Overview
- Tarsometatarsal and naviculocuneiform joints
- Primary, post-traumatic after Lisfranc injury, or inflammatory
- Dorsal midfoot pain on walking and push off, dorsal bossing, flattened arch
- Weight bearing radiographs and guided injections localise the painful joints
- Stiff soled or rocker bottom shoes and orthoses first
- Medial and middle column arthrodesis gives reliable relief
- Mobile lateral column preserved
Western Health Orthopaedic Registrar Presentation – Midfoot Arthritis by Dr Jack Pang
Anatomy
- Medial column, first tarsometatarsal and naviculocuneiform joints
- Middle column, second and third TMT joints, with the recessed second metatarsal base as keystone
- Lateral column, fourth and fifth metatarsocuboid joints, highly mobile
- Lisfranc ligament joins medial cuneiform to second metatarsal base
Aetiology
- Primary arthritis in middle-aged women with flat feet
- Post-traumatic after Lisfranc injury, even after anatomical reduction
- Inflammatory arthritis and Charcot neuroarthropathy
Clinical Features
- Dorsal bossing with shoe pressure and peroneal nerve irritation
- Pain with midfoot abduction and pronation stress
- Silfverskiöld test for gastrocnemius tightness
Investigations
- Weight-bearing AP, oblique and lateral views, the oblique showing the lateral column
- Lateral view for TMT sag and Meary line
- SPECT-CT and image-guided injection localise the pain generator
Management
- Stiff sole, carbon fibre insert or rocker bottom
- Arthrodesis of medial and middle columns is the standard operation
- Preserve the lateral column, using interposition arthroplasty or resection if symptomatic
- Correct abduction, sag and dorsiflexion while preserving metatarsal length
- Plantar tension band principles improve stability
- Dorsal exostectomy alone for bossing with limited arthritis
Complications
- Nonunion at the second and third TMT joints, commoner in smokers, diabetics and Charcot feet
- Superficial and deep peroneal nerve injury and neuroma
- Transfer metatarsalgia from first ray shortening or elevation
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.