Osteoarthritis of the Foot and Ankle

Dr Michelle Marshall

1. Osteoarthritis of the Foot and Ankle Dr Michelle Marshall , PhD, MSc, BSc Research Fellow, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, UK

2. I have no financial relationships with commercial interests to disclose Disclosure Information

3. Overview Foot & ankle OA Definitions Prevalence & incidence Burden Phenotypes Risk Factors Diagnosis Long-term course Management

4. Background Number of annual research study publications in PubMed related to OA by joint site

5. Atlas Knee Hip Hand Foot Ankle Kellgren & Lawrence (1963)    Lane et al. (1993)   Spector et al. (1994)    OARSI atlas - Altman et al. (1995 & 2007)    La Trobe Atlas - Menz et al. (2007)  Kraus et al. (2015)  La Trobe Atlas extension - Murray et al. (2018)  Radiographic OA atlases

6. 1 st MTPJ: first metatarsophalangeal joint 1 st CMJ: first cuneo -metatarsal joint 2 nd CMJ: second cuneo -metatarsal joint NCJ : navicular-first cuneiform joint TNJ: talo -navicular joint Foot: La Trobe Radiographic Atlas ( Menz et al. 2007 OAC )

7. 1 st MTPJ: first metatarsophalangeal joint 1 st CMJ: first cuneo -metatarsal joint 2 nd CMJ: second cuneo -metatarsal joint NCJ : navicular-first cuneiform joint TNJ: talo -navicular joint Foot: La Trobe Radiographic Atlas ( Menz et al. 2007 OAC) Views: weight-bearing DP & lateral Features: osteophytes & JSN graded 0-3 Reliability : Intra- rater k=0.52-0.95 Inter- rater k=0.13-0.87

8. Ankle: radiographic atlases Kraus et al. 2015 OAC Murray et al. 2018 PLOS ONE Joints: Tibiotalar , Talofibular & Subtalar Tibiotalar & Talofibular Views: Weight-bearing AP (Mortise) & Lateral Weight-bearing AP & Lateral Features: Osteophytes & JSN, Graded 0-3 Osteophytes & JSN, Graded 0-3 Reliability: Intra- rater k=0.15-0.94 Inter- rater k=0.09-0.72 Intra- rater k=0.87 Inter- rater k=0.30

9. Imaging: recent developments

10. How prevalent is foot & ankle OA ?

11. Definitions foot & ankle OA Symptoms e.g. pain , aching, stiffness

12. Definitions foot & ankle OA Symptoms e.g. pain , aching, stiffness Population Prevalence Foot Pain 24% Population Prevalence Ankle Pain 15% (Thomas et al. 2011 Pain)

13. Definitions foot & ankle OA Symptoms e.g. pain , aching, stiffness Structural changes e.g. radiographic

14. Systematic reviews: prevalence of foot & ankle OA Trivedi et al. 2010 OAC Murray et al. 2018 PLoS One Region Foot Ankle No. studies 27 18 ≥2 x-ray views 22% 33% Weight bearing x-rays 22% 39% Assessment of radiographic OA 74% KL 7 other methods 14 different methods Joints 1 st MTPJ = 74% Ankle Population prevalence of radiographic OA 6-39% 1 st MTPJ in middle–older adults None

15. Definitions foot & ankle OA Symptoms e.g. pain , aching, stiffness Structural changes e.g. radiographic Symptomatic (radiographic & symptoms)

16. Systematic reviews: prevalence of foot & ankle OA Trivedi et al. 2010 OAC Murray et al. 2018 PLoS One Region Foot Ankle No. studies 27 18 Two x-ray views 22% 33% Weight bearing x-rays 22% 39% Assessment of radiographic OA 74% KL 7 other methods 14 different methods Joints 1 st MTPJ = 74% Ankle Population prevalence of radiographic OA 6-39% 1 st MTPJ in middle–older adults None Population prevalence of symptomatic OA None None

17. Staffordshire, UK

18. Clinical Assessment Study of the Foot (CASF) Postal survey to all adults aged 50 years & over 4 general practices in North Staffordshire, UK Adjusted response rate 56% (n=5109) 1635 reported pain in an around the foot ≤12 months 560 attended clinic where x-rays were obtained (Roddy et al. 2011 JFAR) X X

19. In adults aged 50 years and over: (Roddy et al. 2015 ARD; Murray et al. 2018 PLoS One) Foot Ankle Symptomatic OA (radiographic & pain in last month) 16.7% 3.4% Population prevalence of OA

20. 1 st MTPJ 7.8% 1 st CMJ 3.9% 2 nd CMJ 6.8% NCJ 5.2% TNJ 5.8% (Roddy et al. 2015 ARD) Prevalence: symptomatic radiographic OA Midfoot 12.0%

