A 56-year-old man presents with “years” of left foot pain. The pain has become progressively worse over the last month and is now bothering him every day. He notices the pain more when he is walking up and down stairs, and the pain seems to be relieved with rest. Anteroposterior, lateral, and oblique view X-rays of the left foot show arthritis at the tarsometatarsal (TMT) joint.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Submit your diagnosis to see full explanation.
The midfoot, or tarsometatarsal (TMT) joint, bears the body’s weight as the joint helps propel the foot forward during ambulation. Inflammation of the midfoot can cause pain every time the foot pushes off the ground. Arthritis of the TMT joint can be a disabling condition causing chronic pain with ambulation. The most common cause of arthritis in the midfoot is a prior history of trauma. Post-traumatic arthritis can be caused by a fall or crush injury. A common mechanism of injury is a motor vehicle accident when the foot is plantar flexed during impact. A Lis franc injury, or a fracture dislocation of the midfoot, can also result in midfoot arthritis years after injury. As the supporting ligaments of the midfoot are injured, TMT joints become unstable and hypermobile, and articular cartilage subsequently wears over time.1,2
Pain with TMT joint arthritis can be reproduced by having the patient perform a single leg stance while trying to push off with the affected foot. X-ray findings will include joint space narrowing at the 1st, 2nd, and 3rd metatarsal bases and their articulations with the medial, middle, and lateral cuneiforms. The primary goal of treatment for TMT joint arthritis is to unload the joint with immobilization. A carbon fiber insole orthotic placed in a shoe is usually the first-line treatment to immobilize the midfoot. NSAIDs, along with a period of ice and rest, helps reduce inflammation and pain. Steroid injections done under fluoroscopic guidance are helpful for both diagnostic and therapeutic purposes for persistent pain. TMT joint arthrodesis is the preferred surgical option if all conservative measures fail.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
Rao S, Nawoczenski DA, Baumhauer JF. Midfoot arthritis: nonoperative options and decision making for fusion. Tech Foot Ankle Surg. 2008;7:188-195.
Alyer A, Moore D. Midfoot arthritis. Available at: https://www.orthobullets.com/foot-and-ankle/7036/midfoot-arthritis