Orthotics for first metatarsophalangeal osteoarthritis: Are we asking the wrong question?

Abstract

Orthotic interventions are commonly used in the management of first metatarsophalangeal (MTP) joint osteoarthritis, yet recent systematic review evidence suggests that their average treatment effects are small and unlikely to represent clinically meaningful benefit for the average patient. This has led to a growing perception that orthotics may have limited clinical value. However, such conclusions risk oversimplifying the evidence by conflating a lack of average treatment effect with a lack of utility for individual patients. This commentary explores this tension through critical appraisal of the current evidence base and consideration of treatment effect heterogeneity. It argues that responder heterogeneity, combined with the biomechanical specificity of first MTP osteoarthritis, may explain why orthotics provide substantial benefit for some patients despite weak average effects in trials. The discussion further highlights a mismatch between current osteoarthritis guidelines, which emphasise exercise as a core treatment, and the limited capacity for exercise to meaningfully influence joint loading in distal joints such as the first MTP. Drawing on evidence from hip osteoarthritis, including the CLEAT trial, the commentary contrasts capacity-based and load-modifying interventions and proposes a shift towards more mechanistically informed and individualised treatment strategies.