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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

Objective

To determine whether there are differences in the foot-specific and general health-related quality of life (HRQOL) of people with and without first metatarsophalangeal (MTP) joint osteoarthritis (OA).

Methods

The foot-specific and general HRQOL of 43 participants (mean ± SD age 50.0 ± 10.8 years) with symptomatic radiographically confirmed first MTP joint OA (case group) was compared to an age-, sex-, and body mass index–matched control group. Foot-specific HRQOL was assessed using the Foot Health Status Questionnaire (FHSQ) and general HRQOL was assessed using the Short Form 36 (SF-36) questionnaire. Both questionnaires are validated instruments with 0–100-point domains.

Results

All domains of the FHSQ were significantly lower in the case group (mean ± SD foot pain 55.5 ± 22.3 versus 93.0 ± 7.8, foot function 73.8 ± 20.9 versus 96.9 ± 11.5, footwear 39.1 ± 28.7 versus 76.6 ± 27.0, and general foot health 50.2 ± 27.0 versus 89.7 ± 16.0). Further, the SF-36 physical functioning domain was significantly lower (mean ± SD 82.8 ± 14.7 versus 95.2 ± 6.3) in the case group.

Conclusion

People with first MTP joint OA experience more foot pain, have greater difficulty performing functional weight-bearing activities, find it more difficult to obtain suitable footwear, and perceive their feet to be in a poorer state of health. Additionally, people with symptomatic first MTP joint OA have greater difficulty performing a broad range of physical tasks and activities.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

Osteoarthritis (OA) is the leading cause of chronic pain and disability among older people in developed countries (1). Several large population-based studies have reported that radiographic OA of the first metatarsophalangeal (MTP) joint of the foot is common (2). The prevalence of the condition increases with age, and radiographic first MTP joint OA is present in approximately 46% of women and 32% of men at age 60 years (3). Characteristic radiographic features include joint space narrowing (JSN), osteophyte (OP) proliferation of the metatarsal head and proximal phalanx, subchondral sclerosis, subchondral cysts, and sesamoid hypertrophy (4, 5).

OA of the first MTP joint has been commonly described as either hallux limitus or hallux rigidus. The term used depends on the magnitude of available joint motion and the severity of joint degeneration (4). Hallux limitus is characterized by restricted sagittal plane motion (primarily dorsiflexion), whereas hallux rigidus displays an absence of joint motion due to end-stage degenerative joint disease and subsequent joint ankylosis (4). Although the terms are often used interchangeably, hallux rigidus has been adopted by the World Health Organization in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (6).

People with symptomatic first MTP joint OA typically present with localized pain, stiffness, and an enlarged joint (4, 5). Symptoms are commonly exacerbated by activity and alleviated by rest (4, 5). Reduced first MTP joint dorsiflexion inhibits efficient forward transfer of body weight during the propulsive phase of gait and subsequently leads to alterations in normal foot function (4, 7). Treatment interventions for this condition primarily focus on providing symptomatic relief (8). However, few well-designed studies have investigated the efficacy of these interventions (8).

Traditionally, the severity of chronic musculoskeletal conditions has been categorized according to the level of pain experienced. However, this approach may not necessarily provide a comprehensive and accurate assessment of condition severity from the patient's perspective (9). Health-related quality of life (HRQOL) takes into consideration the patient's perspective of the impact that a chronic condition has on their physical, psychological, and social health and well-being. HRQOL has become a standard and widely used measure of the broad impact of chronic musculoskeletal conditions, including OA (10–13).

A number of generic and specific HRQOL questionnaires have subsequently been developed (10). Generic questionnaires assess universal aspects of general health and well-being, whereas specific questionnaires assess aspects of HRQOL that are associated with a specific condition or body region (10, 14). The Short Form 36 (SF-36) questionnaire (15) and Foot Health Status Questionnaire (FHSQ) (16) are examples of commonly used generic and foot-specific HRQOL measures, respectively. Despite increasing recognition of their importance, few studies have used HRQOL measures to investigate the broad impact of first MTP joint OA (17–19). Using the FHSQ, 3 studies have suggested that symptomatic first MTP joint OA is associated with reduced foot-specific HRQOL (17–19). However, none of these studies compared people with symptomatic first MTP joint OA to an asymptomatic control group. Therefore, it is not possible to determine whether a difference in foot-specific HRQOL exists between people with and without this condition. In addition, the association between symptomatic first MTP joint OA and general HRQOL has not been investigated. Consequently, the impact of symptomatic first MTP joint OA on foot-specific and general HRQOL is not clearly understood.

