Evaluation, diagnosis, and select management of common causes of midfoot pain in adults

INTRODUCTION — Foot pain is common among adults and a frequent reason for primary care visits. Nevertheless, as the differential diagnosis for foot pain is broad, and exposure to foot-related problems is often limited during medical training, many clinicians may not be adequately prepared to assess the patient with foot complaints.

This topic reviews the common causes of midfoot pain in the adult, including descriptions of important conditions and a discussion of how to reach a diagnosis. An overview of foot pain generally, including more detailed discussions of foot anatomy and biomechanics and how to conduct a history and examination of the patient with foot complaints, is provided separately. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults".)

Topics addressing pain in other regions of the foot and specific injuries and conditions are found separately:

●Pain in the forefoot and hindfoot and foot evaluation (see "Evaluation, diagnosis, and select management of common causes of forefoot pain in adults" and "Evaluation and diagnosis of common causes of hindfoot pain in adults" and "Musculoskeletal ultrasound of the ankle and hindfoot")

●Gait and running injuries (see "Clinical assessment of walking and running gait" and "Running injuries of the lower extremities: Patient evaluation and common conditions", section on 'Foot and ankle injuries')

●Foot fractures (see "Metatarsal shaft fractures" and "Stress fractures of the metatarsal shaft" and "Tarsometatarsal (Lisfranc) joint complex injuries" and "Proximal fifth metatarsal fractures" and "Non-stress fractures of the tarsal (foot) navicular" and "Stress fractures of the tarsal (foot) navicular" and "Cuboid and cuneiform fractures" and "Calcaneus fractures")

●Foot pain related to systemic illness and other conditions (see "Evaluation of the diabetic foot" and "Overview of lower extremity peripheral artery disease" and "Overview of lower extremity peripheral nerve syndromes" and "Clinical manifestations and diagnosis of gout" and "Plantar fasciitis")

ANATOMY AND BIOMECHANICS — The anatomy and biomechanics of the foot are reviewed separately. Aspects of foot anatomy and biomechanics of special relevance to midfoot conditions and injuries are discussed here (figure 1). (See "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation", section on 'Anatomy' and "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Basic foot structure and biomechanics'.)

The midfoot plays a unique role in enabling humans to adapt to uneven surfaces while standing and during gait. The structure and relationship among midfoot bones allows both rotation and stability. This arises primarily from the Chopart joint, which is the articulation of the rear foot with the proximal midfoot bones (the navicular and cuboid) (figure 2).

The motions of the navicular and cuboid involve tendons that assist in gait. The navicular has attachments from the posterior tibialis (figure 3), and during propulsion (heel-off and toe-off (figure 4)), the contraction of this muscle allows the navicular to pronate sufficiently to give a mechanical advantage. The cuboid has a shallow groove on its lateral aspect through which the peroneus (fibularis) longus tendon (picture 1) passes before traveling medially underneath the foot to plantar attachments at the bases of the metatarsals (MTs). During supinated foot strike, the peroneal tendons provide stability as they are maximally stretched to hold the foot taut. During the push-off phase of gait, the pronation of the foot repositions the peroneal tendons so they are no longer stretched taut and thus can contract to assist plantar flexion.

Midfoot rotation is part of a kinetic chain that involves subtalar joint motion. When the calcaneus is in eversion (foot pronation), the axes of the talus and calcaneus are parallel. This allows normal plantarflexion and dorsiflexion. When the calcaneus is in inversion (supinated foot strike), the axes of the calcaneus and talus are not parallel; they intersect. This blocks motion at the Chopart joint [1].

The second function of the midfoot is to provide a stable base for the MTs. This enables the MTs to function more effectively as levers aiding propulsion at the Lisfranc joint complex (figure 5). The more proximal recession of the articulation of the second MT at the tarsometatarsal (TMT) joint provides additional stability, enabling the second ray of the foot to act as the longitudinal axis for foot rotation.

EPIDEMIOLOGY OF LOCALIZED MIDFOOT PAIN — While the incidence of midfoot pain in younger adults varies widely by activity and sport participation, adults over age 50 frequently experience midfoot pain. Surveys from the United Kingdom report that symptomatic midfoot osteoarthritis is present in 12 percent of adults [2]. Risk factors for midfoot osteoarthritis include female sex, age over 75 years, lower socioeconomic status, and particular occupational exposures. The reason for the higher incidence among females remains uncertain. Subgroup analyses do not show an association between wearing high-heeled shoes and developing midfoot osteoarthritis. Factors such as obesity, previous foot or ankle injury, and generalized joint pain, as well as the presence of osteoarthritis in interphalangeal joints, are all associated with increased incidence. Comorbidities such as diabetes and neurologic conditions are associated with higher rates of midfoot osteoarthritis and foot pain.

Any anatomic variant that alters biomechanics and places excessive stress on the midfoot can contribute to midfoot pain and injury. As an example, tarsal coalitions block normal foot rotation and often lock the foot in rigid pronation or, more rarely, supination [3]. As rotation helps to dissipate force in the midfoot, this anatomic abnormality increases the risk of injury, particularly to the navicular or cuboid.

Arch structure affects the amount of force absorbed by the midfoot. Epidemiologic studies suggest an increased risk of midfoot pain in individuals with either pes cavus (high arch) or pes planus (flat foot), particularly those with chronic pronation [4-6].

