What is the treatment for a midfoot sprain?

Treatment of Midfoot Sprains

Functional treatment with ankle bracing for 4-6 weeks combined with early exercise therapy is the preferred approach for treating midfoot sprains, as it provides better outcomes compared to immobilization. 1

Initial Assessment and Classification

Midfoot sprains represent injuries to the Lisfranc ligament complex, ranging from partial sprains with no displacement to complete tears with frank diastasis 2. Proper classification is essential for determining appropriate treatment:

• Stage I: Undisplaced injuries (no diastasis)
• Stage II: Diastasis with no arch height loss
• Stage III: Diastasis with arch height loss and frank displacement 2

Weightbearing radiographs are crucial for diagnosis, with bone scintigraphy providing additional sensitivity for detecting these injuries 2.

Acute Treatment Protocol

First 24-72 Hours

1. Protection: Protect the midfoot from further injury using appropriate bracing
2. NSAIDs: Use for pain control and reducing inflammation
   • NSAIDs have been shown to improve pain control, decrease swelling, and allow quicker return to activity 1
   • Options include piroxicam, celecoxib, naproxen, or diclofenac
3. Functional Support: Apply a semi-rigid ankle brace
   • Semi-rigid supports are more effective than tape or elastic bandages 1
   • Lace-up or semi-rigid ankle braces result in shorter time to return to sports and work 1

Important Note on RICE Protocol

The traditional RICE (Rest, Ice, Compression, Elevation) protocol is not recommended as a standalone treatment for midfoot sprains, as there is no evidence that RICE alone, cryotherapy alone, or compression therapy alone positively influences pain, swelling, or function 1.

Treatment Algorithm Based on Injury Severity

Stage I (Undisplaced) Injuries

1. Functional support with ankle brace for 4-6 weeks 1
2. NSAIDs for pain control 1
3. Early exercise therapy starting within 48-72 hours of injury 1
4. Gradual return to activity based on pain and function

Stage II and III (Displaced) Injuries

1. Surgical consultation for anatomic reduction with fixation 2
2. Post-surgical rehabilitation following orthopedic protocols

Exercise Therapy Protocol

Exercise therapy should begin within 48-72 hours of injury and progress through three phases 1:

Phase 1 (Days 2-7)

• Range of motion exercises: Ankle circles, toe curls
• Isometric strengthening: Quad sets, ankle pumps
• Weight bearing as tolerated with brace support

Phase 2 (Weeks 1-3)

• Progressive strengthening: Resistance band exercises for ankle eversion/inversion
• Proprioception training: Single-leg balance exercises
• Midfoot joint mobilization: Shown to reduce pain and improve outcomes 3
  • Focus on forefoot supination, cuboid glide, and plantar 1st tarsometatarsal mobilizations

Phase 3 (Weeks 3-6)

• Sport-specific drills and endurance training
• Balance training on unstable surfaces
• Gradual return to previous activity level

Special Considerations for Athletes

Athletes with midfoot sprains require careful management:

• Return to play timelines:

  • Grade 1 injuries: Approximately 3-4 days 4
  • Grade 2 injuries: Approximately 5 weeks 4
  • Grade 3 injuries requiring surgery: 10+ weeks or longer 4

• Offensive linemen are at higher risk (29.2% of football-related midfoot injuries) 5

• Custom orthoses may be beneficial for athletes returning to play, especially for lateral midfoot sprains 5

Long-term Management

For chronic midfoot pain or arthritis resulting from midfoot sprains:

• Custom orthoses to modify loads at inflamed joints 6
• Activity modification to reduce impact
• Continued proprioceptive training to maintain stability
• Surgical consultation if conservative management fails after 3-6 months 7

Monitoring and Follow-up

• Re-evaluate at 1-2 weeks to assess healing progress
• Monitor for signs of chronic instability or post-traumatic arthritis
• Consider advanced imaging (MRI) if symptoms persist beyond 2-3 weeks

The location of maximal tenderness on physical examination is an important prognostic indicator—injuries with medial and global midfoot tenderness typically require longer recovery periods 5.

Common Pitfalls to Avoid

1. Underdiagnosing the severity of midfoot sprains, leading to inadequate treatment
2. Prolonged immobilization, which can lead to stiffness and delayed return to function
3. Returning to activity too soon, especially with grade 2 and 3 injuries
4. Failing to provide appropriate functional support during the healing phase
5. Overlooking the need for surgical intervention in cases with frank diastasis

By following this evidence-based approach to midfoot sprain treatment, you can optimize outcomes and minimize long-term complications while facilitating a safe return to activity.