Management of first metatarsophalangeal joint osteoarthritis by physical therapists and podiatrists in Australia and the United Kingdom: a cross-sectional survey of current clinical practice

This study was a survey of podiatrists and physical therapists in Australia and the UK. The two countries were chosen due to their similar health care systems and the comparable scopes of practice of the two professions in each. Protocols were approved by the institutional Ethics Committee and participants provided informed consent.

Between July and September 2015, we contacted the Australian Podiatry Association, Australian Physiotherapy Association, The College of Podiatry (UK), The Chartered Society of Physiotherapy (UK) and our podiatry and physiotherapy clinical and university partners (e.g. hospital department managers, local clinics). Our email explained the purpose of our study and requested the distribution of a link to the study plain language statement and the survey. We also advertised directly to podiatrists and physical therapists in Australia and the UK on Facebook. All podiatrists and physical therapists currently registered and practising in Australia and the UK, and who self-reported managing at least one patient with first MTP joint OA in the previous 6 months, were eligible to participate.

Prior to drafting the survey, we conducted a literature search to identify published assessment and treatment approaches for older people with foot pain and/or symptomatic first MTP joint OA. Given the very limited research on the condition, any approach that was published in English was included. Survey questions and a case vignette of a typical patient with first MTP joint OA were then drafted. Case vignettes, which consist of ‘text, images or other forms of stimuli to which research participants are asked to respond’ [11], are accurate and valid tools for assessing clinical practices [12]. The survey was then completed by the researchers and a small number of clinicians currently treating people with first MTP joint OA to test the survey length, and to check for clarity and errors. Interested participants accessed the online survey either directly, by selecting the link distributed in the study information, or by contacting the lead researcher (KP). The survey was administered online using Survey Gizmo (www.​surveygizmo.​com; Boulder, CO) and took approximately 15 min to complete.

The survey comprised six main sections. Sections one and two contained a plain language statement outlining the study, and eligibility questions. Section three contained general demographic questions regarding occupation, qualification(s) and year(s) gained, sex, age, employment setting and grade, frequency treating patients with symptomatic first MTP joint OA, and postgraduate training. The remaining sections of the survey all began with the same first MTP joint OA case vignette (Table 1), followed by questions regarding assessment and treatment practices that clinicians may use at some stage over the course of the patient’s management. Of these, section four presented questions regarding specific investigations, physical performance/impairment measures, and tools and questionnaires relevant for the first MTP joint OA case. This section also contained general questions regarding common treatment approaches and practices for the case patient, such as intervention approaches, referrals, and patient advice including analgesia use and weight loss. Section five included questions on specific exercise prescription practices for the first MTP joint OA case patient, and the final survey section contained a series of questions regarding the prescription and types of foot orthoses. For each of these sections, respondents were required to select from a list any items that they felt were important to use when assessing or treating a patient with OA of the first MTP joint. In addition to selecting a response, respondents were also able to make suggestions for additional assessment or treatment items they felt were important but not included in the survey. Responses for each item selected or suggested were then summed to determine the number of respondents who used each approach.

Data were imported and analysed using SPSS Version 25 (IBM Corporation, Armonk, NY, USA). Demographic data for the group as a whole, and for podiatrists and physical therapists separately, were described using mean (standard deviations; SD), median (inter-quartile range; IQR) or number (percentage), as appropriate. Chi-square tests were used to investigate differences between podiatrists and physical therapists. Where associations were found, standardised residuals were examined to identify sources of significant differences.

