Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: Midfoot arthritis — degeneration of the tarsometatarsal (TMT) joints and surrounding joints of the midfoot — causes chronic arch and dorsal foot pain, swelling, and difficulty with prolonged standing or walking. Common causes include post-traumatic arthrosis after Lisfranc injury (even ‘minor’ sprains), primary osteoarthritis, rheumatoid arthritis, and Charcot neuropathic arthropathy. Conservative management with custom orthotics, rocker-bottom shoes, and injections provides relief for many patients. Surgical arthrodesis (fusion) of the affected TMT joints reliably eliminates arthritic pain, corrects deformity, and provides durable long-term outcomes. Dr. Biernacki at Balance Foot & Ankle plans and performs midfoot fusion procedures for patients across Michigan.
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Understanding Midfoot Arthritis
The midfoot consists of the tarsometatarsal (Lisfranc) joints, the naviculocuneiform joints, and the intercuneiform joints — forming the structural bridge between the hindfoot and forefoot. Arthrosis in these joints — from post-traumatic, primary, or inflammatory causes — disrupts the rigid lever arm function of the midfoot during push-off, causing pain, instability, and progressive arch collapse. The most common cause in younger patients is post-traumatic arthritis after Lisfranc injury, even seemingly minor sprains that were treated non-operatively. In older patients, primary osteoarthritis and rheumatoid disease are frequent causes.
Why Lisfranc Injuries Cause Late Arthritis
Lisfranc injuries span a spectrum from subtle ligamentous sprains to complete fracture-dislocation. Even “minor” Lisfranc sprains with subtle instability, if treated inadequately or missed entirely, allow microscopic joint displacement during weight-bearing that accelerates cartilage wear. Studies show that up to 40–50% of Lisfranc injuries develop significant TMT arthritis within 3–5 years of injury. This is why anatomic reduction and often surgical fixation of unstable Lisfranc injuries is preferred — and why persistent midfoot pain after a “foot sprain” warrants evaluation for underlying TMT pathology including stress radiographs and MRI.
Conservative Management First
Dr. Biernacki initiates conservative care for most midfoot arthritis patients. Custom orthotics with rigid midfoot support and a rocker-bottom modification significantly reduce TMT joint stress during walking. Stiff-soled or carbon fiber insole footwear (shown to be very effective in randomized trials) reduces midfoot joint moment. Corticosteroid injection into affected TMT joints under fluoroscopic or ultrasound guidance provides diagnostic confirmation and temporary therapeutic relief. Activity modification — reducing high-impact loading — slows arthritic progression. Conservative care is continued for 3–6 months before surgery is considered unless deformity is rapidly progressive or patient disability is significant.
Tarsometatarsal Arthrodesis: Definitive Surgical Treatment
TMT arthrodesis (midfoot fusion) eliminates arthritic pain by permanently fusing the involved joints in corrected alignment, converting motion-pain to stable painless fusion. Surgical planning uses weight-bearing CT (WBCT) and conventional X-rays to map all involved joints. Typically, the medial three TMT joints (1st, 2nd, 3rd) are fused — the 4th and 5th are often spared (they provide necessary gait accommodation through residual motion). Joint cartilage is removed, bone graft or demineralized bone matrix applied, and rigid internal fixation (plates, screws) achieved. Concomitant deformity (flatfoot arch collapse, forefoot abduction) is corrected at the same procedure. Outcomes are excellent — >85% patient satisfaction with significant pain reduction and return to desired activities.
Recovery After Midfoot Fusion
Midfoot fusion recovery requires patience. Non-weight-bearing for 6–8 weeks allows initial bone fusion. Progressive weight-bearing in a CAM boot from weeks 8–14. Transition to stiff-soled supportive shoes at 3–4 months with physical therapy for gait retraining. Return to regular activities at 5–6 months; full recovery of strength and endurance by 9–12 months. CT scan at 3–4 months confirms fusion consolidation before full weight-bearing clearance. Hardware removal (2–3% of patients) is occasionally performed if symptomatic hardware causes dorsal impingement.
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Post-midfoot fusion, midfoot arthritis flares, Lisfranc injury immobilization
Patients requiring non-weight-bearing with crutches (need additional support)
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✅ Pros / Benefits
- TMT arthrodesis has >85% patient satisfaction rates — one of the most reliable procedures for chronic midfoot pain.
- Simultaneous deformity correction (flatfoot, forefoot abduction) at the time of fusion addresses all components of complex midfoot disease.
- Rigid internal fixation with modern plating systems allows bone healing without cast immobilization after initial splinting.
❌ Cons / Risks
- 6–8 weeks non-weight-bearing is a significant lifestyle disruption — pre-operative planning for work and home is essential.
- Midfoot fusion reduces midfoot joint motion permanently; most patients adapt well but stiff-soled footwear is often preferred long-term.
- Non-union (failure of bone to fuse) occurs in 5–10% — risk is higher in smokers, diabetics, and patients with vascular disease.
Dr. Tom Biernacki’s Recommendation
Post-Lisfranc arthritis is one of the most under-appreciated causes of chronic foot pain I see. A patient ‘sprains’ their foot, walks on it, and 3 years later they have significant midfoot arthritis because the Lisfranc ligament never healed properly. When they finally come to me with chronic midfoot pain and a flat, collapsed arch, we’re discussing fusion. The lesson: any midfoot sprain that doesn’t resolve in 4–6 weeks needs proper imaging to rule out Lisfranc instability.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
Will I be able to walk normally after midfoot fusion?
Yes — most patients return to normal walking by 5–6 months post-operatively. The midfoot does lose some joint motion with fusion, which is compensated by adjacent joints and a slight adaptation in gait mechanics. Most patients are unaware of the motion loss in daily life and achieve near-normal walking patterns.
Does midfoot fusion require bone graft?
Usually — demineralized bone matrix (DBM) allograft is routinely used to fill joint spaces and stimulate fusion. Autograft (your own bone from the calcaneus or iliac crest) is used in higher-risk cases (revision surgery, smokers, diabetics). Synthetic bone graft substitutes are also options. Dr. Biernacki will discuss the specific graft strategy for your case.
How do I know if my midfoot pain is arthritis vs. plantar fasciitis?
Location is key — plantar fasciitis is primarily at the heel/arch junction, while midfoot arthritis is at or around the midarch, especially on the dorsal (top) and medial surfaces. Weight-bearing X-rays showing joint space narrowing, osteophytes, and sclerosis confirm midfoot arthrosis. Diagnostic injection into the TMT joints that eliminates pain is highly diagnostic.
Can midfoot arthritis be treated without surgery permanently?
Many patients manage midfoot arthritis long-term with custom rigid orthotics, carbon fiber insoles, and activity modification — particularly those with early-stage or mild arthrosis. Surgery is reserved for patients with significant functional limitation despite adequate conservative care. Some patients use these tools for years before eventually choosing surgery.
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
Frequently Asked Questions
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- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
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