Therefore, the aim of this study was to determine whether there are differences in the foot-specific and general HRQOL of people with and without radiographically confirmed symptomatic first MTP joint OA.

Significance & Innovations

  • This is the first study to explore the impact of first metatarsophalangeal (MTP) joint osteoarthritis (OA) on foot-specific and general health-related quality of life (HRQOL) using a case–control study design.

  • People with symptomatic first MTP joint OA display reduced foot-specific and general HRQOL.

  • Interventions for first MTP joint OA that focus on improving foot-specific and general HRQOL may lead to better patient outcomes.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

This investigation formed part of a randomized controlled trial (RCT) assessing the efficacy of intraarticular hyaluronan (hylan G-F 20) for the treatment of radiographically confirmed symptomatic first MTP joint OA (20, 21). Participant recruitment occurred between March 2007 and February 2012. The study was approved by the Human Ethics Committee of La Trobe University, Australia (10–005). Written informed consent was obtained from all participants prior to data collection.

Participants.

The case group was comprised of 43 participants with radiographically confirmed symptomatic first MTP joint OA. Case group participants were randomly drawn from a recent RCT (20, 21). Inclusion criteria for the case group were symptoms of pain in the first MTP joint for at least 3 months, pain rated as at least 20 mm on a 100-mm pain visual analog scale (VAS), pain upon palpation of the dorsal aspect of the first MTP joint, radiographic evidence of first MTP joint OA (score of ≥2 for either OP or JSN in either the dorsoplantar or lateral view using the La Trobe University Radiographic Atlas of Foot OA [22]), and <55° of passive first MTP joint dorsiflexion.

The control group was comprised of 43 asymptomatic participants that did not display radiographic features of first MTP joint OA. Control group participants were matched to the case group participants for age (±5 years), sex, and body mass index (BMI; ±5%). Control group participants were recruited from several sources, including advertisements in daily newspapers, university newsletters, sports and social club newsletters, and classified websites, and posters displayed at universities, community centers, and shopping centers, as well as sports and social clubs. Inclusion criteria for the control group were absence of pain in either lower extremity for the previous year, no radiographic evidence of first MTP joint OA (score of ≤1 for both OP and JSN in both the dorsoplantar and lateral views using the La Trobe University Radiographic Atlas of Foot OA [22]), and ≥55° of passive first MTP joint dorsiflexion.

Participants in both groups were required to be at least age 18 years and able to walk household distances (>50 meters) without the aid of a walker, crutches, or a cane. Exclusion criteria for both groups were previous surgery at the first MTP joint; intraarticular steroid or any other intraarticular injection at the first MTP joint in the previous 6 months; bacterial infection(s) of the foot; significant deformity of the first MTP joint, including hallux abducto valgus; presence of peripheral vascular disease; presence of foot or lower extremity pain (apart from first MTP joint pain in the case group); presence of any systemic inflammatory condition; any medical condition that the investigators deemed to make a participant unsuitable for inclusion; pregnant or lactating women; cognitive impairment; and involvement in any clinical research study in the previous 3 months.

Data collection.

Assessments were completed at a Health Sciences Clinic at La Trobe University, Melbourne, Victoria, Australia. Assessments for the case and control groups were performed by 2 of the authors (GVZ and SMB, respectively). In order to satisfy the assumption of independence for data, 1 foot was assessed for each participant (23). The foot with the most painful first MTP joint was assessed for case group participants. The control group participants had the same foot assessed as the matched case group participant.

Medical history and demographic information.