21. Incidence Clearwater OA Study N=1592 adults aged 40-91 free of 1 st MTPJ OA Mean follow-up 7 years Incident radiographic OA (K&L ≥2) 25% in left 1 st MTPJ 27% in right 1 st MTPJ ( Mahiquez et al. 2006 Foot Ankle Int ) Chingford Study Follow-up 19 years Incident radiographic OA (La Trobe ≥2 ) 7% in left 1 st MTPJ 17% in right 1 st MTPJ (OARSI 2019 Poster 367)

22. What is the burden of foot & ankle OA ?

23. Burden of foot & ankle OA 69% experience disabling pain (Roddy et al. 2015 ARD) Functional limitation & impairment in balance , strength & locomotor ability ( Menz et al. 2001 J Am Podiatr Med Assoc ) Disabling foot pain is a risk factor for falls ( Menz et al. 2006 J Gerontol A Biol Sci Med Sci ) Poorer physical & social health (Bergin et al. 2012 AC&R) Reduced ability to work (OR=1.9) (Sayre et al. 2010 PLoS One) Common cause for GP consultation; 8% MSK consultations ( Menz et al. 2010 Rheumatol )

24. Are there any identifiable patterns of joint involvement?

25. Across both feet: 42% multiple (≥2) joints affected OA clustered across both feet OA was highly symmetrical 0-20.7 1 st MTPJ OR = 10.5 1 st CMJ OR = 11.5 2 nd CMJ OR = 10.0 NCJ OR = 20.7 TNJ OR = 10.3 ( Rathod et al. 2016 AC&R) Patterns of foot OA

26. Within a foot: ( Rathod et al. 2016 AC&R) Patterns of foot OA

27. No/minimal foot OA I solated 1 st MTPJ OA Polyarticular OA class size - n (%) 339 (64%) 112 (22%) 82 (15%) ( Rathod et al. 2016 AC&R)

28. No/minimal foot OA I solated 1 st MTPJ OA Polyarticular OA class size - n (%) 339 (64%) 112 (22%) 82 (15%) % Foot p ain on most / all days in last month 50% 51% 69% Mean foot p ain severity (NRS 0-10)† 5.2 4.9 6.0 MFPDI Function score (-2 to 2) † -0.7 -0.9 0.0 † Higher scores indicate greater pain and functional difficulties

29. No/minimal foot OA I solated 1 st MTPJ OA Polyarticular OA class size - n (%) 339 (64%) 112 (22%) 82 (15%) % Female Sex 52% 54% 77% Mean Age (years) 63.9 66.1 67.3 Mean BMI (kg/m 2 ) 29.9 30.1 32.5 % Nodal OA 21% 22% 34%

30. Risk factors for foot & ankle OA

31. Clinical Assessment Study of the Foot (CASF ) (Roddy et al. 2015 ARD; Thomas et al. 2015 OAC; Murray et al. 2018 PLoS One) Foot 1 st MTPJ Midfoot Ankle Gender: Men Women 14.3% 18.9% 6.7% 8.8% 10.3% 13.7% 2.9% 3.9% Age: 50-64 65-74 ≥75 15.9% 17.0% 18.5% 6.9% 8.7% 9.0% 11.8% 11.1% 14.4% 3.6% 3.2% 3.1% Socio-economic class : Managerial & professional Intermediate occupations Routine & manual 10.2% 17.9% 18.2% 4.8% 8.7% 8.3% 6.9% 12.6% 13.3% 2.4% 3.0% 4.1% Evidence of possible risk factors

32. 1 st MTPJ Bone shape & size differences ( Zammit et al. 2009 J Orthop Sports Phys Ther ) Increasing 1 st MTPJ OA severity was associated with hallux valgus & greater foot pronation ( Menz et al. 2015 OAC ) Individuals with >5 o foot pronation 23 % more likely to develop 1st MTPJ OA than normal alignment ( Mahiquez et al. 2006 Foot & Ankle Int ) Evidence of possible risk factors Arch Index

33. Midfoot Case control study midfoot OA associated with: Increase pronation Increased midfoot pressures ( Menz et al. 2010 OAC) CASF Study - Symptomatic midfoot OA associated with: Pain in other lower limb joints = aOR 8.5 Obesity (BMI ≥30 vs <30) = aOR 2.0 Diabetes = aOR 1.9 Previous injury/trauma = aOR 1.6 (Thomas et al. 2015 AR&T) Evidence of possible risk factors