Pes planus is normal for infants and young children, who have ligamentous laxity, and arch structure evolves as part of normal development. By 10 years, only 4 percent of children manifest pes planus, while adults have a prevalence of 15 to 23 percent. The increased prevalence of pes planus from childhood to adulthood suggests that breakdown of supporting structures, such as the posterior tibialis tendon and spring ligament, occurs throughout life. Obesity may increase the risk [7]. Individuals who have abnormal arch structure or anatomic problems in the midfoot are more likely to experience pain from demanding weightbearing sports. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes" and "Foot and ankle pain in the active child or skeletally immature adolescent: Evaluation".)

The Framingham foot study, a structured assessment of foot health in 3378 individuals, included evaluations of arch posture and dynamic foot strike with pronation and supination [4]. Individuals with pes planus and pronation experienced increased rates of foot pain. Among athletes and military personnel in the study, cavus feet were associated with increased foot pain and injuries. Among older adults whose primary activity was walking, cavus foot and supinated foot strike were not associated with increased pain and were in fact associated with decreased arch and rearfoot pain in females. Arch pain affected significant numbers of study participants, including 5.3 percent of the 1403 males and 8.1 percent of the 1794 females (average age was 66).

HISTORY AND EXAMINATION — The history and examination of patients complaining of foot pain are reviewed in detail separately. Aspects of particular relevance to midfoot pain are discussed below (figure 1). (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Anatomy and biomechanics' and "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Anatomy-based approach to diagnosis'.)

Important questions to ask the patient with midfoot pain include the following:

●Was the onset of your foot pain sudden or gradual?

•Gradual pain occurs with osteoarthritis, arch strain, and other chronic conditions. Abrupt onset of pain raises the possibility of avulsion fracture, stress fracture, tendon rupture, cuboid subluxation, and other injuries.

●Does your pain localize over the medial aspect of the midportion of the longitudinal arch (figure 6)?

•Pain at this location suggests navicular pathology until excluded by another definitive diagnosis. Navicular injury can lead to long-term morbidity, so determining the cause of pain is important.

●Does your pain primarily involve the lateral midfoot?

•The lateral midfoot is a less common location for foot pain. The cuboid and the base of the fifth metatarsal (MT) must be assessed carefully.

●Do you ever feel unstable when you land on the outside of your foot?

•Instability suggests possible tendon or ligament strain or rupture or, less commonly, cuboid subluxation.

●Do you feel the pain on the dorsum or plantar surface of the foot?

•Dorsal pain most commonly arises from arthritic conditions. Plantar pain occurs with nodules and other soft tissue injury, as well as marked structural collapse.

●Do you get relief with certain types of footwear or orthotic devices?

•When biomechanical factors such as excessive pronation cause pain, longitudinal arch support often relieves symptoms. This is also true for arch collapse or strain.

Important midfoot structures to observe and examine include the following:

●Longitudinal arch height (figure 6)

●Navicular tuberosity (picture 2) and "N spot" (picture 3) (see 'Medial arch (navicular) injury' below)

●Foot pronation or supination during gait (see "Clinical assessment of walking and running gait")

●Medial tarsometatarsal (TMT) region (TMT bossing) (see 'Dorsal exostosis of tarsometatarsal bones (tarsometatarsal bossing)' below)

●Lisfranc joint line (figure 5) (see 'Tarsometatarsal (Lisfranc) joint complex injuries' below)

●Cuboid and base of fifth MT (see 'Base of fifth metatarsal injury' below and 'Fractures of cuboid and cuneiform bones' below and 'Cuboid subluxation and cuboid syndrome' below)

Observation is important when examining the patient complaining of midfoot pain (figure 7 and figure 8 and figure 9). Visual inspection allows the clinician to determine whether there is excessive arch height (picture 4) or collapse of the arch (picture 5). An extremely prominent navicular tuberosity suggests the possibility of an accessory navicular (picture 6).

Observing a standing patient from the rear enables the clinician to identify foot pronation and, when this is present, whether the pronation arises from a drop of the midfoot (picture 7) or from rear foot shift secondary to subtalar joint subluxation. Such subluxation manifests as calcaneal valgus (picture 5). If such a patient performs a heel raise, the clinician should see inversion of the calcaneus. If not, the patient likely has a posterior tibial tendon rupture.

Observing the patient walking or running helps the examiner to determine if there is excess pronation or supination. (See "Clinical assessment of walking and running gait".)

When osteoarthritis affects the TMT joint (Lisfranc joint) (figure 5 and image 1), a common site for osteoarthritis of the foot, a ridge is often seen at the articulation of the MT and tarsal bones. This common finding appears like a bump on the medial aspect of the dorsal arch (picture 8). Palpation of the TMT joints may reveal warmth, swelling, or tenderness in the setting of osteoarthritis. Bone spurring at the TMT joints feels like a ridge. To assess Lisfranc joint stability (and pain due to an injury causing instability), the examiner stabilizes the midfoot with one hand while grasping the forefoot with the other and moving it into dorsal- and plantarflexion.

Palpation of the navicular focuses on the navicular tuberosity. This is the attachment site for an accessory navicular and the site of attachment for the posterior tibialis tendon. The "N spot" is the high point of the dorsal navicular, between the tibialis anterior and extensor hallucis longus tendons, and a common site of tenderness in patients with navicular stress fracture (picture 3). Along with palpation, gentle manipulation of the navicular in the vertical plane may reveal excess motion when the spring (calcaneonavicular) ligament is torn or insufficient.