All of the participants completed a questionnaire to obtain information concerning their medical history, current medications, and level of education (years). Case group participants were also required to provide the following information: first MTP joint affected (left, right, both), duration of first MTP joint pain (months), and severity of first MTP joint pain during walking (100-mm pain VAS) and rest (100-mm pain VAS) over the previous week (20). Height (cm), weight (kg), and BMI (kg/m2) were calculated for each participant.

Assessment of first MTP joint dorsiflexion range of motion.

Passive non–weight-bearing dorsiflexion range of motion of the first MTP joint was measured in accordance with the procedure described by Hopson et al (24). The first metatarsal and proximal phalanx of the hallux were bisected in the sagittal plane. A dorsiflexion force was then applied to the hallux until end range of motion was reached. The angle between the 2 lines was measured using a handheld goniometer. We have shown that the interrater reliability for this measurement in people displaying first MTP joint pain is excellent (intraclass correlation coefficient [ICC] 0.95, 95% confidence interval 0.88–0.98) (25).

Radiographic severity of first MTP joint OA.

Weight-bearing dorsoplantar and lateral foot radiographs were obtained with the participant standing in a relaxed bipedal stance position. All radiographs were taken by the same medical imaging company using a Shimadzu UD150LRII 50 kW/30 kHz Generator, 0.6/1.2 P18DE-80S high-speed x-ray tube, and AGFA MD40 CR digital phosphor plates in a 24 cm × 30 cm cassette.

The La Trobe University Radiographic Atlas of Foot OA was used to assess the severity of first MTP joint OA on the dorsoplantar and lateral foot radiographs (22). All measures were conducted by 1 experienced rater (SEM), who was involved in the development of the atlas. The presence of JSN was graded as either none (score 0), definite (score 1), severe (score 2), or joint fusion (score 3), and the presence of OP was graded as either absent (score 0), small (score 1), moderate (score 2), or severe (score 3) (22). The total first MTP joint OA score was calculated by summing the JSN and OP scores for both radiographic views (range 0–12). The atlas has been shown to have good to excellent intra- and interrater reliability for grading the presence of OP and the severity of JSN for the first MTP joint (κ = 0.64–0.95) (22).

Assessment of foot-specific HRQOL.

Foot-specific HRQOL was assessed by using the FHSQ (16). The FHSQ consists of 13 questions that assess 4 domains of foot health: foot pain, foot function, footwear, and general foot health. Questions within each domain are scored using a Likert response format. Participant responses were then transformed into a score ranging from 0–100 for each domain, with a score of 100 indicating optimum foot health (16). The FHSQ has a high degree of content, criterion, and construct validity (Cronbach's α = 0.89–0.95), as well as high test–retest reliability (ICCs 0.74–0.92) and internal consistency (Cronbach's α = 0.85–0.88) (16). The FHSQ has been rated as one of the highest-quality foot-specific health outcome measures available (26, 27).

Assessment of general HRQOL.

General HRQOL was assessed using the SF-36 version 2.0 (28). The SF-36 consists of 36 questions that measure 8 domains of general health: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. These 8 domains represent the health domains most frequently affected by the disease and its treatment (15, 29). Questions within each domain are scored using a Likert response format. Participant responses were transformed into a score ranging from 0–100 (optimal score) for each domain (28). Numerous studies, including those using populations with OA, have shown that the SF-36 demonstrates sound validity and reliability (15, 30–34).

Sample size.

The sample size calculation was based on a clinically meaningful difference between the groups of 13 points in the pain domain of the FHSQ (21). Assuming an SD of 18.5 (21), a power of 90%, and a significance level of P < 0.05, we required 43 participants for each group.

Statistical analyses.

