Nonpharmacologic Treatment Options for OA Pain of the First MTP Joint

Footwear and orthoses can provide relief for those experiencing pain from osteoarthritis of the first MTP joint.

Patient preference and footwear choices may play a role in the success of treatments for osteoarthritis (OA) of the first metatarsophalangeal (MTP) joint, according to a recent Australian study by conducted Menz and colleagues, published in Arthritis Care and Research.  The investigators reported that foot orthoses were perceived by users to offer greater improvement in pain compared with “rocker” footwear.

An estimated 35% of people older than age of 35 show radiographic signs of osteoarthritis of the first MTP joint,1 and  nearly 8% of people older than age 50 exhibit progressive symptoms of joint pain and stiffness, bone deformity, and impaired range of motion.2 Previous evaluation of treatments for osteoarthritis of the first MTP joint—including surgical interventions, physical therapy, anti-inflammatory medications, orthoses, and footwear—has been limited and the findings largely inconclusive.3

“Our research suggests that footwear and orthoses may help alleviate pain by altering the distribution of load under the foot while walking,” reported lead author Hylton Menz, PhD. A total of 102 participants aged 22 to 78 years were randomly assigned to receive either foot orthoses (n=52) or rocker footwear (n=50). All participants received an informational handout on the care and use of their intervention.

Modalities Compared

The chosen orthotics supplied were customized to each patient, using full-length inserts modified with cutouts below the first MTP joint. Those who showed a pronation score of at least 7 points on the Foot Posture Index (FPI) also received a beveled wedge that was customized to improve the score by at least 2 points.3,4 The second group received a personally fitted pair of rocker-sole shoes designed with a rounded heel and soft cushioned sole to roll the foot forward.


After 12 weeks of use, both groups showed indications of improved foot health, as measured by increases in the Foot Health Status Questionnaire (FHSQ) pain domain score of 17 points in the orthoses group and 22 points in the rocker footwear group.  

Those wearing orthoses had a global perception of greater improvement in secondary outcomes including functional status, pain and stiffness, and physical activity levels, although statistical measurements of these domains were similar in both groups.

Differences in adherence between the groups may have influenced outcomes; people in the orthoses group wore their inserts for an average of 448 hours compared with a much lower 287 hours of wear among the footwear group. The investigators attributed this significant difference in wearing times largely to aesthetic choices, as the shoes may have not been considered attractive by all participants, matched all attire, or been considered “work appropriate” in all cases. Benefits to the orthoses, the authors pointed out, were that they were transferrable to most types of footwear and were hidden from view.

Additionally, more people in the rocker footwear group complained of mild adverse events, including blisters and general discomfort. A more significant problem was an increase in new back pain, although people with existing back pain may have experienced improvement.

Summary and Clinical Applicability

MTP joint pain secondary to joint damage in OA is a common cause of metatarsalgia. Appropriate foot wear and orthoses have been shown to alleviate pain in the first MTP joint from OA.  Foot orthoses with metatarsal pads may help redistribute and relieve pressure from the joints. For more severe limitation of 1st metatarsophalangeal motion or pain, the use of rigid orthoses, carbon fiber plates, or external shoe bars or rocker soles may be necessary to reduce motion at the joint.


  1. Trivedi B, Marshall M, Belcher J, et al. A systematic review of radiographic definitions of foot osteoarthritis in population-based studies. Osteoarthr Cartil. 2010;18:1027-1035.
  2. Roddy E, Thomas MJ, Marshall M, et al. The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: the Clinical Assessment Study of the Foot. Ann Rheum Dis. 2015;74:156-163.
  3. Vanore JV, Christensen, J, Kravitz SR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: hallux rigidus. J Foot Ankle Surg.2003;42:124-136.
  4. Walsh BJ, Redmond AC, Chockalingam N, et al. A case-series study to explore the efficacy of foot orthoses in treating first metatarsophalangeal foot pain. J Foot Ankle Res. 2010;3:17.