Palpation of the cuboid may reveal pain or excess motion. To identify the cuboid, palpate the base of the fifth MT and move proximally until you feel a small bone approximately the width of the thumb. Grasping this bone between the thumb and index finger allows the examiner to assess dorsal and plantar motion (picture 9 and movie 1). When laxity seems greater than the opposite foot, cuboid subluxation may be present.

DIAGNOSTIC APPROACH TO MIDFOOT PAIN — The authors begin their assessment of the patient with midfoot pain by obtaining a history. The first determination is whether the pain stems from acute trauma or developed suddenly, or whether it developed in a more chronic manner. If chronic, it is important to ask about any underlying medical condition (eg, diabetes mellitus, arthritis, gout) and whether the pain is associated with or follows a particular activity. It is also important to know about any long-standing structural problems with the foot.

Once the distinction between acute and chronic pain is made, location of the pain helps to narrow the likely differential diagnosis. A table and flow chart summarizing common diagnostic considerations in the patient with midfoot pain are provided (table 1 and algorithm 1).

Acute midfoot pain — In patients with acute traumatic pain along the medial midfoot, the clinician should carefully assess the navicular for swelling and tenderness. Swelling, focal tenderness, and dysfunction of the posterior tibial tendon suggest an acute tear. Important questions to ask and key clinical findings for assessing midfoot pain are summarized in the following table (table 1). (See 'Medial arch (navicular) injury' below.)

For acute traumatic pain along the lateral midfoot, the clinician should focus their assessment on the following structures:

●Base of the proximal fifth metatarsal (MT) (see "Proximal fifth metatarsal fractures")

●Cuboid (see 'Cuboid subluxation and cuboid syndrome' below and "Cuboid and cuneiform fractures")

●Peroneal (fibularis) tendons (see "Non-Achilles ankle tendinopathy")

Avulsion fracture of fifth MT, cuboid subluxation, and a partial or complete tear of a peroneal (fibularis) tendon (usually peroneus brevis) are the most likely injuries.

Dorsal or plantar midfoot pain from acute trauma is relatively uncommon. Important injuries to consider include:

●Crush injury (typically obvious from history and inspection)

●Lisfranc joint complex injury (see "Tarsometatarsal (Lisfranc) joint complex injuries")

●Major direct or indirect trauma leading to multiple potential injuries (eg, fractures)

When a clinician suspects injuries of this type, a thorough evaluation, including appropriate diagnostic imaging, determines the extent of injury.

Medical conditions sometimes cause acute dorsal midfoot pain. Such conditions include the following:

●Gout (See "Clinical manifestations and diagnosis of gout" and "Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease".)

●Flare of midfoot osteoarthritis

●Acute exacerbation of diabetic or other peripheral neuropathy (See "Evaluation of the diabetic foot" and "Overview of lower extremity peripheral nerve syndromes".)

Chronic midfoot pain — Location is important for helping to determine the cause of chronic midfoot pain as well. Chronic pain along the medial midfoot should direct the clinician's attention to the navicular and posterior tibial tendon. If the examination reveals focal tenderness or dysfunction involving either structure, the diagnostic evaluation should focus on key problems. These include chronic posterior tibial tendinopathy, partial tear or pain from a symptomatic accessory navicular, and arthritic changes.

When there are no obvious positive findings on examination, the clinician should assess the degree of pes planus (ie, flat foot) and assess the patient's gait to detect whether there is significant pronation during the stance phase (picture 10), which places increased stress on the medial aspect of the arch and is a likely cause of pain. (See "Clinical assessment of walking and running gait".)

The approach is similar for chronic lateral foot pain. Important structures to assess include the cuboid, peroneal tendons, and base of the fifth MT. When there are no obvious positive findings on examination, the clinician should assess cuboid stability (picture 9 and movie 1). If there are no signs of cuboid instability, the next step is to assess the patient's gait looking for supination during foot strike. This finding suggests that increased stress is being placed on lateral foot structures.

Chronic dorsal midfoot pain merits assessment for osteoarthritis (image 1), particularly if the examination shows TMT bossing. Diabetes mellitus, peripheral neuropathy, gout, and other medical conditions are possible sources of pain.

For patients with chronic plantar surface pain, the clinician should look for signs of tearing in the midportion of the plantar fascia and for abnormal structures that may contribute to pain, such as deep nodules, cysts, atypical bursae, and neuromas. Ultrasound and other imaging tools can help to guide this diagnostic workup [8].

COMMON CAUSES OF MIDFOOT PAIN — A flow chart is provided that summarizes common causes of midfoot pain organized by timing (acute versus chronic) and location (algorithm 1).

Acute injuries

Base of fifth metatarsal injury — The proximal base of the fifth metatarsal (MT) is highly prone to injury. Fractures at the base of the fifth MT and acute tendinous injury of the peroneal tendon (primarily peroneus brevis) near its insertion onto the base of the fifth MT can cause acute pain in this area. Patients complain of pain at the outer aspect of the midfoot and may think they have an ankle sprain. Often, they point directly to the styloid prominence of the fifth MT as the site of pain. The styloid is where the peroneus brevis tendon inserts and is a common location for tendon injury and avulsion fracture (image 2). Other injuries of the proximal fifth MT include proximal diaphyseal (Jones) fractures (image 3) and stress fractures (image 4).