Statistical analyses were performed using SPSS for Windows, version 17. In order to satisfy the assumption of independence for data, 1 foot was assessed for each participant (23). All data were explored for normality prior to statistical analysis by determination of skewness, kurtosis, and the Shapiro-Wilk statistic, as well as visual inspection of histograms. Attempts were made to transform any non-normal continuous scaled data; however, only BMI could be transformed. Therefore, normally distributed continuous scaled data (age, weight, height, level of education, first MTP joint dorsiflexion, and BMI) were compared between the case and control groups using independent t-tests, and non–normally distributed continuous scaled data and ordinal scaled data (radiographic OA total score, FHSQ, and SF-36 domain scores) were compared using Mann-Whitney U tests. Chi-square or Fisher's exact tests were used to compare categorical scaled data (prevalence of comorbidities and medication usage) between the groups. Effect sizes (Cohen's d) were calculated for differences between the case and control groups' mean scores on each FHSQ and SF-36 domain (35), and scores were classified as small (∼0.20), medium (∼0.50), and large (∼0.80) (36). Spearman's rho statistics were used to explore correlations between each of the radiographic features of first MTP joint OA and the first MTP joint total radiographic OA score with each of the domains of the FHSQ and SF-36 in the case group participants, and relationships between the domain scores of the FHSQ with the SF-36. The significance level was adjusted to 0.01 for all analyses to reduce the family-wise Type I error rate.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

Participant characteristics.

Descriptive characteristics for the case and control group participants are shown in Tables 1 and 2. Mean first MTP joint dorsiflexion for the case group was significantly less than the control group (t84 = 15.60, P < 0.001). The mean radiographic OA total score was significantly greater for the case group (Mann-Whitney U = 2.00, P < 0.001). No other statistically significant differences between the groups were found.

Table 1. Participant characteristics*
 Case group (n = 43)Control group (n = 43)P
  • *

    Values are the mean ± SD unless otherwise indicated. BMI = body mass index; VAS = visual analog scale; MTP = metatarsophalangeal.

  • Differences between groups were analyzed using an independent t-test.

Age, years50.0 ± 10.848.7 ± 10.70.569
Male sex, no. (%)20 (46.5)20 (46.5)
Height, cm170.6 ± 9.1170.5 ± 9.80.959
Weight, kg77.5 ± 12.977.5 ± 13.90.990
BMI, kg/m226.6 ± 4.026.6 ± 3.90.971
Education, years15.7 ± 4.416.6 ± 3.30.280
Side assessed, frequency (left/right)18/2518/25
Symptom duration, months50.7 ± 36.4
Pain during walking (100-mm pain VAS)50.7 ± 16.3
Pain during rest (100-mm pain VAS)34.0 ± 22.5
First MTP joint dorsiflexion, degrees53.3 ± 13.093.3 ± 10.7< 0.001
Table 2. Comparison of radiographic severity of first MTP joint OA*
 Case group (n = 43)Control group (n = 43)P
  • *

    Values are the number (percentage) unless otherwise indicated. The presence of joint space narrowing was graded as either none (score 0), definite (score 1), severe (score 2), or joint fusion (score 3), and the presence of osteophytes was graded as either absent (score 0), small (score 1), moderate (score 2), or severe (score 3) (22). The total first metatarsophalangeal (MTP) joint radiographic osteoarthritis (OA) score was calculated by summing the joint space narrowing and osteophyte scores for both radiographic views (range 0–12). IQR = interquartile range.

  • Differences between groups were analyzed using the Mann-Whitney U test.

Dorsal osteophytes   
 None0 (0.0)30 (69.8)
 Small6 (14.0)13 (30.2)
 Moderate30 (69.8)0 (0.0)
 Severe7 (16.3)0 (0.0)
Dorsal joint space narrowing   
 None4 (9.3)31 (72.1)
 Definite26 (60.5)12 (27.9)
 Severe12 (27.9)0 (0.0)
 Fusion1 (2.3)0 (0.0)
Lateral osteophytes   
 None0 (0.0)31 (72.1)
 Small2 (4.7)12 (27.9)
 Moderate32 (74.4)0 (0.0)
 Severe9 (20.9)0 (0.0)
Lateral joint space narrowing   
 None4 (9.3)36 (83.7)
 Definite32 (74.4)7 (16.3)
 Severe7 (16.3)0 (0.0)
 Fusion0 (0.0)0 (0.0)
Radiographic OA total score, median (range, IQR)6 (3–10, 1)1 (0–3, 2)< 0.001

Self-reported comorbidities and medication usage for the case and control groups are shown in Tables 3 and 4, respectively. A significantly greater number of case group participants reported having foot OA (χ2 = 64.23, P < 0.001) and used at least 1 medication (χ2 = 9.12, P = 0.003). No other statistically significant differences between the groups were found.

