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Overview © Reed GroupA midfoot fracture is a break in one or all of the bones in the midfoot (navicular, cuboid, and 3 cuneiforms). Navicular fractures are classified as dorsal avulsion fractures, tuberosity fractures, nondisplaced body fractures, displaced body fractures, or osteochondral fractures. Cuboid fractures can occur in isolation but are more often seen in conjunction with other fractures.
Cuneiform fractures are classified as avulsion fractures, body fractures, or fracture-dislocations. Injuries to the tarsometatarsal joint complex (Lisfranc's fracture or Lisfranc fracture dislocation) occur at the articulation between the midfoot (3 cuneiform bones and the cuboid) and the forefoot (5 metatarsals).
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Plain radiograph (x-ray) of both feet showing a normal right foot and and an arthritic left foot involving the left 2nd and 3rd TMT joints. Any condition that damages the cartilage (joint surface) will cause midfoot arthritis to develop. Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning. CT images give excellent information on bone structure and is superior to plain radiography in that respect. The natural history of midfoot arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse. The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state.
As the midfoot arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.
Non-operative management for midfoot arthritis aims at relieving pain and return to full activity including sports whenever possible. The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with midfoot arthritis by reducing inflammation in the joint.
Physiotherapy works by strengthening muscles around not only the midfoot joints but the whole kinetic chain.
Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment. There is no one treatment that has a reliably successful, quick and easy cure for arthritis.
Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.
At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis.
There are a number of treatments that involve an injection or series of injections for the treatment of midfoot arthritis. The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours.
It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal. Surgical management is reserved for patients who have failed to respond to non operative treatment. Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first. This operation has excellent outcomes in terms of pain relief and return to activities of daily living. It involves removing all remnants of the diseased joint (cartilage) and fusing the the bones so that no joint exists. The operation is usually carried out through one or more incisions on the top (dorsum) of the foot. It should be borne in mind that complications can result from a condition with or without surgery. Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer.
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital. For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.
Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster. If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed.
Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. The most challenging part of the recovery was the time of non weight bearing, adjusting to a wheel chair, walking frame and relying on others help.
Get a wheel chair, I had one upstairs and downstairs as I found crutches difficult to use.  The walking frame supplied by the hospital was great but I found it difficult to hop very far with it. Fortunately we have a walk in shower, my husband fixed a grab rail in it and lowered the shower holder and soap dish holder for easy use and I bought a shower stool and waterproof cover (Limbo bag) for the plaster.
Let your friends and neighbours know you are house bound, the company helps keep the spirits up. Generally arthritis of the midfoot presents as aching pain on the dorsum (top) of the foot.
Non surgical treatment of midfoot arthritis includes: shoe wear modification, insoles, pain medication and change in activity. The most common operative treatment for midfoot arthritis is an arthrodesis (fusion) of the tarsometatarsal and or cuneiform joints.
A reliable option, fusion of the midfoot aims to convert stiff painful joints into solid comfortable ones.
He has a deep passion for deformities of the foot and ankle including but not limited to bunions. The whole idea of suspicious x-rays, suggesting a fracture but requiring an MRI to confirm, and the ultimate diagnosis of a midfoot sprain makes me think that the initial x rays showed joint widening and a mild lisfranc dislocation, but that the MRI didn't show a fracture, just some ligamentous injury. CausesThis type of injury classically occurred when a horseman fell while riding, having trapped his foot in the stirrup or fell into a drain.