Tenderness elicited by squeezing the fifth MT (not the tendon insertion) or by percussion of the bone, or sensitivity in the bone when a tuning fork is placed, suggests a higher likelihood of bone injury. Observational research suggests that Jones fractures may occur more often in those with a high medial arch and a longer fifth MT, anatomic features that increase stress at the proximal portion of the bone [9]. Injuries of the proximal fifth MT can be difficult to diagnose, and some have high complication rates and so warrant close evaluation, including imaging and possibly referral. Less common clinical conditions that may trigger pain in this location include apophysitis in adolescents or trauma to an os vesalianum (an accessory ossicle found at the base of the fifth MT). (See "Proximal fifth metatarsal fractures" and "Non-Achilles ankle tendinopathy".)

Medial arch (navicular) injury — Injuries to the navicular bone and related structures jeopardize the structural integrity of the medial foot arch and thus can lead to severe disability and chronic pain. Therefore, navicular injury is considered high risk, particularly for runners. Such injuries include navicular stress fractures, tendinopathy of the posterior tibialis tendon insertion onto the navicular, traumatic separation of an accessory navicular, and partial or complete tears of the attachment of the plantar calcaneonavicular (ie, spring) ligament. Unless the clinician has experience managing injuries of the medial arch, consultation with a foot and ankle surgeon should be obtained for navicular injuries, including fractures or separation of an accessory navicular, and complete or partial ruptures of the posterior tibialis tendon or spring ligament, as such injuries often compromise the integrity of the longitudinal arch. A rare injury is an isolated dislocation of the navicular without associated fracture [10].

The navicular serves as the keystone for the medial or longitudinal arch (figure 6). Neighboring structures that help to maintain arch integrity include the spring ligament and the posterior tibialis tendon, a large portion of which attaches to the navicular. Complete or partial tear of the spring ligament is the most common cause of loss of longitudinal arch height, followed by complete or partial tears of the posterior tibialis tendon [11]. (See "Non-Achilles ankle tendinopathy".)

When a patient complains of medial arch pain, the first thing to determine is whether the longitudinal arch remains intact. This must be done by observing the patient bearing their full weight. Whether the arches of both feet are symmetric can generally be determined by observation alone, but when doubt exists, the examiner can measure the arch height from the floor to a fixed landmark (eg, navicular prominence) while the patient is standing. Acute loss of the arch in one foot implies rupture of either the spring ligament or the posterior tibialis tendon. With either condition, swelling and tenderness are present below the medial malleolus. Unilateral failure of the heel to move into varus during a heel raise suggests the injury is a posterior tibialis rupture. This observation is made most easily by observing the patient from behind while they perform a heel raise (picture 7 and movie 2).

Anteroposterior and lateral foot radiographs may demonstrate a tarsal coalition (image 5) or arthritic spurring in the tarsal tunnel or along the medial malleolus. Depending on available resources, clinicians may choose magnetic resonance imaging (MRI) or ultrasound to help diagnose posterior tibial tendon injury as limited studies demonstrate comparable accuracy for diagnosing tendinopathy. Spring ligament and accessory navicular injury are better assessed with MRI, although ultrasound may be used [12]. The management of posterior tibial tendon injury is discussed in detail separately. (See "Non-Achilles ankle tendinopathy", section on 'Medial ankle tendinopathy'.)

Palpation of the medial arch should focus on identifying tenderness directly over the navicular. The navicular prominence is inferior and anterior to the medial malleolus (picture 3). Palpation may identify tenderness arising from a partial avulsion of the insertion of the posterior tibialis tendon, a partial separation of an accessory navicular, or a stress fracture of the navicular bone. Tenderness directly over the body of the navicular in the superior medial arch alongside the anterior tibialis tendon (the "N spot") suggests a navicular stress fracture, and such an injury should be assumed until ruled out by diagnostic imaging [13]. Unless a standard radiograph of the foot with navicular views reveals the fracture, an MRI or computed tomography (CT) study should be ordered at the initial evaluation (image 6).

Navicular stress fracture — While uncommon in most sports, tarsal navicular stress fractures are relatively common among long-distance runners and participants in track and field, particularly sprinters, hurdlers, and jumpers. These fractures have a higher risk of complications, and advanced imaging should be performed early if one is suspected. (See "Stress fractures of the tarsal (foot) navicular".)

Patients with a navicular stress fracture typically present anywhere from a few weeks to many months following the onset of pain, often after conservative measures have failed to alleviate symptoms. Pain typically begins insidiously and gradually develops into a nagging, deep, dull ache that may occur with simple ambulation in some but only with high-impact activities (eg, running) in others. Rest typically relieves the pain. While some patients localize the pain to a focal point over the dorsomedial midfoot, others may struggle to localize their symptoms and may indicate maximal pain anywhere between the MTs and the tibial (medial) malleolus. Persistent medial arch pain, particularly pain that occurs during sleep, is highly suggestive. Tenderness at the navicular is the most common examination finding (picture 3), but physical findings may be absent.

Navicular stress fractures, particularly larger ones, are at high risk of delayed union, nonunion, and avascular necrosis, and athletes may not be able to return to sport successfully without appropriate treatment. The classic study of navicular stress fractures suggests that they rarely heal if the patient remains weightbearing [14]. Thus, definitive treatment includes several weeks of nonweightbearing and immobilization using a removable boot or short leg cast and referral to a foot and ankle specialist.

Accessory navicular syndromes — Accessory ossicles are common along the medial superior border of the navicular, contiguous with the posterior tibial tendon (picture 6). These are called accessory naviculars, and there are three basic types (image 7). In a review of 1240 patients presenting with chronic foot pain, plain radiographs revealed an accessory navicular in 20.9 percent [15]. According to this study, the accessory navicular accounted for foot pain in 2 percent of cases, or up to 10 percent of the patients identified with the ossicle. Other studies report a prevalence ranging from 2 to 20 percent.

