Edited by Mark Perry MD
Midfoot arthritis is characterized by pain and swelling in the midfoot that is aggravated by standing and walking. There is often an associated bony prominence on the top of the foot. Usually the symptoms develop gradually over time although it can occur following a major midfoot injury such as a Lisfranc fracture. Non-operative treatment consisting of use of a stiff-soled comfort shoe; activity modification; weight-loss; and anti-inflammatory medication can be quite effective. If non-operative treatment fails patients may benefit from surgery to fuse the arthritic midfoot joints.
Patients with midfoot arthritis will experience discomfort in the midfoot. This is usually exacerbated by standing and walking. It can be painful first thing in the morning for the first few steps and also after getting up from a sitting or lying position. This is due to “start-up” pain.
Occasionally, there is a history of significant injury to the midfoot such as a Lisfranc fracture. More commonly, the midfoot arthritis occurs from gradual wear and tear.
Physical examination may reveal swelling in the midfoot. There is often generalized tenderness in the midfoot area. A bony prominence in the midfoot is common. However, not all bony prominences in this area represents arthritis. It is not uncommon for people to have local shoe wear irritation from a bony prominence known as a tarsal boss. This does not necessarily signify significant midfoot arthritis.
Weight-bearing x-rays will demonstrate loss of joint space in the midfoot joints which is characteristic of arthritis. The joint between the midfoot and forefoot (tarsometatarsal or “Lisfranc” joint) is most commonly involved, although the smaller joints of the midfoot (intercuneiform joints) may also be involved.
Midfoot arthritis can often be managed successfully without surgery. The key components of non-operative treatment are:
- A stiff-soled comfort shoe: By having a stiff sole, the amount of force concentrated in the midfoot will be limited. In a similar manner, a slight rocker contour to the shoe will help disperse the force away from the midfoot and smoothly up the leg.
- Activity Modification: Activity modification to limit the amount of the time that the patient stands and the number of steps will also be helpful in limiting symptoms.
- Weight-loss: Losing excess weight will help to decrease the amount of force going through the arthritic midfoot with each step.
- Calf Stretching (Flexibilty improvement of adjacent joints): Unnecessary motion or stress through the midfoot can be decreased by stretching the calf muscle (gastrocsoleus complex and heel cord)
- Anti-inflammatory Medications: Non-Steroidal Anti-Inflammatory medications (NSAIDs) may also be beneficial. A lot of the pain symptoms are due to the body’s inflammatory response to the arthritic changes in the foot and NSAIDs can help decrease these symptoms.
- Off Loading: Decreasing the load through the midfoot by using assisting devices such as a cane, knee walker, or crutches may be helpful in the short-term if the symptoms have flared up.
Patients with a local bony prominence may benefit from removal of bone spurs. However, this will usually not help the arthritic pain. Therefore, if an operation is deemed necessary, it is often necessary to fuse the involved joints (midfoot fusion). By eliminating the movement through the arthritic joints, the pain originating from these joints is eradicated. Essentially it converts a painful stiff joint to a painless stiff joint. However, a midfoot fusion does not preclude pain from other joints and other areas of the foot from continuing to be symptomatic.
This type of surgery requires strong fixation and a period of non-weight bearing (or limited weight bearing) for 6-8 weeks.
Complications of surgery may include:
- Delayed union
- Wound healing problems
- Nerve injury or irritation
- Deep Vein Thrombosis (DVT or Blood clot)
- Pulmonary embolism (PE)
In addition, patients may have persistent pain, as the fusion of the midfoot joint will not help pain that originates from other areas of the foot such as tendons, ligaments, or other joints.