34. Ankle Tertiary care patients with KL grades 3-4 70-78% Ankle OA is post-traumatic Malalignment Instability Incongruity 13-23% Secondary OA 7-9% Primary OA (Saltzman et al. 2005 Iowa Orthop J; Valderranano et al. 2009 Clin Orthop Relat Res; Nelson et al. 2017 JFAR) Evidence of possible risk factors

35. Evidence of possible risk factors Foot 1 st MTPJ Midfoot Ankle Female sex     Older age    ? Lower socioeconomic status     Bone shape & size   Foot posture, alignment or deformity    Injury/trauma   Obesity  Diabetes 

36. Diagnosis of foot & ankle OA

37. S ymptoms Pain S tiffness Clinical signs Swelling Pain on palpation Limited range of motion Crepitus Dorsal exotosis Diagnosis foot & ankle OA

38. N=181 people with 1 st MTPJ pain 77% radiographic OA Diagnostic variables pain > 25 months dorsal exostosis of 1 st MTPJ hard-end feel Crepitus <64 degrees of dorsiflexion ≥3 of these observations sensitivity 88%, specificity 71%, AUC 0.87 ( Zammit et al. 2011 OAC) Diagnosis 1 st MTPJ OA

39. N=274 people with midfoot pain 43% symptomatic radiographic OA D iagnostic variables Older age Female sex Increased BMI Increased arch index (flatter foot) Poor model fit sensitivity 30%, specificity 88%, AUC 0.64 (Thomas et al. 2015 OAC) Diagnosis midfoot OA

40. Course of foot & ankle OA

41. Radiographic course Clearwater OA Study 36-42 months Progression of 1 st MTPJ = 21-29% & 1 st CMJ = 3-7% (Wilder et al. 2005 J Am Podiatr Med Assoc ) Chingford Study 19 years Progression of 1 st MTPJ = 29% in left & 35% in right (OARSI 2019 Poster 367 ) Course of foot OA Symptomatic course CASF study 18 months Few differences seen in pain and function ( Downes et al. 2018 AC&R)

42. Management of foot & ankle OA (non-surgical)

43. Physical therapy 1 st MPTPJ OA – Package physical interventions vs package plus strengthening exercises, gait training & sesamoid mobilisation, 12 sessions in 4wks (n=20) (Shamus et al. 2004 J Orthop Sports Phys Ther ) Footwear & foot orthoses 1 st MTPJ OA – RCT Rocker-soled footwear vs foot orthoses (n=88) ( Menz et al. 2016 AC&R) Midfoot OA - feasibility pilot RCT functional foot orthoses vs sham orthoses (n=33) ( Halstead et al. 2016 Clin Rheumatol ) Management foot & ankle OA

44. Analgesia No evidence use of paracetamol (acetaminophen); topical NSAIDs & capsaicin Oral NSAIDs 2 studies in foot OA similarly effective 1000mg naproxen vs 20mg piroxicam for 8 wks ( Jennings 1994 J Am Podiatr Med Assoc ) 1000mg naproxen vs 800mg etodolac for 5wks (Jennings 1997 Lower Extremity) Management foot & ankle OA

45. Intra-articular Injections Systematic review use in ankle OA 27 studies inc 7 RCTs evaluated Hyaluronic acid Pooled results 3 studies ( n=109) Hyaluronic acid vs placebo (saline ) significantly improved pain, function & stiffness over 6m ( Vannabouathong et al. 2018 Foot & Ankle Int ) 2 RCTs 1 st MTPJ Hyaluronic acid vs corticosteroid over 3m (n=37) (Pons et al. 2007 Foot & Ankle Int ) Hyaluronic acid vs saline over 6m (n=151) ( Munteanu et al. 2011 ARD) Management foot & ankle OA

46. Summary & future directions Foot & ankle OA have been relatively neglected Symptomatic radiographic foot OA is a common problem; ankle OA less common. Foot & ankle OA are disabling, & adversely affects physical & social functioning, & ability to work Ankle OA accepted post traumatic form; isolated 1 st MTPJ OA & polyarticular OA may be different clinical entities Longitudinal studies are needed to investigate risk factors, & the incidence, progression & prognosis of foot and ankle OA Limited evidence for the conservative management of foot and ankle OA; further RCTs are needed.

47. International Foot and Ankle OA Consortium Sat 4 th May 6.30pm In Chesnut East

48. Acknowledgments Keele University Prof George Peat Prof Hylton Menz Dr Edward Roddy Dr Martin Thomas Trishna Rathod Dr Milisa Bucknall-Blagojevic Dr Charlotte Murray Dr Thomas Downes Dr B ansari Trivedi Funding for the CASF study: Arthritis Research UK (now VERSUS ARTHRITIS) Service support costs through West Midlands North CLRN

49. Thank you

50. Any Questions