Accessory navicular bones are often associated with pes planus (picture 6). If they create pressure or friction within the patient's shoe, this can produce pain. Severe pain may represent an avulsion of a fibrous or bony union (type 2 (picture 11) or 3 accessory navicular). A shearing force created by an accessory navicular that lies close to the posterior tibialis tendon can cause pain and may contribute to tendinopathy.

It is important to determine whether a bony irregularity represents an avulsion fracture involving the navicular tuberosity, rather than an accessory navicular. In general, avulsion fractures occur acutely and cause greater swelling and discoloration. On plain radiograph, the cortical margins of avulsion fractures are irregular, while those involving an accessory navicular are smooth. The difference in the appearance of the borders of an avulsion fracture and an accessory ossicle is well seen in the following radiograph (image 8).

Many accessory navicular injuries, including minor avulsions, are treated initially with conservative care focused on control of pain and inflammation with over-the-counter analgesics and custom orthotics [16]. Surgery is needed for some injuries to allow a full return to activity. If symptoms and function fail to improve with six to eight weeks of conservative care or if an avulsion fracture is large, referral to a foot and ankle surgeon is appropriate. Limited observational evidence suggest that surgical treatment is effective [17,18].

Spring ligament (calcaneonavicular) rupture — While acquired flat foot (pes planus) in adults most often indicates a posterior tibial tendon tear, in some cases, collapse of the medial arch is caused by a rupture of the spring ligament (picture 7 and movie 2) [16,19-21]. Distinguishing this condition from a posterior tibial tendon injury by examination alone is difficult; both cause localized swelling and tenderness. MRI and ultrasound findings may indicate that the ligament is injured. In most cases involving significant medial arch collapse, both the posterior tibial tendon and the spring ligament show pathologic changes. Surgical exploration to confirm the diagnosis of isolated spring ligament injury and surgical repair are reserved for individuals experiencing persistent pain not relieved by conservative measures.

Fractures of cuboid and cuneiform bones — Cuboid and cuneiform fractures are uncommon and typically cause pain over the dorsal or dorsolateral aspect of the foot, lateral to the navicular (figure 2). Cuboid stress fractures occur most often in athletes participating in ballet, rugby, running, and gymnastics.

A large retrospective review of cuboid fractures identified five patterns of injury. The most common mechanism, accounting for 48 percent of all fractures, consisted of an avulsion at the calcaneal cuboid articulation. Fractures of the body of the cuboid and intra-articular fracture extending through the body accounted for 13 and 6.8 percent, respectively. The remaining 30 percent of injuries were more complex trauma involving the cuboid and the Lisfranc joint, crush injuries of the lateral column, or extensive joint displacement [22]. Isolated cuboid stress fracture is rare and often mistaken for an ankle sprain [23].

Cuneiform stress fractures have been noted in sprinters in track and field. Traumatic fractures of either bone typically cause severe pain and occur from major foot trauma and crush injuries. Severe injuries are evident on plain radiographs, but small fractures and stress fractures often require more advanced imaging techniques for diagnosis. These injuries are discussed in greater detail separately. (See "Cuboid and cuneiform fractures".)

Tarsometatarsal (Lisfranc) joint complex injuries — Injuries to the tarsometatarsal (TMT) joint complex (including the Lisfranc joint) are serious but uncommon causes of midfoot pain typically due to significant trauma, either direct or indirect. Patients with TMT joint complex injuries typically present with significant pain and swelling in the midfoot immediately following such trauma. Physical examination reveals swelling, tenderness over any of the TMT joints, and inability to bear weight or walk without a limp.

While high-energy mechanisms (eg, motor vehicle collision) are the most common cause, TMT injuries can occur from low-energy mechanisms, typically involving an axial load placed on a plantarflexed foot. This can occur from missing a step when descending a stairway or during sport when one player lands on the heel of another whose foot is plantar-flexed. When necessary, definitive diagnosis may require advanced diagnostic imaging. In a review of 82 sports-related Lisfranc injuries sustained by college athletes in the United States, American football and basketball were the sports most often involved, and return to sport required an average of 7.5 months [24]. These injuries are discussed in greater detail separately. (See "Tarsometatarsal (Lisfranc) joint complex injuries".)

Cuboid subluxation — Cuboid subluxation causes extreme lateral foot pain that may prevent patients from bearing weight. Painful episodes can occur acutely following an inversion (supination) injury of a plantarflexed ankle or possibly from minor foot trauma. Ballet is the activity most often associated with cuboid subluxation. However, acute episodes most often stem from chronic injury resulting in repeated episodes of subluxation. This condition, termed cuboid syndrome, is discussed further below. (See 'Cuboid subluxation and cuboid syndrome' below.)

Stress fracture of other tarsal bones, osteochondral defect, and other uncommon injuries — Persistent midfoot pain in an endurance or high-impact athlete may stem from stress fractures of midfoot tarsal bones, although such injuries are rare. Stress fractures of the cuneiform and cuboid stress fractures are also rare but documented in case reports [25,26]. (See "Overview of stress fractures".)

A rare cause of lateral pain around the cuboid is calcaneocuboid osteochondral defect. The mechanism and potential anatomic variations predisposing to this injury are not known [27]. Painful osteochondral lesions that fail to improve with conservative care should be referred to a foot and ankle surgeon.

