Background Pain in the first metatarsophalangeal joint (MTPJ) is common, though the link between pathology and symptoms is poorly understood.

Objectives To examine the relationship between pain, function and ultrasound (US)-detected pathology in the first MTPJ.

Methods 33 subjects with first MTPJ pain and 20 asymptomatic controls completed questionnaires about pain and function, then underwent clinical examination, US examination and objective assessment of function using a motion tracking system.

Results Low-level grey scale synovitis and osteophytes were common in patients and controls. Osteophytes were more prevalent in symptomatic first MTPJ [24/33 (73%) vs. 7/20 (35%), p=0.007], and greater osteophyte numbers were weakly associated with higher levels of pain [increase in pain VAS per osteophyte (95% CI)=13.78mm (0.12mm-27.43mm), p=0.048]. A power Doppler (PD) signal was present in a fifth of painful first MTPJs and absent in controls. A PD signal was associated with osteophytes and joint space narrowing but was not independently related to target joint pain. For all first MTPJs, osteophytes and the presence of a PD signal was associated with worse patient-reported function. US features did not predict objective function.

Conclusion Osteophytes, representing subchondral bone remodelling, were associated with the presence of first MTPJ pain and, together with more severe (PD) synovitis, also contributed to poorer function. Detailed imaging of bone may provide more information on peripheral pain associations.