Table 3. Self-reported participant comorbidities*
 Case group (n = 43)Control group (n = 43)P
  • *

    Values are the number (percentage). OA = osteoarthritis.

  • Differences between groups were analyzed using either Fisher's exact test or a chi-square test.

  • Statistically significant difference.

Any comorbidity (excluding OA in feet)17 (39.5)10 (23.3)0.104
Psoriasis2 (4.7)4 (9.3)0.676
Leg cramps8 (18.6)3 (7.0)0.176
Diabetes mellitus3 (7.0)0 (0.0)0.241
Cancer4 (9.3)2 (4.7)0.676
OA   
 Hand(s)7 (16.3)2 (4.7)0.156
 Spine2 (4.7)1 (2.3)1.000
 Hip(s)4 (9.3)1 (2.3)0.360
 Knee(s)3 (7.0)1 (2.3)0.616
 Feet38 (88.4)1 (2.3)< 0.001
Table 4. Self-reported participant medication usage*
 Case group (n = 43)Control group (n = 43)P
  • *

    Values are the number (percentage).

  • Differences between groups were analyzed using either Fisher's exact test or a chi-square test.

  • Statistically significant difference.

Any medication28 (65.1)14 (32.6)0.003
Antihypertensives12 (27.9)4 (9.3)0.027
Anticoagulants, antithrombotics5 (11.6)0 (0.0)0.055
Hypolipidemic agents7 (16.3)3 (7.0)0.178
Nonsteroidal antiinflammatory drugs3 (7.0)1 (2.3)0.616
Simple analgesics and antipyretics0 (0.0)1 (2.3)1.000
Antidepressants4 (9.3)2 (4.7)0.676
Bronchodilator aerosols and inhalations, bronchospasm relaxants4 (9.3)1 (2.3)0.360
Hyperacidity, reflux, and ulcer agents1 (2.3)2 (4.7)1.000
Bladder function disorder agents1 (2.3)0 (0.0)1.000
Thyroid hormones and antithyroid agents1 (2.3)2 (4.7)1.000
Gonadal hormones2 (4.7)0 (0.0)0.494
Glucosamine and chondroitin combination0 (0.0)1 (2.3)1.000
Glucosamine3 (7.0)1 (2.3)0.616
Vitamin D0 (0.0)1 (2.3)1.000
Fish oil6 (14.0)1 (2.3)0.110

Comparison of FHSQ domain scores.

All domain scores of the FHSQ were significantly lower in the cases (Table 5). Cases had significantly lower scores for the foot pain (Mann-Whitney U = 109.50, P < 0.001, Cohen's d = −2.24), foot function (Mann-Whitney U = 200.50, P < 0.001, Cohen's d = −1.37), footwear (Mann-Whitney U = 320.50, P < 0.001, Cohen's d = −1.35), and general foot health (Mann-Whitney U = 177.00, P < 0.001, Cohen's d = −1.78) domains of the FHSQ.

Table 5. Comparison of FHSQ and SF-36 domain scores*
 Case group (n = 43)Control group (n = 43)PEffect size (Cohen's d)
  • *

    Values are the mean ± SD unless otherwise indicated. FHSQ = Foot Health Status Questionnaire; SF-36 = Short Form 36.

  • Differences between groups were analyzed using Mann-Whitney U tests.

  • Statistically significant difference.

FHSQ    
 Foot pain55.5 ± 22.393.0 ± 7.8< 0.001−2.24
 Foot function73.8 ± 20.996.9 ± 11.5< 0.001−1.37
 Footwear39.1 ± 28.776.6 ± 27.0< 0.001−1.35
 General foot health50.2 ± 27.089.7 ± 16.0< 0.001−1.78
SF-36 questionnaire    
 Physical functioning82.8 ± 14.795.2 ± 6.3< 0.001−1.10
 Role physical86.3 ± 18.094.0 ± 8.80.067−0.54
 Bodily pain66.8 ± 21.265.2 ± 24.80.3860.07
 General health79.4 ± 14.883.3 ± 14.20.154−0.27
 Vitality61.3 ± 18.168.3 ± 15.20.050−0.42
 Social functioning84.9 ± 18.893.6 ± 13.50.016−0.53
 Role emotional90.9 ± 15.294.6 ± 9.80.319−0.29
 Mental health78.8 ± 15.981.6 ± 13.60.386−0.19

Comparison of SF-36 questionnaire domain scores.

