Toe fusion for arthritis cut pain, bests watchful waiting

Clinical takeaway: When a stiff, painful big toe joint has limited walking for a year or more despite activity and footwear changes, a foot and ankle consult is now better supported. Fusion trades joint motion for pain relief, so patients should understand what they are giving up.

Every step ends with the big toe bending upward as the heel lifts. When osteoarthritis stiffens that joint, the whole gait adapts: shorter stride, weight rolled to the outside of the foot, a closet narrowed to whatever has a rigid sole. Hallux rigidus, osteoarthritis of the first metatarsophalangeal joint, narrows the joint space and builds a dorsal osteophyte the patient can feel through the top of a shoe.

Once walking pain sits at four or higher out of 10, patients start asking what else can be done. Activity modification, stiff-soled footwear, orthoses, and NSAIDs are all standard, but none has convincing evidence behind it. Joint fusion is the operation most often recommended.

Symptomatic radiographic arthritis of the big toe joint affects as many as 8% of adults older than 50, and many of those patients are managed in primary care indefinitely without reaching a foot and ankle clinic. Guideline recommendations point toward surgery once symptoms remain debilitating, but they rest on case series and set no threshold for how long to wait. That is the gap a single-center randomized trial set out to close.

Fusion produced one of the larger effects in elective orthopedic surgery. At 12 months, walking pain among the 45 patients randomized to the operation had fallen to 1.3 from 6 on a 10-point scale, against 5.7 in the 45 who waited, an adjusted difference of 5.0 points where 1.7 counts as clinically meaningful.

In the comparison group, pain did not improve at any point, and 64% crossed over to surgery within the year. Among operated patients, 89% said they could accept the result permanently, against 20% of those waiting, and benefit held across 11 of 12 secondary outcomes covering rest pain, function, quality of life, and analgesic use.

Ninety adults 40 and older were randomly assigned at a single Finnish hospital, all with grade I to III radiographic disease, walking pain of at least 4, and more than a year of symptoms. Watchful waiting was minimal by design: a leaflet, footwear changes, and analgesics at the patient's discretion, with no orthoses, injections, or physical therapy. Patients with rheumatoid arthritis, peripheral neuropathy, and poorly controlled diabetes were excluded, which leaves out a share of the foot pain seen in primary care.

For a patient whose big toe has hurt for years, the practical shift is that continued observation is now the option carrying the burden of proof. The waiting arm shows what the untreated course looks like over a year: no improvement, and most patients eventually asking for the operation anyway. That reframes the conversation from whether to keep trying conservative measures to whether the patient is ready to trade motion at the joint for pain relief. But fusion is permanent and toe-off mechanics change afterward, which may matter for runners or workers whose lack of balance may impair their safety.

Source: Miettinen M, et al. (2026 Aug 11) Ann Intern Med. Surgery Versus Watchful Waiting for First Metatarsophalangeal Joint Osteoarthritis: A Randomized Controlled Trial