Major trauma of midfoot — While not common, major midfoot trauma occurs in motor vehicle collisions, falls, crush injuries, and sometimes sport. Such trauma may entail crush injuries involving multiple structures, fractures of multiple tarsal bones and the bases of MTs, and dislocations of the Chopart or Lisfranc joints. Major trauma involving the Lisfranc or Chopart joints that requires open reduction and internal fixation often has negative effects on mid- to long-term quality of life [28]. Chopart joint injury leads to major limitations in foot function. Surgical treatment is often required; fusion is reserved for the most severe injuries [29].

Rarely, traumatic midfoot injury may be complicated by compartment syndrome, as pressure in constrained foot compartments increases and compromises blood flow. If not diagnosed and managed quickly, permanent damage and disability can result [30]. (See "Acute compartment syndrome of the extremities".)

Chronic conditions of the midfoot

Post-traumatic arthritis — The most common injury leading to post-traumatic arthritis in the midfoot is a Lisfranc sprain, fracture, or fracture dislocation. Major crush injuries or traumatic complex fractures involving tarsal bones also trigger long-term midfoot arthritis (image 1). The first TMT joint is the second most frequent location for foot arthritis following the first metatarsophalangeal joint. (See "Tarsometatarsal (Lisfranc) joint complex injuries".)

Extensor tendinopathy of the foot — Patients can injure extensor tendons of the foot (figure 10) through overuse or sometimes from unusual activity. As examples, extensor digitorum longus tendinopathy has been reported in ultra-marathon runners [31] and in windsurfers due to foot strap placement [32]. Activities including frequent beach walking, stair or ladder climbing, and ballet or modern dancing all can potentially cause overuse injuries that affect extensor tendons. As these tendons play a less significant role than others during walking, running, and jumping, injury is less common. In most cases, extensor tendinopathy of the foot presents as redness, swelling, and pain over the dorsum of the midfoot. There are case reports of gonococcal and tuberculous tendon sheath infections in these tendons, so it is important to consider infection if the history does not reveal an activity or injury that is likely to account for the clinical findings. (See "Non-Achilles ankle tendinopathy", section on 'Anterior ankle tendinopathy'.)

Peroneal (fibularis) brevis, longus, and posterior tibial tendinopathy — Tendinopathy of the peroneal or posterior tibial tendons typically causes pain around the lateral or medial ankle, respectively, that increases gradually. However, with severe tendinopathy or tendon tears, swelling and pain may extend into the midfoot. Pain with resisted movement, varying degrees of swelling, and tenderness around the affected tendon are typical. These injuries are reviewed separately. (See "Non-Achilles ankle tendinopathy".)

Cuboid subluxation and cuboid syndrome — Cuboid subluxation causes extreme lateral foot pain that may prevent patients from bearing weight [33-35]. Painful episodes can begin acutely following an inversion (supination) injury of a plantarflexed ankle or possibly from minor foot trauma. Ballet is the activity most often associated with cuboid subluxation. In one series, just over 6 percent of such sprains caused some degree of cuboid subluxation [34].

More commonly, cuboid subluxation is diagnosed after months of intermittent lateral ankle pain that is often sharp. This condition is commonly termed "cuboid syndrome," and most case reports involve ballet or running. A proposed mechanism involves minor injuries to the multiple ligaments that stabilize the cuboid, leading to intermittent subluxation and varying degrees of pain.

The cuboid articulates medially with the navicular and the lateral cuneiform, posteriorly with the calcaneus, and anteriorly with the fourth and fifth MT bases. Subluxation occurs if the intertarsal ligaments between one or more of the articulations that stabilize the cuboid tear, allowing the bone to shift position [33]. The tendon of the peroneus longus passes below the cuboid before traversing the foot, and forceful contraction of this muscle-tendon unit can displace the cuboid from its normal position.

The examiner can readily palpate the cuboid, which lies anterior to the calcaneus and behind the base of the fifth MT (picture 9 and movie 1). In contrast to peroneal tendinopathy, focal tenderness over the cuboid is often present, and the midtarsal adduction test elicits pain. This test is performed by stabilizing the ankle and subtalar joint with one hand while the other hand applies an adduction (or varus) force to the midfoot (picture 12). Cuboid subluxation is discussed in greater detail separately. (See "Non-Achilles ankle tendinopathy", section on 'Differential diagnosis of lateral ankle tendinopathy'.)

Dorsal exostosis of tarsometatarsal bones (tarsometatarsal bossing) — Dorsal exostosis of the TMT bones, also referred to as TMT bossing, refers to a prominence and deformity along the dorsum of the articulation of the MT base with the adjacent tarsal bone (picture 8) [36]. This is a common problem for adults over 40 and younger patients with a neuropathic foot. The TMT joints are located between the cuneiforms, cuboid, and base of the MTs. The second TMT joint is recessed proximally by approximately 1 cm and is crossed by the Lisfranc ligament, which runs from the lateral aspect of the first cuneiform to the base of the second MT (figure 11). This entire complex forms the Lisfranc joint (figure 5). Degenerative change to this joint complex usually stems from traumatic injury. Excessive pressure from gait abnormalities, subclinical injuries, chronic micro-trauma in a neuropathic foot, and congenital issues such as brachymetatarsia likely contribute in many cases.

