New York State Medical Treatment Guidelines for Forefoot

and Midfoot Fractures in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Forefoot and Midfoot Fractures.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Diagnostic Studies for Forefoot and Midfoot Fractures in workers compensation patients

  1. Diagnostic Studies for Forefoot and Midfoot Fractures in workers compensation patients for X-Rays is recommended as a first-line investigation for possible midfoot or forefoot fractures.

    Indications:Look for any fractures in the forefoot or midfoot

    Rationale for Recommendation:Fractures can be detected with an X-ray, fracture plane(s) direction, the extent of the involvement of the if they are sufficiently large, the interphalangeal and metatarsal phalangeal joints might change management to favour surgery (see below). a fracture In the case of negative radiographs, pursue a clinical suspicion Radiographs could be beneficial; after roughly seven days, there should. The fracture line resorption will then be apparent.


  2. MRI for Suspected Acute Forefoot and Midfoot Fractures

    MRI for Suspected Acute Forefoot and Midfoot Fractures is recommended for occult suspicion and stress fracture in certain patients.

    Indications:typically used when there is a suspicion of an undetected condition or stress fracture although some consider CT to be superior to the fore or midfoot.

    Rationale for Recommendation:MRI should not be the first treatment option. test. MRI could be a crucial diagnostic tool for the analysis of Possible navicular and tarsometatarsal joint injuries (Lisfranc injury) and for the early detection of a possible stress fracture. MRI is also employed to assess avascular necrosis and a potential hidden fracture.


  3. Bone Scanning for Forefoot and Midfoot Fractures

    Bone Scanning for Forefoot and Midfoot Fractures is recommended typically used when there is a suspicion of an undetected condition or stress fracture although some consider CT to be superior to the fore or midfoot.

    Indications:usually used when there is a possibility that the tarsal and metatarsal bones may have fractured occultly.

    Rationale for Recommendation :For the majority of patients with forefoot and midfoot fractures, bone scans are not necessary for assessment. For patients who have a high clinical suspicion but a negative x-ray or CT scan, a bone scan may be justified.

CT Imaging

CT for Diagnosis and Classification of Forefoot and Midfoot Fractures

CT for Diagnosis and Classification of Forefoot and Midfoot Fractures is recommended in a small number of people for forefoot and fractures in the midfoot

Indications: To better understand fracture displacement, articular involvement, and subluxation of afflicted joints, tarsal and metatarsal bone fractures that have fractured or broken into many pieces are evaluated. This is typically used as a backup diagnostic technique to x-rays.

Rationale for Recommendation: CT should not be a first-line treatment. test. CT might be a crucial diagnostic method to get more clarity. subluxation, articular involvement, and fracture displacement is advised for some people with afflicted joints.

Medications for Forefoot and Midfoot Fractures

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. A viable substitute for acetaminophen (or its homolog paracetamol) NSAIDs for individuals who are not NSAID candidates, despite the majority of evidence hints that acetaminophen is just marginally less effective.

There is proof that NSAIDs are equally as effective as opioids, such as tramadol, for relieving pain. impairing.

  1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

    Non-Steroidal Anti-inflammatory Drugs (NSAIDs) is recommended for managing pain from metatarsal or phalangeal fractures.

    Indications:NSAIDs are advised as a kind of treatment for phalangeal or metatarsal fracture pain that is acute, subacute, chronic, or postoperative. First, try over-the-counter (OTC) medications to see whether they work.

    Frequency/Duration: Many patients could find it reasonable to use as needed.

    Indications for Discontinuation: Resolution of ankle/foot discomfort, ineffectiveness, or emergence of side effects requiring termination.


  2. NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding

    NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding is recommended concurrent use of histamine type 2 receptor blockers, proton pump inhibitors, misoprostol, sucralfate, and other cytoprotective classes of medications for individuals at high risk of gastrointestinal bleeding.

    Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a prolonged course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

    Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended. Dose and frequency per manufacturer. There is not generally believed to be substantial differences in efficacy for prevention of gastrointestinal bleeding.

    Indications for Discontinuation:Intolerance, the emergence of unfavourable effects, or stopping using NSAIDs.


  3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended The first-line treatment options of acetaminophen or aspirin seem to be the safest in terms of cardiovascular side effects. Non-selective NSAIDs are suggested as an alternative to COX-2-specific drugs when necessary.

    When taking low-dose aspirin for the main or secondary prevention of cardiovascular disease, an NSAID should be taken at least 30 minutes after or eight hours before the aspirin. This will lessen the likelihood that the NSAID will counteract the protective effects of the aspirin.


  4. Acetaminophen for Treatment of Acute, Subacute, or Chronic Phalangeal or Metatarsal Fracture Pain

    Acetaminophen for Treatment of Acute, Subacute, or Chronic Phalangeal or Metatarsal Fracture Pain is Recommended to treat severe, mild, or persistent illnesses Specifically in patients, pain related to phalangeal or metatarsal fractures Contraindications to NSAIDs.

    Indications: Acute, subacute, and chronic foot/ankle pain in all individuals chronic and following surgery.

    Dose/Frequency:As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity. Indications for Discontinuation:displacement of fracture/joint dislocation 2mm.