In that picture, the circle shows a lisfranc dislocation, which basically involves damage to the ligament connecting the 2nd metatarsal to the 1st cuneiform, and leads to the widening between the first two metatarsals you see in the picture. I’ve used this Herringbone pattern taping technique on several types of injuries including an x-ray confirmed midfoot sprain, a swimmer with excessive foot motion and a runner putting in high mileage.
It is especially effective for complex bony structures that support the body in full weight bearing. Step 4: Before tacking down the tape end, pull the skin down gently at the ending point towards the starting point. Step 5: Repeat this technique from the 5th metatarsal, across the top of the foot and ending on the inside 1st metatarsal arch area. Step 6: Continue this pattern of pulling the outsides up, across, and towards the mid-line of the foot.
Step 7: As the sprain heals and the athlete goes back into competition, I will tape the foot with a little bit of weight bearing pressure.
In 2004 I began the journey to create the most versatile and progressive balance training system. The onset and symptoms of osteoarthritis in the foot and ankle can vary dramatically based on foot type, previous injury and genetic predisposition to osteoarthritis. The underlying cause of OA is unknown, but it seems to have both a genetic predisposition and relationship to joint trauma. Injectable hylan G-F 20 (Synvisc), or what is called viscosupplementation, is popular for large joints including the ankle. Surgical treatment of osteoarthritis may be required if bracing and medical treatment proves ineffective. Another technique called arthrodiastasis involves off-loading the ankle with a distraction fixator. Rheumatoid arthritis (RA) is a complex and debilitating disease that affects about 1 percent of the general population. Treatment of rheumatoid arthritis in the foot can be quite complex and depends on the patient's response to treatment.
Although treatment of the immune response is the primary goal in RA, bracing and joint support are critical.
Symptoms of psoriatic arthritis in the foot include focal swelling of the interphalangeal joint of the toes. The Arch Binder slips over the mid-foot and is worn around the arch, with or without shoes offering elastic compression and arch support and pain relief. Lighter than a feather and stronger than steel, Carbon Graphite Spring Plates stiffen shoe soles, limiting range of motion in the forefoot and midfoot, helping with many conditions such as forefoot capsulitis, metatarsalgia, Morton's neuroma, arch pain, arthritis, turf toe, hallux limitus and metatarsal fractures.
The Carbon Graphite Shoe Plate - Flat is used to stiffen shoes and protect the foot from puncture injuries. The Arch Binder with Metatarsal Pad slips over the forefoot like a sleeve and is worn around the arch, relieving arch and metatarsal pain. Made of durable vegetable tanned leather, the Pedag Viva Full Length Arch Support is a universal arch support for all shoes and boots. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. These job classifications are based on the amount of physical effort required to perform the work. The severity of fracture, individual's age, complications of the injury, the employer's ability to modify as necessary the work activities and environment, and the rate of healing may also affect disability duration. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service.
In the early stages when there is inflammation with no damage to the joint they maybe normal. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification.
The use of a shoe with a rocker bottom sole can also help as it helps spread the load away from the midfoot. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate.
Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.
We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre.
The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.
The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital. Use this information to help you understand your condition, possible treatment and recovery. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.
The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You can do this by massaging cream (E45 for example) into the scar and around the wound area. If the car is manual then regardless of the side operated on it will be roughly 3 months post surgery. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks.
If this is painful, rubbing and making shoewear difficult, it is possible to surgically osteotomise (remove) the bony bump to negate these symptoms.
At present, such an injury happens typically when one steps into a hole and the foot twists heavily. As if Doctor Rivers was stupid enough to let Paul return to the game and play thru the injury which probably agravated Pierce's injury. The foot is a great example as it is made from 7 tarsal bones, 5 metacarpal bones and 14 phalanges- that’s 26 bones connected and stabilized as you walk, run and jump. This type of injury involves the midfoot structures and can include bone fracture or ligament sprains. When you bear weight your bones splay and spread from one another but also must stay supportive to prevent total collapse.
But for those who have a ligament sprain and are in a walking boot or are allowed to play with restriction- this is a great tape technique.
Don’t over correct the foot and excessively pull the foot towards the head because normal walking mechanics may be compromised. I have the athlete sit on the taping table, bend their knee and put their foot down on the taping table. A little bit of joint re-positioning from a gentle pull of the tape is effective instead of cranking down on the area.
Since 1999, I’ve worked in sports medicine as a Certified Athletic Trainer from the National Athletic Trainers Association. In a young, healthy individual, subchondral bone acts as a shock absorber for loads applied to the joint.

Many authors speculate the cause may be mechanical as discussed above, but others describe changes such as biologic, biochemical, enzymatic or even a combination of these.
Although this still is considered an "off-label" use of Synvisc, studies show an injection can reduce the symptoms of osteoarthritis for three to 12 months. Rheumatoid arthritis is an autoimmune disease that effects women three times more than men. Medical care of rheumatoid arthritis should be managed by a rheumatologist who is familiar with the side effects of medications that reduce the body's autoimmune response. Reiter's Syndrome often is described as a sexually transmitted disease because of the disease's history of occurring after sexual intercourse with a partner infected with a chlamydial infection. Placed under an existing innersole, the shoe becomes more rigid, limiting motion in the midfoot and forefoot.
The metatarsal pad helps with Morton's neuroma, capsulitis, metatarsalgia and forefoot pain.
Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.
The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles.
Fractures of the midfoot, a relatively stable area, are rare, but among them, navicular fractures are the most common (Ho).
If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it.
A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
If you drive an automatic and the left foot has been operated on then it will be roughly 4 weeks before you can drive short distances. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake.
If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm. The  5 metatarsal, or long foot bones, connect with the medial cuneiform, intermediate cuneiform, lateral cuneiform and the cuboid bones. However, once in weight bearing the x-ray will show the joint gaping and opening up indicating a sprained ligament or fracture. A midfoot sprain may present as a sore arch, plantarfascitis, general bruising or unknown pain. If pain is increased then the tape is too tight or taped in the opposite direction as advised. I've helped all levels of athletes from physical therapy to youth and professional athletics. Today we have the most unique product line including unbreakable medicine balls, responsive rope balls and balance training accessories. Each type of arthritis has a characteristic group of symptoms such as onset, location and type of pain. Cartilage has no nerve endings to sense pain, but the subchondral bone is filled with nerve endings. In fact every joint in the body seems to undergo the changes of osetoarthritis at different rates. The choice of each procedure depends on the location of the osteoarthritis and general health of the patient.
In the case of RA the immune system attacks the cells lining the joint capsule called the synovium. X-rays of advanced cases may show slow erosive changes that are called a pencil and cup deformity. These symptoms occur seven to 14 days after intercourse and subside over a period of several months to years. Fractures of the bones in the midfoot usually are not isolated injuries; there are often multiple fractures or fracture-dislocations.
Navicular stress fractures are usually sports-related and account for up to 35% of all stress fractures in athletes (Ameres). Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.
If symptoms do not ease during this period, one has to question whether the diagnosis is correct.
Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active. American football players occasionally get this injury, often when they have their foot pointing down and someone lands on their heel.TreatmentTreatment options include operative or non-operative treatment.
The tape pulls the metatarsals upward towards the metacarpals and inward towards the mid-line of the foot.
Angle across the top of the foot and diagonally upwards toward the outside of the foot and ankle. I love helping athletes rehab from injury, getting back to the starting line-up and helping them compete at their best. Arthritis may be called mono-articular or polyarticular depending upon the number of joints involved. This finding is seen in the metatarsal phalangeal joints where the metatarsal head resembles the point of the pencil and the base of the proximal phalanx (toe) is the receiving cup. If the dislocation is less than 2 mm, the fracture can be managed with casting for 6 weeks. If left untreated, arthritis may result in progressive erosion of the surface cartilage and instability of the joint.

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