Patients with TMT bossing typically notice a rigid, bony bump on the dorsum of the foot, most commonly along the medial column at the intersection of the midfoot and forefoot. Initially, the prominence is asymptomatic, but as the deformity increases, most patients begin experiencing pain over the dorsum of the midfoot either from arthritic change or pressure from their shoe. They may notice some swelling and redness after prolonged standing or after wearing shoes with minimal support.

Some patients may experience numbness at the dorsal foot that extends into the great toe from pressure exerted on the overlying medial dorsal cutaneous nerve, a branch from the superficial peroneal (fibular) nerve (figure 12). This nerve travels superficial to the first TMT joint and supplies sensation to the medial foot and great toe. With the patient standing or seated, the examiner can see spurring at the Lisfranc joint, often over the first and second TMT joints but sometimes extending across the entire joint complex. These rigid spurs may be tender to palpation.

Confirmation of TMT bossing requires standard posteroanterior and lateral radiographs of the foot. Standing radiographs are preferred to look for signs of a remote, untreated Lisfranc joint dislocation. Signs of such an injury include wider than normal separation of the first and second rays, a fleck sign, and dorsal displacement of the second MT shaft on a standing lateral view. The diagnosis of many Lisfranc joint injuries is delayed. Virtually all grades of Lisfranc injury lead to chronic pain and midfoot dysfunction and degenerative change resulting in TMT bossing [37]. (See "Tarsometatarsal (Lisfranc) joint complex injuries".)

Additional imaging is rarely indicated, but bone scan or MRI can demonstrate the degree of inflammatory response around this joint. Treatment focuses on relieving symptoms with analgesics, including topical or oral nonsteroidal antiinflammatory drugs or other medication, and support with customized arch pads or standard store-bought arch supports. Custom orthotics may relieve pain and assist gait more effectively in certain cases, particularly patients with structural breakdown of other areas of the foot.

While some evidence supports surgical intervention for TMT arthritis involving TMT joints of the great (first) and adjacent (second and third) toes, this has primarily been studied in patients with concomitant hallux valgus or who developed osteoarthritis following a Lisfranc injury. Outcomes for surgery of TMT joints four and five (smaller toes) have been poor, and such procedures are used sparingly. Referral to foot and ankle surgeons is reserved for patients with intractable pain following conservative interventions, to include custom orthotics and specialized shoe modifications.

Neuropathic Charcot changes — Charcot arthropathy, a severe form of midfoot arthritis in patients who lack normal foot sensation (eg, diabetics), affects the Lisfranc joint in approximately 40 percent of cases (picture 13) [38]. As degeneration of the midfoot progresses, the joints of the midfoot begin to sublux and dislocate, eventually leading to collapse of the midfoot arch. The affected bones may ultimately fuse. Charcot changes, caused by diabetes in most cases in developed countries, can arise from any idiopathic neuropathy, including those that arise from vasculitis or as a complication of chemotherapy. Tabes dorsalis is a late manifestation of neurosyphilis that affects the posterior columns of the spinal cord and leads to ataxia and sensory loss over the lower extremity that has been associated with midfoot arthropathy. (See "Neurosyphilis".)

Tarsal coalitions — Tarsal coalitions are defined as abnormal fibrous, cartilaginous, or bony unions found most commonly between the calcaneus and navicular and less commonly between the calcaneus and talus or cuboid (image 5). Symptomatic patients with tarsal coalition may complain of pain over the subtalar joint of the foot. Pain may worsen with activity, walking on uneven ground, or running. Examination reveals a rigid pes planus, hindfoot valgus, loss of subtalar motion, and limited, painful inversion of the foot.

While clinicians may suspect these in patients with a rigid pes planus, they are often identified only when a plain radiograph or CT reveals the anomaly. However, as many are fibrous or cartilaginous, the sensitivity of radiographs and CT is limited. In a study of 100 cadaver feet, CT identified only 55.5 percent of the tarsal coalitions noted on dissection [39]. MRI demonstrates greater sensitivity and specificity for identifying tarsal coalition, and observational studies suggest a prevalence comparable to that reported in cadaver studies (approximately 11 percent versus 13 percent in cadaver studies) [40]. While clinical reports suggest that symptomatic tarsal coalitions are uncommon (approximately 1 percent of feet), the actual prevalence of the condition remains unclear [3].

Surgery for tarsal coalition is performed most often in children or young adults. The indication is persistent pain, often accompanied by gait impairment. In adults, tarsal coalition is usually an incidental finding. Even in pediatric cases, surgeons often prefer a minimum of six months of conservative care before surgical intervention. Nonoperative care entails orthotics, rehabilitation exercises, cryotherapy, and medication for symptom relief. A systematic review of 25 retrospective studies with a high risk of bias, involving 760 tarsal coalitions, reported a surgical success rate of just under 80 percent and a complication rate of about 5 percent [41].

Medical conditions causing midfoot pain

Gout and crystal-induced arthritis — Gout commonly affects the foot. While most cases involve the first MTP joint, involvement of midfoot joints is relatively common. A typical attack is intensely inflammatory, characterized by severe pain, redness, swelling, and disability. The maximal severity of the attack is usually reached over several hours. The signs of inflammation associated with acute gout often extend beyond the confines of the joint that is primarily involved. (See "Clinical manifestations and diagnosis of gout" and "Treatment of gout flares".)

Calcium pyrophosphate crystal deposition affects the foot less often but in rare cases causes sufficient destruction to mimic a Charcot joint [42]. (See "Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease" and "Treatment of calcium pyrophosphate crystal deposition (CPPD) disease".)

