The Troublesome Tarsometatarsal 4-5 Joint: An Unrecognized Condition in Lateral Midfoot Pain

Pain in the lateral midfoot is a frequent and often confusing problem. It is a descriptive term that represents a constellation of symptoms. The anatomical regions that can serve as a cause of pain include: the lateral subtalar joint (STJ) ligamentous and muscular structures; the calcaneocuboid joint (CCJ); and the lateral column of Lisfranc joint, tarsometatarsal joint (TMT) 4-5. 

Common differential diagnoses of lateral midfoot pain may include: 

• peroneal brevis/longus tenosynovitis and stenosis at the calcaneoperoneal tubercle;
• os peroneum syndrome at the cuboid notch;
• fifth metatarsal stress fracture at the metaphyseal-diaphyseal junction (DeLee fracture);
• cuboid peroneal syndrome;
• tenosynovitis/stenosis at the cuboid notch;
• cuboid stress fracture;
• calcaneocuboid joint capsulitis or osteoarthritis; and
• hypermobility and/or osteoarthritis at the cuboid and fourth and fifth metatarsal joints (TMT 4-5).

The TMT 4-5 articular anatomy and the soft tissue structures that support the fourth and fifth metatarsals to the cuboid include the interosseous ligaments, dorsal and plantar cubometatarsal ligaments, and a slip from the long plantar ligament. Additionally, the fourth and fifth metatarsals receive slips from the tibialis posterior tendon and take the origin of the oblique head of the adductor hallucis muscle. The fifth metatarsal also receives a slip from the lateral band of the plantar fascia which can serve as an etiologic source of fifth metatarsal base fractures. A study by Qatu and colleagues evaluated the shape and size of the articular cartilage of the fourth and fifth metatarsal bases. It demonstrated that the lateral fourth metatarsal base is predominantly triangle-shaped and composed of 49% of articular cartilage.¹ Alternatively, the medial fifth metatarsal base is composed of 48% articular cartilage and is predominantly oval in shape.¹ This cadaveric study demonstrated that the articular surfaces of the fourth and fifth metatarsal are predominantly flat and thus contribute to larger ranges of motion.

Biomechanical Function of the Lisfranc Lateral Column

A cadaveric study by Ouzounian and Shereff demonstrated that the range of motion of the midfoot in the sagittal plane is greatest at the fourth and fifth TMT joints, calculated at 9.6 and 10.2 degrees respectively.² This is compared to 7.0 degrees of motion at the talonavicular joint (TNJ) and 2.3 degrees at the calcaneocuboid joint.² This range of motion provided by the TMT 4-5 joint has proven significant to allow accommodation to uneven surfaces.³ Thus, this joint complex has been referred to as the subtalar joint of the midfoot. In overuse situations, compensation occurs primarily due to conditions of the medial pedal structures. Plantar fasciitis, tibialis posterior tendonitis, midfoot capsulitis and osteoarthritis, hallux limitus, and ankle instability are among the common pedal conditions that can lead to lateral foot overload by compensatory mechanisms. Proximal conditions such as hip and knee OA can also lead to overload of the lateral column. These symptoms primarily generate from increased intra-articular joint contact pressures or frank arthritic changes. Myerson describes preservation of these joints in Lisfranc’s traumatic fracture dislocations. This is for the reasons described as well as tolerance of these joints to osteoarthritis. The fifth metatarsal composes a ray allowing triplane motion. It pronates (metatarsus quintus pronatus) to allow terrain adaptation and supinates (metatarsus quintus supinatus) when stability of the midfoot is required. Motion here remains independent of the subtalar joint.

Clinical Manifestations at TMT 4-5 Joint Secondary to Hypermobility or Osteoarthritis

We typically see that patients with hypermobility or osteoarthritis at this joint will demonstrate no associated symptoms while non-weight-bearing, and there is usually no edema present. When first loading weight (post-static), they may describe symptoms as “excruciating” and often require numerous antalgic steps before attaining full weight-bearing. The symptoms are often diffuse and nonspecific but confined to the lateral midfoot. We usually find that there is usually no history of trauma, as the symptoms onset is primarily insidious. The patient will often describe the foot as “broken,” and thus will seek medical treatment. In our experience, this is a very common scenario that can occur post-plantar fascia release. In these cases, when subjecting the lateral midfoot to inversion stress, the patient will describe significant severe pain. Palpation directly over the TMT 4-5 joints will elicit pain. It also can remain a residual problem after a traumatic event or sprain affecting the midfoot.

Diagnostic Pearls to Consider

There is no gold standard concerning diagnostic testing for pathology in this area. Plain film radiographs may note medial subluxation of the fourth metatarsal on the cuboid, which can represent the presence of hypermobility. Radiographs in combination with computed tomography (CT) scans may also demonstrate degenerative changes at those respective joints. A technetium-99m magnesium diphosphonate (MDP) bone scan may show uptake in the soft tissue angiogram phase, representing increased blood flow and thus inflammation secondary to hypermobility. If osteoarthritis is present, one will see focality at the bone phase. Magnetic resonance imaging (MRI) may also indicate marrow edema, primarily at the cuboid on the T2 (water) images.⁴ 

Notes on Conservative and Surgical Treatment Options

The initial approach will attempt to focalize symptoms and thus better target therapy by confining the usual diffuse symptoms that accompany pathology at the TMT 4-5 joint. Utilization of nonsteroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, and taping with longitudinal arch padding can be helpful to reduce these symptoms.⁵ Orthotics can also be useful for maintenance treatment. Functional devices with a deep heel seat, lateral clip, extended medial flange, and a cuboid support can potentially reduce recurrence. Physical therapy can be of help, but in our experience should be oriented to managing compensatory symptoms. Fluoroscopically guided intra-articular corticosteroids utilizing 80 mg of methylprednisolone acetate or 40 mg of triamcinolone acetonide with a mixture of 0.5% bupivacaine followed by 3 weeks in long leg immobilizer can prove effective.⁶ Options also exist with biologics such as platelet-rich plasma. 

