Treatment for Midfoot Sprain
Functional treatment with a three-phase approach is the recommended management for midfoot sprains, including PRICE protocol initially, followed by exercises and progressive return to activity.
Initial Assessment and Classification
Midfoot sprains represent injuries to the Lisfranc ligament complex and can be classified into three stages:
- Stage I: Undisplaced injuries
- Stage II: Diastasis with no arch height loss
- Stage III: Diastasis with arch height loss 1
Proper assessment is crucial as the location of maximal tenderness on physical examination is an important prognostic indicator. Injuries with medial and global midfoot tenderness typically have longer recovery times compared to lateral midfoot sprains 2.
Immediate Management (0-72 hours)
PRICE Protocol
The PRICE (Protection, Rest, Ice, Compression, Elevation) protocol is recommended for the initial management of midfoot sprains:
- Protection: Protect the midfoot with a compressive device
- Rest: Rest for up to 72 hours to allow ligaments to heal
- Ice: Apply ice to reduce edema and decrease pain
- Compression: Use compression to limit swelling
- Elevation: Elevate the foot to reduce swelling 3
Cryotherapy
- Apply cold therapy using ice wrapped in a damp cloth for 20 minutes, 3-4 times daily
- Avoid direct ice-to-skin contact to prevent cold injury
- While the evidence for cryotherapy alone is inconclusive, it may be beneficial when combined with exercise therapy 3
Pain Management
- NSAIDs are recommended for short-term pain relief, improved function, decreased swelling, and more rapid return to activity
- Studies show NSAIDs like piroxicam, celecoxib, and naproxen provide better pain control compared to placebo 3
- Be aware that NSAIDs may delay natural healing by suppressing inflammation necessary for tissue recovery 3
Rehabilitation Phase (48-72 hours onward)
Functional Treatment
Functional treatment is superior to immobilization for midfoot sprains:
- Patients return to sports 4.6 days sooner with functional treatment
- Patients return to work 7.1 days sooner with functional treatment 3
External Support
- Use lace-up or semirigid supports rather than tape or elastic bandages
- Semirigid ankle support results in shorter time to return to sports and work, and less ankle instability 3
- For midfoot sprains specifically, functional support should be used for 4-6 weeks 3
Exercise Program
Begin exercises to restore motion and strength within 48-72 hours of injury:
- Focus on strengthening exercises for hip, trunk, and lower leg muscles
- Include eccentric strengthening exercises
- Incorporate balance and proprioception training
- Gradually increase intensity and duration of exercises 3, 4
Midfoot Joint Mobilization
- Midfoot joint mobilization techniques (forefoot supination, cuboid glide, and plantar 1st tarsometatarsal mobilization) combined with home exercises have been shown to reduce pain and improve function
- These techniques yield greater pain reduction and perceived improvement compared to sham treatment 5
Return to Activity Phase
Progressive Return
- Begin with walk/run intervals
- Gradually increase running duration and intensity
- Monitor for symptom recurrence
- Return to full activity should be based on pain-free movement, normal strength and flexibility, and adequate functional performance 4
Recovery Timelines
Recovery times vary based on injury severity:
- Grade 1 (mild) sprains: Average 3.1 days of time lost
- Grade 2 (moderate) sprains: Average 36 days of time lost
- Grade 3 (severe) sprains requiring surgery: 73+ days for return to play 6
Surgical Considerations
Surgery is indicated for:
- Stage II and III injuries with diastasis
- Injuries with frank diastasis (94% of NFL team physicians recommend surgery)
- Patients who have failed 3-6 months of conservative therapy 6, 1
Prevention of Recurrence
- Proper warm-up and cool-down routines
- Gradual increase in training intensity (no more than 10% per week)
- Appropriate footwear with adequate shock absorption
- Continuing maintenance exercises focusing on strength and flexibility 4
Red Flags for Further Evaluation
Seek further evaluation if:
- Pain persists despite 2-3 weeks of conservative treatment
- Severe pain doesn't improve with rest
- Night pain or pain at rest occurs
- Consider imaging to rule out stress fractures or other conditions if symptoms persist 4
Most athletes can expect a successful return to play after midfoot sprain with appropriate management, with studies showing 92% successful return rates for non-operatively treated cases 6.