Rheumatoid arthritis and osteoarthritis — Rheumatoid arthritis commonly causes foot pain, affecting the majority of patients in several published studies (range 61.7 to 89 percent) [43]. Foot pain is the presenting complaint in approximately 35 percent of patients subsequently diagnosed with rheumatoid arthritis. Frequently, pain occurs daily and is often severe [44]. While the forefoot is the most common location, midfoot pain occurred in 32 percent of affected patients in one series. Involvement of the midfoot had the greatest negative impact on walking [45]. (See "Diagnosis and differential diagnosis of rheumatoid arthritis" and "Clinical manifestations of rheumatoid arthritis".)

Osteoarthritis commonly affects the talonavicular joint of the midfoot (aggravated by pes planus) (image 1). (See "Clinical manifestations and diagnosis of osteoarthritis" and "Overview of the management of osteoarthritis".)

Cutaneous conditions of the midfoot

Dorsal foot ganglia — Dorsal foot ganglia can occur proximal to any of the foot joints and along extensor tendon sheaths (picture 14). Ganglia are the most common nodule found in the foot, accounting for nearly 40 percent of lesions that present to surgeons. They typically involve the dorsum of the mid- or forefoot and the toes. They are less common over the heel and the flexor tendon sheaths in the foot. Common locations include the various TMT joints, the tarsal-tarsal joints, and talonavicular or calcaneocuboid joints. Up to 85 percent of cases affect females [46].

Ganglia are firm nodules that typically are not painful unless constrictive shoes rub against them. Most nodules have limited mobility and are partially compressible with manual pressure or a change in foot position. Imaging studies are unnecessary unless the diagnosis is in doubt. Ultrasound allows easy identification of ganglia and may enable the examiner to see if the lesion connects to a proximal joint capsule (image 9). Conservative treatment may include foot pads and compression of the ganglion with an arch strap. Definitive treatment is reviewed separately. (See "Ganglion cysts of the wrist and hand", section on 'Treatment'.)

Plantar fibromatosis (Ledderhose disease) — Plantar fibromatosis is a relatively rare hyperproliferative disease affecting the plantar fascia [47]. The condition may be isolated to areas of the plantar fascia anywhere from the heel throughout the arch (picture 15). While thought to be more common in males and older adults, cases have been described in children and adolescents.

The condition sometimes occurs with other fibromatous disorders like Dupuytren contracture, Peyronie disease, and knuckle pads. The patient notices nodules on the plantar surface of the foot. These often cause pain with standing or walking after the nodules become larger. The nodules are usually visible to the examiner and on palpation are movable.

Simple interventions such as cutouts placed in sports insoles or donut-type cushions may adequately relieve symptoms. In other situations, direct injection of a low-dose glucocorticoid into the nodules may reduce their size. Accurate injection requires ultrasound guidance. Adjunctive treatments include orthotics, stretching, and antiinflammatory drugs. Surgery is ineffective as recurrence is common.

Uncommon causes — Rare causes of focal midfoot pain include Muller-Weiss disease in adults and Kohler disease in children. Both appear to be an osteochondrosis involving the navicular. The condition is progressive in adults but may resolve in children. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Köhler disease (navicular osteochondrosis)'.)

SUMMARY AND RECOMMENDATIONS

●Anatomy – The midfoot extends from the proximal portion of the metatarsal (MT) bones to the proximal ends of the tarsal bones, namely the cuboid and the tarsal navicular (figure 1). The midfoot plays an important role in enabling humans to adapt to uneven surfaces while standing and during gait. (See 'Anatomy and biomechanics' above.)

●Epidemiology – The incidence of midfoot pain in younger adults varies widely by activity and sport participation, but adults over age 50 frequently experience midfoot pain. Pain is commonly caused by direct or chronic trauma and medical conditions affecting joints (eg, osteoarthritis) or soft tissues. (See 'Epidemiology of localized midfoot pain' above.)

●History and physical examination – Important elements of the history and examination in patients complaining of foot pain are reviewed separately. Aspects of particular relevance to midfoot pain are discussed above. (See "Overview of foot anatomy and biomechanics and assessment of foot pain in adults", section on 'Anatomy-based approach to diagnosis' and 'History and examination' above.)

Important aspects of the history in the patient with midfoot pain include the onset of pain (sudden or gradual), pain location, and provocative and palliating factors. (See 'History and examination' above.)

Important midfoot structures to observe and examine include the following:

•Longitudinal arch height (figure 6)

•Navicular tuberosity (picture 2) and "N spot" (picture 3) (see 'Medial arch (navicular) injury' above)

•Foot pronation or supination during gait (see "Clinical assessment of walking and running gait")

•Medial tarsometatarsal (TMT) region (eg, TMT bossing (picture 8)) (see 'Dorsal exostosis of tarsometatarsal bones (tarsometatarsal bossing)' above)

•Lisfranc joint line (figure 5) (see 'Tarsometatarsal (Lisfranc) joint complex injuries' above)

•Cuboid and base of fifth MT (see 'Base of fifth metatarsal injury' above and 'Fractures of cuboid and cuneiform bones' above and 'Cuboid subluxation and cuboid syndrome' above)

●Diagnostic approach – Our suggested diagnostic approach to the patient with midfoot pain is described above. Important questions to ask and key clinical findings for assessing midfoot pain are summarized in the following table (table 1). Specific causes of midfoot pain are summarized in the text (algorithm 1). (See 'Diagnostic approach to midfoot pain' above and 'Common causes of midfoot pain' above.)