In cases that have failed conservative treatment, the following surgical options can be considered: 

• resection (dowel) interpositional arthroplasty;
• anchovy tendon interposition;
• spherical ceramic ball interposition; or
• isolated arthrodesis of the TMT 4-5 joint. 

The orthopedic literature notes tendon interposition utilized in the following symptomatic joints: 

• trapeziometacarpal joint;
• carpometacarpal joints;
• radioulnar joint;
• sternoclavicular joint;
• glenohumeral joint; and
• temporomandibular joint.

The presentation of joint function and mobility has become a standard in chronic recalcitrant cases of residual TMT 4-5 joint pain. This can be, as stated, secondary to hypermobility or OA changes. Mirmiran and Hembree described interpositional arthroplasty utilizing a Dowel technique encompassing the peroneous tertius or brevis in a cohort of 3 patients. This technique involves curettage of the hyaline articular cartilage of the fourth and fifth metatarsal bases and the distal articular surface of the cuboid, which creates 1 cm of joint space.⁵ This allows better joint mobility as well as decompression of the subchondral surfaces, thus addressing the source of pain. The harvested tendon is then placed into the joint as a form of interposition. Surgeons may or may not use a 0.062-inch Kirschner wire (K-wire) across the fifth metatarsal-cuboid joint. The patient is then non-weight-bearing in a posterior splint for 3 weeks.⁵ After K-wire and suture removal, the patient is in a weight-bearing long leg immobilizer for 3 more weeks. 

In the case of the anchovy interposition, a 4-mm burr creates a spherical defect across the joint from dorsal to plantar. The surgeon takes care to not resect the plantar joint. Then, either tendon from the peroneus tertius or brevis or an allomatrix graft is rolled into the size of an anchovy and sutured with 3-0 polyglactin 910. It is then placed into the osseous tunnels where no form of fixation is needed. This also serves to preserve motion as well as decompress the subchondral surfaces. Postoperatively, care is similar to that with the dowel technique. A study performed by Shawen and team evaluated surgical outcomes of the spherical ceramic implant utilized as a form of interpositional arthroplasty. Thirteen patients underwent this procedure after failed resection arthroplasties (dowel), with outcomes demonstrating an 87% improvement in the American Orthopaedic Foot and Ankle Society (AOFAS) scores postoperatively.⁷ 

Recent studies contend that arthrodesis should be reserved for cases with severe arthritic changes or structural deformity. The literature relates that the TMT 4-5 joint serves as a relatively challenging joint for achievement of arthrodesis. A study by Derner and colleagues noted a 10.8% incidence of nonunion is 37 patients. Arthrodesis also limits midfoot adaptations and leads to increased stress at the cuboid interface and calcaneocuboid joint itself.⁸

Conclusion

Lateral midfoot pain often presents chronically and with many potential etiologies. Often the symptoms are nonspecific but severe, and not associated with edema or trauma. The calcaneocuboid joint seems to often serve as the culprit. Lack of recognition of the TMT 4-5 joint and its vital function can lead to failure to recognize this joint as a common problem. Compensation and post-traumatic residuals can lead to patients presenting with chronic lateral midfoot pain.  

Dr. Visser is a past president of the St. Louis Podiatric Medical Society and the Missouri Podiatric Medical Association. He served as an examiner of the American Board of Podiatric Surgery and on the Missouri State Board of Podiatric Medicine over several governorships. He’s been a residency director for 40 years, most currently, at SSM-Depaul Foot and Ankle Reconstructive and Trauma Surgical Program in St. Louis, MO.

Dr. Lozano is a first-year podiatric resident at SSM Health DePaul Hospital in St. Louis, MO. 
 

References
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2.    Ouzounian Tj, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10(3):140-146 Anatomic Description of the Fourth and Fifth Tarsometatarsal
3.    Casciato D, Yancovitz S, Olivová J, Singh B. Anatomic Description of the Distal and Intercuneiform Articulations: A Cadaveric Study. J Foot Ankle Surg. 2021;60(6):1137-1143. doi:10.1053/j.jfas.2021.04.016
4.    Arnold JB, Halstead J, Martín-Hervás C, et al. Bone Marrow Lesions and Magnetic Resonance Imaging-Detected Structural Abnormalities in Patients With Midfoot Pain and Osteoarthritis: A Cross-Sectional Study. Arthritis Care Res (Hoboken). 2023;75(5):1113-1122. doi:10.1002/acr.24955
5.    Mirmiran R, Hembree JL. Tendon interpositional arthroplasty of the fourth-fifth metatarsocuboid joint. J Foot Ankle Surg. 2002 May 1;41(3):173-7.
6.    Protheroe D, Gadgil A. Guided Intra-articular Corticosteroid Injections in the Midfoot. Foot Ankle Int. 2018;39(8):1001-1004. doi:10.1177/1071100718779983
7.    Shawen SB, Anderson RB, Cohen BE, Hammit MD, Davis WH. Spherical Ceramic Interpositional Arthroplasty for Basal Fourth and Fifth Metatarsal Arthritis. Foot Ankle Int. 2007;28(8):896-901. doi:10.3113/FAI.2007.0896
8.    Derner R, Derner BS, Olsen A. Fusion of the Tarsometatarsal Joints: A Focus on Lateral Column Fusion Nonunion Rates. J Foot Ankle Surg. 2020;59(4):704-710. doi:10.1053/j.jfas.2019.12.004