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THE ANKLE is a complex body part that plays a critical role in mobility and stability. Ankle pain may be due to sprains, arthritis, breaks and tendon problems.
THE FOREFOOT extends from the ball of the foot to the toes. Forefoot pain may be due to bunions, toe deformities and neuromas.
THE MIDFOOT runs from the ball of the foot to the heel and includes the arch. Midfoot pain may be due to arthritis or stress fractures.
THE HINDFOOT, also known as the heel, is the area between the ankle and the foot's arch. Heel pain may be due to plantar fasciitis or Achilles tendon problems.

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Midfoot Conditions

The midfoot runs from the ball of the foot to the heel and includes the arch. Dr. Jan-Eric Esway treats a wide variety of midfoot conditions, including arthritis, stress fractures and bone breaks. (Each is covered in detail below.)


Arthritis is caused by the wearing of cartilage between joints. Cartilage is the normally smooth, fibrous tissue that covers the ends of bones allowing them to glide over each other. Patients with high arches are particularly prone to midfoot arthritis. No cure for arthritis exists, but treatment can increase a patient's comfort and mobility.

Generally, arthritis is characterized by pain, stiffness and swelling of the joint. These symptoms usually are worse in the morning and when getting up from rest.

Non-surgical treatment options include physical therapy, anti-inflammatory medications, shoe-wear modifications and orthotics. Sometimes, injections can be helpful in relieving symptoms.

Surgical treatments are rarely used to treat midfoot arthritis. Only in the most severe cases is fusion, or arthrodesis, used to alleviate symptoms. Doctors remove the abnormal cartilage and then use screws to hold the two bones together while they heal. Although joint movement is sacrificed, patients typically are still functional and able to enjoy more activities than they did previously. However, 4-6 months of healing time and recovery are usually necessary.

Posterior Tibial Tendon Dysfunction (PTTD)

The posterior tibial tendon provides support to the midfoot and assists in walking. This thin rope-like piece of tissue runs down the inside of the ankle and underneath the arch. If the tendon weakens or becomes damaged or diseased, this can cause the arch to fall. Commonly known as "adult-acquired flatfoot," posterior tibial tendon dysfunction (PTTD) can occur in one or both feet. Overuse is the most common cause, usually from excessive walking, running, hiking, or stair climbing. Symptoms of this condition include flattening of the arch, pain, swelling, and inward rolling of the ankle. These issues will become more pronounced as the disorder progresses, and arthritis may develop in the ankle.

As PTTD is a progressive disorder, receiving treatment as early as possible is recommended. Surgery typically will not be necessary except in advanced cases. Non-surgical techniques, including orthotics, braces, or casts, physical therapy, prescription and OTC medication, and shoe modifications, can often help to alleviate discomfort and resolve the issue.

Stress Fractures

A stress fracture is a crack that does not completely go through the bone. Initially called "marching fractures,"they were first noted in 19th century soldiers who marched too far or too often. The injury has two main causes: too much repetitive stress on a bone and/or weakness of the bone, which can result from a number of factors. If the repeated strain is greater than the strength of the bone, then it will fracture. Midfoot stress fractures are usually seen in the navicular, cuneiform, and metatarsal bones and occur most frequently in runners, competitive athletes, and young women. Stress fractures are usually not seen on X-rays; a bone scan or MRI is often necessary to make the diagnosis. Treatment depends on the cause but usually involves rest, wearing a cast boot for about six weeks, and then slowly returning to normal activities. In some cases, additional evaluation and treatment for osteopenia and/or osteoporosis is necessary.

Bone Breaks

Bone breaks in the midfoot area are usually severe when they occur. They are, most commonly caused by the foot bending back on itself. Historically, this occurred in cavalry soldiers when they would fall off the horse with their foot caught in the stirrup. Damage to the midfoot area is serious because it plays a major role in movement and stability. Breaks lead to pain, swelling, bruising and an inability to walk or put weight on the affected foot. The foot also may have a deformity due to the broken bones shifting from their normal alignment.

Severe injuries often require surgery. Generally, surgeons align broken bones by securing them in place with screws. These may need to be removed later, depending on the situation. The speed of recovery depends on the severity of the injury.

Lisfranc Injury

The Lisfranc joint is named after the French surgeon who served in Napoleon's army in the 19th century and first described injury to this area. Also known as the tarsometatarsal (TMT) joint, the Lisfranc joint includes the ligaments and bones of the upper midfoot. Damage to this region, which can be a sprain, ligament tear, dislocation, or fracture, commonly occurs as a result of a twist, fall, or athletic injury. In many cases, other soft and bony tissues will be affected. Patients with this condition may experience pain, swelling, bruising, difficulty walking, and deformity. Treatment will depend on the severity and type of injury sustained. To learn more about the evaluation and treatment of Lisfranc injuries, please read "Lisfranc Injuries: What Have We Learned Since Napoleon's Era?" Dr. Esway co-authored this article, which was published in the journal Operative Techniques in Orthopaedics.

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