Treatments for Forefoot and Midfoot Fractures

  1. Nonoperative Management for Non-Displaced TarsalMetatarsal Injury (Lisfranc)

    Nonoperative Management for Non-Displaced TarsalMetatarsal Injury (Lisfranc) is recommended for select patients.

    Indications:displacement of fracture/joint dislocation 2mm.

    Management:Cast that is not weight-bearing for six weeks.


  2. Operative Management for Displaced Tarsal-Metatarsal Injury (Lisfranc)

    Operative Management for Displaced Tarsal-Metatarsal Injury (Lisfranc) is recommended for a tarsal-metatarsal injury that is unstable.

    Indications: joint dislocation greater than 2 mm and fracture joint displacement.

    Management:The healing process could begin with therapy and last for four to five months. removing hardware before starting a full activity

    Rationale for Recommendations:Therapy could be the first step in the healing process, which might persist for four to five months. hardware removal before a full activity is started. Evidence for the Management of Lisfranc Injuries


  3. Non-Operative Management for Non-Displaced Metatarsal Fractures

    Non-Operative Management for Non-Displaced Metatarsal Fractures is recommended for non-displaced metatarsal fractures. Indications: Shaft fractures with a dorsal angulation of less than 10, without displacement or with displacement of up to 3 to 4 mm in either the dorsal or plantar directions.


  4. Operative Management for Displaced Metatarsal Shaft Fractures

    Operative Management for Displaced Metatarsal Shaft Fractures is recommended for misaligned metatarsal shaft fractures. foot and ankle conditions: Indications:Several metatarsals may fracture, coupled with a shaft fracture near the metatarsal head, if they become dislocated..

    Management: Internal fixation with screws, plates, or percutaneous pinning; four to six weeks of no weight bearing. weight-bearing progression over the following four to six weeks in a walking cast or fracture shoe/boot. after radiographic proof of union, full weight-bearing in stiff-soled footwear.

    Rationale for Recommendations: The physical and radiographic findings determine the best immobilisation or fixation approach.

    Non-operative Management for Proximal Fifth Metatarsal Fractures (Including Joints and Avulsion)

    Non-operative Management for Proximal Fifth Metatarsal Fractures (Including Joints and Avulsion) is Recommended for select patients.

    Indications: non-displaced, 1 to 2 mm step-off on the articular surface, or less than 30% of the articular surface with a cuboid; avulsion of tuberosity; Jones Patient/provider preference: fracture.

    Management: Play the same movie for one and six weeks. Jones fracture: immobilisation in a non-weight-bearing short-leg cast for one to six weeks; then, until union, in a walking cast or hard-sole shoe.


  5. Operative Management for Fifth Displaced Metatarsal Shaft Fractures (Jones, Avulsion)

    Operative Management for Fifth Displaced Metatarsal Shaft Fractures (Jones, Avulsion) is Recommended for select patients.

    Indications:Avulsion of tuberosity: step-off on the articular surface that is displaced by more than 1 to 2 mm, or more than 30% of the articular surface that is cuboid; Jones Patient/provider preference is a fracture

    Management: Evidence for the Management of Proximal Fifth Metatarsal Injuries

    Rationale for Recommendations:The physical and radiographic findings determine the best immobilisation or fixation approach.


  6. Immobilization for Distal, Middle, or Proximal Phalanx

    Immobilization for Distal, Middle, or Proximal Phalanx are recommended for the care of specific patients.

    Indications:less than 25% of the articular surface is involved and is closed, non-displaced, or stable after reduction.

    Management:Closed reduction following digital or hematoma block, post-reduction film obtained, repeated at one and six weeks, and toe splinted with buddy taping to adjacent toe until nontender (three to four weeks), omitting hallux. Consider further immobilisation with a postoperative shoe or cast-boot.


  7. Operative Management for Distal, Middle, or Proximal Phalanx Fractures

    Operative Management for Distal, Middle, or Proximal Phalanx Fractures are Recommended for the care of specific patients.

    Indications:Great toe displacement fractures that were difficult to reduce and couldn’t be held with a tape splint..

    Rationale for Recommendations: Therefore, the immobilisation or fixation strategy is determined by the radiological and physical findings. It usually only affects multiple toe fractures or displaced fractures of the great toe.


  8. Non-operative Management for Lower Extremity Stress Fractures

    Non-operative Management for Lower Extremity Stress Fractures is recommended -for lower extremity stress fractures at low risk. for lower extremity stress fractures at low risk.

    Indications:stress fractures that are not displaced.

    Management: All non-displaced stress fractures are initially treated with conservative measures.


  9. Operative Management for Lower Extremity Stress Fractures

    Operative Management for Lower Extremity Stress Fractures is recommended for displaced or non-responding lower extremity stress fractures, such as navicular stress fractures, that cannot be treated nonoperatively.

    Rationale for Recommendations: Responses to stress fractures in most cases, respond to activity limitation. Activity Restrictions are consequently advised. Those stress fractures that do not react or that have moved are handled effectively. Sometimes, experts will choose to treat a certain patient first. Non-operatively treated mildly displaced fractures.

What our office can do if you have Forefoot and Midfoot Fractures as a result of a workers compensation injury

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.

Call Us Now!

Based on 96 reviews
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18


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I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

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