Two hundred respondents (n = 113 (57%) podiatrists and n = 140 (70%) from Australia) completed the survey. The clinical and demographic characteristics of the sample are displayed in Table 2. There were slightly more females and podiatrists in the sample, and the group had an average of nearly 15 years of clinical experience. Characteristics of the podiatrist and physical therapist clinician subgroups were generally similar, although there were more physical therapist respondents than podiatrists from the UK, and there were more podiatrists than physical therapists in the 40–49 years age range. More podiatrists than physical therapists reported treating patients with first MTP joint OA frequently (28% vs 16%, P < 0.001) and very frequently (51% vs 1%, P < 0.001) and fewer reported treating these patients infrequently (2% vs 26%, P < 0.001) and somewhat frequently (19% vs 56%, P < 0.001). More physical therapists had undertaken postgraduate training in exercise therapy (51% vs 23%, P = 0.000) and manual therapy (64% vs 37%, P = 0.001), whilst more podiatrists had undertaken postgraduate training in pharmacology (21% vs 7%, P = 0.02) and orthotic/footwear prescription (55% vs 23%, P < 0.001).

Assessment tests for the vignette patient with first MTP joint OA are listed in Table 3. In the cohort as a whole, most (n = 164, 82%) indicated that they would order some kind of investigation, predominantly an x-ray (n = 151, 92%), with few other investigations typically performed. Most (n = 141, 71%) said they would use a standardised performance or impairment measure, with the most common being first MTP joint range of motion, visual gait assessment, and a foot posture assessment. Half of the sample indicated that they would use a patient-reported questionnaire as part of the assessment, most frequently a visual analogue or numerical rating scale of pain.

Responses from podiatrists and physical therapists were similar, except more podiatrists indicated that they would perform Jack’s test/Hubscher’s manoeuvre (P < 0.001) and use the Foot Function Index (P < 0.007). More physical therapists indicated they would want a laboratory test performed on the patient (P = 0.007), and that they would use heel raise (P = 0.008) and hallux strength (P = 0.004) tests, and use the Short Form 12 or 36 questionnaire (P = 0.001).

A range of treatment strategies were employed by the respondents to treat the vignette patient with first MTP joint OA (Table 4). In the entire cohort, the most common strategy was taping or padding, followed by exercise therapy, and hallux mobilisation/manipulation. Nearly all respondents indicated that they would offer advice, and that they would address analgesic use and the patient’s weight as part of the treatment.

There were several differences in the treatments most commonly used by podiatrists and physical therapists to manage the vignette patient. For example, more podiatrists indicated that they would use shoe stiffening inserts (p < 0.001) and more would advise the patient on appropriate footwear (p = 0.005) and to avoid painful movements/activities (p = 0.04). In contrast, more physical therapists said they would use exercise therapy, hallux and other joint manipulation/mobilisation, massage, and gait retraining (all p < 0.001), and more would advise the patient on pacing of activities and nutrition (both p < 0.001) and on use of heat/ice (p = 0.032). More podiatrists indicated that they would discuss/recommend over-the-counter (p < 0.001) and alternative (p = 0.012) medications, while more physical therapists said they would advise the patient to discuss analgesia with their general practitioner (p = 0.010) and would provide advice about weight loss (p = 0.001).

Table 5 lists the most common exercise and orthotic treatments that podiatrists and physical therapists would use for the vignette patient. Flexibility/range of motion exercise was the most common response in the group as a whole, followed by intrinsic and extrinsic muscle strength exercises. More than three quarters of the sample/indicated that they would use a foot orthosis, with most using a custom-made device followed by a prefabricated device.

There were a number of differences between the most common exercise and orthotic approaches used by podiatrists and physical therapists. For instance, more podiatrists indicated that they would prescribe an orthotic device (p < 0.001), and of those, most would prescribe custom orthoses (p < 0.001). In contrast, more physical therapists than podiatrists indicated that they would use exercise approaches (p < 0.001). In particular, more physical therapists responded that they would use intrinsic and extrinsic foot strengthening, aerobic training, and proprioception/balance exercise (all p < 0.001), as well as hydrotherapy (p = 0.008) and increasing general exercise (p = 0.004). Although fewer physical therapists than podiatrists indicated that they would prescribe orthoses, those that did mostly responded that they would prescribe an over-the-counter device (p = 0.005).