SF-36 questionnaire domain scores for the case and control groups are shown in Table 5. The case group participants had a significantly lower score for the physical functioning domain (Mann-Whitney U = 421.00, P < 0.001, Cohen's d = −1.10). No other statistically significant differences between the groups were found for any of the other SF-36 domains.

Correlations between radiographic features of first MTP joint OA and HRQOL.

In the cases, there were no statistically significant correlations between the severity of radiographic features of first MTP joint OA with domain scores of the FHSQ or SF-36 (Table 6).

Table 6. Correlations between radiographic features of first metatarsophalangeal joint OA with FHSQ and SF-36 domain scores*
 Dorsal osteophytesDorsal joint space narrowingLateral osteophytesLateral joint space narrowingRadiographic OA total score
  • *

    Values are the Spearman's rho correlation. OA = osteoarthritis; FHSQ = Foot Health Status Questionnaire; SF-36 = Short Form 36.

FHSQ     
 Foot pain0.082−0.0380.1920.2000.118
 Foot function0.0100.1080.0900.2500.111
 Footwear0.009−0.1670.0440.1400.136
 General foot health0.0340.0240.1050.0030.022
SF-36 questionnaire     
 Physical functioning0.092−0.280−0.40−0.308−0.209
 Role physical−0.099−0.1110.1400.022−0.057
 Bodily pain−0.019−0.1280.0580.082−0.075
 General health0.032−0.1140.153−0.050−0.007
 Vitality−0.158−0.0900.1540.069−0.056
 Social functioning−0.1060.1040.0700.0910.116
 Role emotional−0.201−0.2790.0610.034−0.308
 Mental health−0.145−0.0230.0000.115−0.066

Correlations between the FHSQ domains with the SF-36 physical functioning domain.

Correlational analysis was performed to determine the association between each of the FHSQ domains with the SF-36 physical functioning domain scores. All domain scores of the FHSQ were significantly (P < 0.001) correlated with the SF-36 physical functioning domain score (FHSQ foot pain: r = 0.518, FHSQ foot function: r = 0.547, FHSQ footwear: r = 0.405, and FHSQ general foot health: r = 0.543).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

First MTP joint OA is recognized as a condition that commonly causes foot pain (4, 5). However, no studies have comprehensively investigated the broad impact of this condition using HRQOL outcome measures. Therefore, the primary objective of this study was to compare the foot-specific and general HRQOL of people with and without symptomatic first MTP joint OA.

Foot-specific HRQOL was investigated using the FHSQ. All FHSQ domain scores (foot pain, foot function, footwear, and general foot health) were significantly lower in the case group, indicating that symptomatic first MTP joint OA is associated with reduced foot-specific HRQOL. However, the severity of radiographic OA at the first MTP joint was not correlated with any FHSQ domain scores in the case group participants. These findings demonstrate that people with symptomatic first MTP joint OA experience more foot pain, have greater difficulty performing functional weight-bearing activities, find it more difficult to obtain suitable footwear, and perceive their feet to be in a poorer state of health than those without this condition. However, the severity of impairment is not related to the severity of radiographic degeneration at the first MTP joint. Our findings support earlier case series studies suggesting that people with symptomatic first MTP joint OA have suboptimal FHSQ scores (17–19), but provide stronger evidence due to the inclusion of a control group.

