Midfoot Arthritis

Midfoot arthritis is wear of the joints in the middle of the foot — the tarsometatarsal (Lisfranc) and midtarsal joints that form the arch. It causes pain across the top or inner side of the foot, stiffness and difficulty on uneven ground or prolonged standing. Treatment starts with orthotics, footwear changes and activity modification; fusion surgery is considered if these fail.

Symptomatic midfoot osteoarthritis was present in 12.0% of people aged over 50 in one UK community study (Thomas et al., Arthritis Res Ther 2015, PMID 26166410). Causes include primary (idiopathic) osteoarthritis, inflammatory arthritis, and post-traumatic arthritis — most commonly after a Lisfranc injury. As many as 20% of subtle Lisfranc injuries may be missed at initial presentation (Podolnick et al., Clin Orthop Relat Res 2017, PMID 27796800).

What are the symptoms?

• Aching or sharp pain across the midfoot, worse with activity and better with rest
• Swelling and tenderness over the top of the foot
• Stiffness in the arch, particularly in the morning
• A bony prominence or lump on the top of the foot
• Difficulty walking on uneven ground or going up stairs
• Pain when pushing off during walking or running

What causes it?

• Previous Lisfranc fracture or ligament injury — the most common post-traumatic cause
• Osteoarthritis from wear of the midfoot joints
• Inflammatory arthritis such as rheumatoid arthritis
• Flat foot deformity causing progressive collapse and overload of the midfoot
• Increased mechanical load through the arch (for example from obesity or prolonged standing)

How is it diagnosed?

Diagnosis is by clinical examination and weight-bearing X-rays, which show joint-space narrowing, bone spurs or arch collapse. Weight-bearing radiographs are essential, and for complex deformity cross-sectional imaging (CT with or without MRI) is recommended. Targeted local anaesthetic injections under guidance can help confirm which joints are painful.

What are the non-surgical options?

First-line care, per Mr Hester's live page, includes:

• Analgesia / anti-inflammatory medication (NSAIDs) when suitable
• Medial arch support insoles
• Stiff-soled or rocker-bottom shoes; ankle-foot orthoses in some cases
• Activity modification (reducing impact and prolonged walking on hard surfaces)
• Weight management where relevant
• Physiotherapy for calf stretching and gait retraining
• Corticosteroid or viscosupplementation injections into the affected joints under ultrasound or X-ray guidance

Injection effects can be variable and limited, with proven benefits at 2 weeks after ultrasound-guided injection and less at 3 months. The live page states that injections can provide temporary relief but do not stop arthritis progressing, and are useful for confirming which joints are causing symptoms.

When is surgery recommended?

Surgery is considered when conservative measures fail to give adequate relief and quality of life is significantly affected. The usual operation is midfoot fusion (arthrodesis) of the painful joints: damaged joint surfaces are removed and the bones fixed with screws, plates or staples so that painful movement is eliminated while the overall shape of the foot is preserved. Not every midfoot joint needs to be fused — the procedure is tailored to the joints that are affected.

Fusing a single midfoot joint in isolation is rare, and surgeons often consider a combination of the first, second and third tarsometatarsal joints, and the naviculocuneiform joint if it is symptomatic. If flat foot deformity has contributed, a heel-bone realignment (calcaneal osteotomy) may be performed at the same time.

Mr Hester's live page states that surgery is performed under general anaesthetic and typically requires an overnight hospital stay.

What are the risks?

Risks include infection and wound problems, nerve injury or scar sensitivity (including neuroma), deep vein thrombosis or pulmonary embolism, non-union, implant-related problems, metatarsalgia, adjacent-joint arthritis over time, stiffness or altered gait, and need for further surgery or metalwork removal.

What is recovery like?

From Mr Hester's live midfoot arthritis page:

• 0–6 weeks: non-weight-bearing in a cast; foot elevated
• 6 weeks: cast removed; wound review; transition to a walking boot
• 6–12 weeks: gradual weight-bearing in the boot; physiotherapy begins
• 3–4 months: transition to supportive trainers; X-ray to confirm fusion
• 4–6 months: return to most daily activities; custom orthotics often recommended long-term
• 6–12 months: return to low-impact sport and fuller activity if fusion is confirmed and comfortable

Most people walk well after midfoot fusion, though the foot is stiffer. A rocker-soled shoe or custom orthotic is usually recommended long-term.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Kurup H, Vasukutty N. Midfoot arthritis- current concepts review. Journal of Clinical Orthopaedics and Trauma. 2020. PMID: 32405198. https://pubmed.ncbi.nlm.nih.gov/32405198/
2. Midfoot osteoarthritis: a guide for patients. Kent Community Health NHS Foundation Trust. https://www.kentcht.nhs.uk/leaflet/midfoot-osteoarthritis/
3. Orthopaedic Surgery — Midfoot Fusion (Arthrodesis). Northern Care Alliance NHS Foundation Trust. https://www.northerncarealliance.nhs.uk/patient-information/patient-leaflets/orthopaedic-surgery-midfoot-fusion-arthrodesis
4. Thomas MJ, Peat G, Rathod T, Marshall M, Moore A, Menz HB, Roddy E. The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot. Arthritis Res Ther. 2015;17(1):178. PMID: 26166410. https://pubmed.ncbi.nlm.nih.gov/26166410/
5. Podolnick JD, Donovan DS, DeBellis N, Pino A. Is Pes Cavus Alignment Associated With Lisfranc Injuries of the Foot? Clin Orthop Relat Res. 2017;475(5):1463–1469. PMID: 27796800. https://pubmed.ncbi.nlm.nih.gov/27796800/