ from the treatments usually proposed in Osteoarthritis and is based, therefore, on the association of non-pharmacological and pharmacological measures.
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Non-pharmacological treatments
Orthotic treatment
- Standard standard footwear
- Footwear is paramount. The doctor must insist on its importance to the patient. The latter should privilege wide and deep shoes. The heel should not be more than 4 cm. The sole must be thick and of good quality to absorb the loads and the blows.
Orthopedics Osteoarthritis of the foot
- The plantar orthoses
- Custom-made plantar orthoses can be made. They must be made by a podiatrist with precision, they must be adapted to the patient and can be used in standard shoes as long as they do not have a heel of more than 4 cm. Indeed, beyond 4 cm, the back of the foot is no longer functional and the front of the foot does not extend when performing the step, which suppresses the possibilities of action of the sole. Sometimes it may also be necessary to resort to new shoes or a half number plus, to enter the template.
- The plantar orthoses are made with flexible materials. They must adapt to the expected objective: distribution of the supports, absorption of the blows, maximum comfort, rigid sole in the form of cradle to reduce to the maximum the movement of the metatarso-phalangeal joint in the case of hallux rigidus. The patient must be warned that the plantar orthosis, like the appliances, requires an adaptation time (usually 8 to 15 days).
- The other adapted solutions
- In case of major deformations of the foot in relation to an evolved Osteoarthritis, customized orthopedic shoes can be made.
- Orthoplasty
- Orthoplasty consists of manufacturing a custom-made toe device designed to reduce a deformation or suppress a painful support. The toe orthosis is worn with the use of shoes. It can be associated with a plantar orthosis. For example, in the case of dorsal osteophyte in relation to a metatarso-phalangeal osteoarthritis of the first radius (hallux rigidus), limiting rubbing with the shoe.
Patient education It is necessary to inform the patient about the importance of joint saving measures. They have to give advice for joint rest. This rest consists of a limitation of standing stops and long walks.
Re-education
Its objective is to maintain the functional potential. Associates various techniques such as reeducation of walking, foot and plant massage, flexibility exercises, active and passive mobilizations (hallux rigidus incipient), muscular reinforcement, proprioception and sensory afferentation (stimulates plantar sensitivity), physiotherapy that associates the thermotherapy and ultrasound.
Local treatments
They must be privileged with regard to systemic treatments.
Topics
Applied locally, NSAIDs are effective in superficial Osteoarthritis. They have fewer side effects and are better tolerated than oral NSAIDs.
Intra-articular corticosteroid treatments
Used as a symptomatic treatment for all arthrotic joints, they can be injected intra-articularly in case of painful access to quickly relieve the patient.
Its effects usually disappear after a few weeks. Relative rest of the infiltrated joint is recommended for 24-48 hours.
Systemic treatments
Analgesics: paracetamol
The choice of analgesic treatment is based on an accurate estimate of pain. The intensity of the pains should be taken into account to prescribe an analgesic of adapted effectiveness. The recommended analgesic of first intention is paracetamol, up to 3 grams a day.
It is necessary to take repeated shots to be effective, and this must be explained to the patient. Your tolerance is good. In case of renal insufficiency or chronic alcoholism, it is convenient to adapt the doses.
Non-steroidal anti-inflammatories and Coxibs
NSAIDs should be reserved as a 2nd option in case of failure of paracetamol and / or in case of inflammatory access.
They should always be prescribed and used at the lowest effective dose and for the shortest possible time.
The choice of an NSAID should be made taking into account its safety profile and the individual risk factors of the patient.
There is no need to prescribe conventional NSAIDs or coxibs in case of an evolutive peptic ulcer or gastro-intestinal bleeding, a history of digestive bleeding or perforation during NSAID treatment.
NSAIDs are susceptible to induce an acute IR, it is necessary to remain particularly attentive with patients treated with diuretics, which present a risk of hypovolemia or impaired renal function.
In patients with confirmed ischemic heart disease, peripheral arterial disease and / or history of stroke (including transient ischemic attack), coxibs are contraindicated and non-selective anti-inflammatory drugs should be used with caution after thorough evaluation.
Opioid analgesics
In case of rebellious pain, intolerance to paracetamol or counter-indication to NSAIDs, it is possible to resort to analgesics of sections 2 and 3 of WHO (weak and strong opioids).
They can allow to pass a painful episode, but they have frequent undesirable effects (nausea-vomiting, problems of higher functions, severe constipation).
Its indication and its benefit / risk ratio must be well evaluated.
Surgical treatment
hallux rigidus
Surgical treatment concerns, in 90% of cases, hallux rigidus.
It is summarized to the arthrodesis that indolence contributes in exchange for a loss of mobility that, in general, is already very compromised. The prosthetic replacement of the first metatarsophalangeal joint remains controversial. In effect, all the prostheses have shown to have a high complication rate (early unsealing, implant fracture, dislocation ...) Outside the first radius, surgery is proposed as a last resort.
It should be noted that foot surgery is delicate and, depending on the series, complications reach 10 to 30% of cases. The most frequent complications are: infection, phlebitis, unsightly scars or protrusions and difficulties to wear (residual edema).