We also evaluated the general HRQOL of the participants using the SF-36 questionnaire. Our results showed that the physical functioning domain of the SF-36 was significantly lower in the case group. Similar to our analysis of foot-specific HRQOL, there were no correlations between the severity of radiographic OA at the first MTP joint with SF-36 domain scores in the case group participants. These findings indicate that people with symptomatic first MTP joint OA have greater difficulty performing a broad range of physical tasks and activities than those without this condition, but the severity of impairment is not related to the severity of radiographic degeneration at the first MTP joint. Further, although not statistically significant, there was also a trend showing that participants with symptomatic first MTP joint OA displayed reduced role physical (d = −0.54), vitality (d = −0.42), and social functioning (d = −0.53) SF-36 domain scores. Our study findings are novel, since no previous study has investigated the general HRQOL of people with first MTP joint OA. Previous studies have shown that all SF-36 domain scores are negatively impacted in those with OA occurring at the hip and knee joints, suggesting that first MTP joint OA has a less broad impact on HRQOL (12, 13). Nevertheless, our results do reinforce the notion that chronic musculoskeletal disease such as OA has a multidimensional impact on HRQOL.

This study addressed the limitations of the previous studies in this area (17–19). First, a reliable radiographic classification system was used to determine the presence and severity of first MTP joint OA (22). Second, both the foot-specific and general HRQOL of people with symptomatic first MTP joint OA was compared to that of an age-, sex-, and BMI-matched control group. There were no significant differences between the case and control groups for the level of education and self-reported comorbidities (except for foot OA). Therefore, we can conclude that the significant differences in HRQOL domains between our study groups are unlikely to be due to these commonly recognized confounding factors. Third, the participants were recruited from the community; therefore, the findings are likely to be broadly generalizable to the general population.

The findings of this study must be interpreted in the context of several limitations. First, although the results of this case–control study suggest that symptomatic first MTP joint OA is associated with reduced foot-specific HRQOL as well as the physical functioning aspect of general HRQOL, we cannot confirm that this relationship is causal. Second, our analyses showed that there were statistically significant correlations between each of the FHSQ domain scores with the SF-36 physical functioning domain scores, suggesting that, to some extent, these tools are measuring overlapping constructs. Third, the validity of the FHSQ and SF-36 for measuring the HRQOL of people with first MTP joint OA has not been fully established. Importantly, the clinically important difference in domain scores of the FHSQ and SF-36 for people with first MTP joint OA is not known. Consequently, it is difficult to determine if the magnitude of the effects observed in this study between those with and without first MTP joint OA are clinically meaningful. However, to attempt to assess the magnitude of any differences, we did determine normalized effect sizes (Cohen's d), and these differences were large (−2.24 to −1.10) for all domains of foot-specific HRQOL and the physical functioning domain of general HRQOL. Fourth, the case group was comprised of participants with radiographically confirmed symptomatic first MTP joint OA. However, people with radiographically confirmed first MTP joint OA may be asymptomatic (37, 38). Therefore, the findings only apply to people with radiographically confirmed symptomatic first MTP joint OA.

The findings of this study indicate that symptomatic first MTP joint OA has a much broader impact than localized pain and discomfort. Symptomatic first MTP joint OA is associated with large reductions in all aspects of foot-specific HRQOL and in the physical functioning aspect of general HRQOL. From a clinical and research perspective, the aspects of foot-specific and general HRQOL that were found to be reduced in people with symptomatic first MTP joint OA should be assessed in those presenting with this condition. Further, treatment interventions for first MTP joint OA that focus on improving localized symptoms as well as those aspects of HRQOL that were shown to be significantly reduced in people with symptomatic first MTP joint OA may lead to improved patient outcomes.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Munteanu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Bergin, Munteanu, Menz.

Acquisition of data. Bergin, Munteanu, Zammit.

Analysis and interpretation of data. Bergin, Munteanu, Nikolopoulos.

ROLE OF THE STUDY SPONSOR

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

Genzyme Australasia played no role in the study design; the collection, analysis, or interpretation of the data; the writing of the manuscript; or the decision to submit the manuscript for publication. Publication of this article was not contingent on the approval of Genzyme Australasia.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES

The authors would like to thank the staff of Southern Cross Medical Imaging for their assistance.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. ROLE OF THE STUDY SPONSOR
  9. Acknowledgements
  10. REFERENCES
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