Midtarsal Joint Pain – The Clinical Syndrome
The midtarsal joints are an uncommon cause of ankle and foot pain. Midtarsal joint pain may be seen in patients who repeatedly point their toes, such as ballet dancers and football punters. Most patients with midtarsal joint pain secondary to osteoarthritis and posttraumatic arthritis pain report pain localized to the dorsum of the foot. The muscles associated with the midtarsal joints and their attaching tendons also are susceptible to trauma and to wear and tear from overuse and misuse and may contribute to the patient’s clinical symptoms. Activity, especially inversion and adduction of the midtarsal joints, makes the pain worse; rest and heat provide some relief. The pain is constant and characterized as aching; it may interfere with sleep. Some patients report a grating or popping sensation with use of the joint, and crepitus may be present on physical examination. In addition to the pain, patients with arthritis of the midtarsal joint often experience a gradual decrease in functional ability with decreasing midtarsal range of motion, making simple everyday tasks, such as walking and climbing stairs, quite difficult.
Signs and Symptoms
Examination of the ankle and foot of patients with arthritis of the midtarsal joints reveals diffuse tenderness to palpation. The ankle and dorsum of the foot may feel hot to touch, and swelling may be present. Adduction and inversion of the foot and range of motion of the ankle exacerbate the pain. Weight bearing also may exacerbate the patient’s pain, and a hesitant, antalgic gait may be present. Crepitus is often present on range of motion of the joint.
How is Midtarsal Joint Pain diagnosed?
Plain radiographs are indicated in all patients with midtarsal joint pain. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. Magnetic resonance imaging (MRI) of the midtarsal is indicated if joint instability, occult mass, or tumor is suspected and to confirm the diagnosis.
The midtarsal joint is susceptible to the development of arthritis from a variety of conditions that have in common the ability to damage the joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in midtarsal joint pain. Rheumatoid arthritis and posttraumatic arthritis also are common causes of midtarsal pain secondary to arthritis. Less common causes of arthritis-induced midtarsal pain include collagen-vascular diseases, infection, and Lyme disease. Acute infectious arthritis usually is accompanied by considerable systemic symptoms, including fever and malaise; an astute clinician should easily recognize this condition and treat it appropriately with culture and antibiotics, rather than injection therapy. The collagen-vascular diseases generally manifest as polyarthropathy rather than monoarthropathy limited to the midtarsal joint, although midtarsal pain secondary to collagen-vascular disease responds well to injection of the joints with a local anesthetic and steroid.
Lumbar radiculopathy may mimic the pain and disability associated with arthritis of the midtarsal joints. In such patients, the ankle examination should be negative. Entrapment neuropathies, such as tarsal tunnel syndrome, and bursitis of the ankle may confuse the diagnosis; both conditions may coexist with arthritis of the midtarsal joint. Primary and metastatic tumors of the distal tibia and fibula and spine and occult fractures also may manifest in a manner analogous to arthritis of the midtarsal joint.
Initial treatment of the pain and functional disability associated with arthritis of the midtarsal joints should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. Avoidance of repetitive activities that aggravate the patient’s symptoms and short-term immobilization of the ankle joint may provide relief. For patients who do not respond to these treatment modalities, an injection of the midtarsal joints with a local anesthetic and steroid may be a reasonable next step.
Complications and Pitfalls
Failure to identify primary or metastatic tumor of the ankle or spine that is responsible for the pain may yield disastrous results. The major complication of intra-articular injection of the midtarsal joints is infection. This complication should be exceedingly rare if strict aseptic technique is followed. Approximately 25% of patients report a transient increase in pain after intra-articular injection of the midtarsal joints, and patients should be warned of this possibility.CLINICAL PEARLS
Pain emanating from the midtarsal joints is commonly seen in individuals who forcefully point their toes, such as ballet dancers and football punters. This injection technique is extremely effective in the treatment of pain secondary to the previously mentioned causes of arthritis of the midtarsal joint. Coexistent bursitis and tendinitis may contribute to midtarsal joint pain and may require additional treatment with more localized injection of a local anesthetic and depot steroid. This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator. The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection. The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for midtarsal pain. Vigorous exercises should be avoided because they would exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.