Understanding Midfoot Sprains: Causes, Symptoms & Physiotherapy Treatment

Midfoot pain is something people often brush off as “just a twist,” but the midfoot plays a huge role in stability, push-off strength, and shock absorption. When this area is injured, even simple tasks like walking to the letterbox or standing on your toes can feel impossible.

One common and often misunderstood injury in this region is a midfoot sprain, sometimes involving the Lisfranc ligament complex.

What Is a Midfoot Sprain?

A midfoot sprain is when the ligaments in the middle of your foot, between the arch and the ankle, are overstretched or torn. It often feels like a deep ache or sharp pain in the arch, especially when walking, jumping, or pushing off. Sprains range from minor ligament strain to partial tearing and, in more severe cases, instability of the TMT joints.

If instability is present, it is sometimes referred to as a Lisfranc injury, a more serious subset of midfoot sprains.

How Do Midfoot Sprains Happen?

Midfoot sprains can occur from both high-energy and low-energy mechanisms.

Common Everyday Causes 

• Twisting your foot when stepping off a curb

• Landing awkwardly from a jump

• Stumbling or slipping

• Having your foot bent backwards or sideways under load

• Kicking the ground accidentally during sport

  
  

Sport & High-Load Causes

• Tackles or collisions where the foot is planted

• Sudden pivoting or cutting movements

• Forceful plantarflexion (foot pointed down) while weight-bearing

  
  

Technical Mechanisms

• Axial loading through a plantarflexed foot

• Rotational force causing widening of the TMT joints

• Shear forces disrupting dorsal or plantar midfoot ligaments

• Micro-instability from chronic overuse or repetitive strain

Common Signs & Symptoms

What Patients Typically Feel

• Pain in the middle of the foot or arch, especially when walking

• Swelling across the top or inside of the midfoot

• Pain pushing off the toes or during single-leg balance

• Difficulty walking on uneven ground

• Bruising under the arch (a classic sign of Lisfranc involvement)

• Feeling like the foot is “weak” or “giving way”

  
  

Clinical Signs Physiotherapists Assess

• Local tenderness over the TMT joints

• Pain with midfoot compression or torsion tests

• Reduced push-off strength

• Pain with tiptoe walking

• Forefoot abduction/adduction pain

• In more serious cases: midfoot widening or instability on stress testing

Physiotherapy Treatment for Midfoot Sprains

Management depends on severity, but physiotherapy is essential for restoring stability, strength, and function.

1. Early Management

Load Modification

• Reduce weight-bearing during painful periods

• Possible use of a CAM boot, stiff-soled shoe, heel wedge or taping for 2–4 weeks (mild) or 6+ weeks (moderate)

• Avoid running, jumping, or twisting movements

  
  

Pain & Swelling Control

• Ice early if swollen

• Elevation

• Soft-tissue techniques as pain allows

2. Mid-Stage Rehabilitation

Restoring Mobility Safely

• Gentle midfoot mobility once swelling decreases

• Ankle and toe range of motion exercises

• Avoid excessive stretching of the injured ligaments early on

  
  

Strengthening

Physio programs often include:

• Intrinsic foot muscle strengthening (short-foot, towel curls)

• Calf strengthening (soleus and gastrocnemius)

• Tibialis posterior control for arch support

• Peroneal and anterior tibialis strengthening

• Balance and proprioceptive training

  
  

Load Re-Introduction

• Gradual increase in walking distance

• Controlled gym work (bike, sled push, light step-ups)

• Low-impact cardio before running

  
  

3. Late-Stage Return to Sport / Running

A full return to sport or running includes:

• Hop progressions: double → single → multi-directional

• Running technique and gait retraining

• Plyometric progressions

• Sport-specific agility and cutting drills

Return-to-play criteria generally include:

• Full pain-free weight bearing

• No tenderness on palpation

• Strong, stable midfoot during hop testing

• Ability to complete change-of-direction drills pain-free

When Referral is Needed

Physiotherapists will refer to a foot & ankle specialist when:

• Severe swelling, bruising under the foot, or difficulty weight-bearing

• Possible Lisfranc displacement

• Suspected fractures (2nd metatarsal base, cuboid, cuneiform)

• Pain persists despite correct rehab

• The foot shows signs of instability

High-grade Lisfranc sprains may require imaging or surgical review.

Differential Diagnosis: What Else Could It Be?

Midfoot pain can mimic several other conditions, so physiotherapists carefully rule out alternatives:

1. Stress Fracture

• Metatarsal base, navicular, cuboid

• Very focal bony tenderness

• Pain increases with hopping or impact

  
  

2. Plantar Fasciitis

• Pain more medial/heel-based

• Worse in the morning, improves with warm-up

  
  

3. Tibialis Posterior Tendinopathy

• Pain along inside of ankle/arch

• Worse with prolonged walking or single-leg calf raises

  
  

4. Extensor Tendinopathy

• Pain on top of foot

• Pain with resisted toe extension

  
  

5. Midfoot Osteoarthritis / Joint Synovitis

• Stiffness and swelling across midfoot joints

• More chronic, less traumatic

  
  

6. Morton’s Neuroma

• Burning or numbness in toes

• Electric sensation with toe squeeze

  
  

7. Peroneal Tendon Injuries

• Pain outside of foot/ankle

• Often linked to rolling ankle outward

  
  

Midfoot sprains are more than just a “simple twist.” They can range from mild ligament irritation to more complex Lisfranc injuries, and early diagnosis makes a big difference in recovery.

With the right physiotherapy plan, focusing on stability, strength, load progression, and gait mechanics, most people return to full activity without long-term issues. If you’ve had a twist, fall, or persistent arch pain, it’s worth getting assessed early to rule out anything more serious.