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Medial cuneiform bone

The medial cuneiform is the largest of the three cuneiform bones in the foot. It is located in the medial midfoot, articulating proximally with the navicular, distally with the base of the first metatarsal, laterally with the intermediate cuneiform, and sometimes with the base of the second metatarsal. It plays a vital role in foot stability, medial longitudinal arch support, and weight transmission from the hindfoot to the forefoot.

Synonyms

  • First cuneiform

  • Internal cuneiform

Synonyms

  • Middle cuneiform

  • Second cuneiform

Joints

  • Proximal articulation: Navicular bone

  • Distal articulation: Base of first metatarsal

  • Lateral articulation: Intermediate cuneiform, occasionally base of second metatarsal

Ligament Attachments

  • Dorsal and plantar cuneonavicular ligaments: Connect navicular to medial cuneiform

  • Intercuneiform ligaments: Bind medial cuneiform to intermediate and lateral cuneiforms

  • Dorsal and plantar cuneometatarsal ligaments: Link medial cuneiform to first metatarsal

  • Lisfranc ligament: Strong oblique ligament attaching medial cuneiform to base of second metatarsal, crucial for midfoot stability

Tendon and Muscle Attachments

  • Insertion: Tibialis anterior inserts into medial cuneiform (medial surface)

  • Insertion: Fibularis (peroneus) longus tendon inserts on lateral side of medial cuneiform (plantar surface)

  • Relation: Tibialis posterior tendon attaches partially to medial cuneiform

  • Relation: Foot intrinsic muscles (first dorsal interosseous and abductor hallucis) are related medially and inferiorly

Nerve Supply

  • Deep peroneal nerve: Supplies articular branches to intercuneiform joints

  • Medial plantar nerve: Contributes to cuneometatarsal joint innervation

  • Saphenous nerve: Provides superficial cutaneous innervation overlying medial cuneiform

Arterial Supply

  • Dorsalis pedis artery: Supplies dorsal aspect via medial tarsal branches

  • Medial plantar artery: Supplies plantar surface

  • Anastomotic branches: From lateral plantar artery and deep plantar arch

Venous Drainage

  • Dorsal venous network → great saphenous vein medially

  • Plantar venous plexus → posterior tibial and peroneal veins

Function

  • Provides stable base for first ray (first metatarsal–cuneiform axis)

  • Supports medial longitudinal arch of the foot

  • Acts as an anchor for tendon insertions critical for gait and propulsion

Clinical Significance

  • Fractures: Rare in isolation; usually part of Lisfranc injury complex

  • Lisfranc injury: Disruption of ligament between medial cuneiform and second metatarsal base → midfoot instability

  • Degenerative arthritis: In cuneometatarsal or intercuneiform joints

  • Stress injuries: Seen in athletes and runners with repetitive midfoot loading

  • Imaging: MRI/CT critical for detecting subtle fractures, ligamentous injuries, and midfoot instability

MRI Appearance

  • T1-weighted images:

    • Marrow: intermediate-to-high signal depending on fat content

    • Cortical bone: low signal (dark rim)

    • Fractures: linear low-signal defects crossing bone

    • AVN (rare): diffuse low-signal changes

  • T2-weighted images:

    • Normal marrow: intermediate to high signal depending on fat

    • Cortical bone: low signal

    • Stress reactions or fractures: bright hyperintense marrow signal

    • Joint effusion or Lisfranc ligament tear: bright fluid signal adjacent to articulation

  • STIR:

    • Normal marrow suppressed (dark)

    • Pathology: bright hyperintense signal in edema, fractures, or stress changes

  • Proton Density Fat-Saturated (PD FS):

    • Normal: homogeneous marrow with cortical low-signal rim

    • Pathology: bright signal areas highlight fractures, marrow edema, and Lisfranc injuries

  • T1 Fat-Sat Post-Contrast:

    • Normal: minimal uniform enhancement

    • Pathology: enhancing marrow edema, inflammatory or neoplastic infiltration

    • AVN: non-enhancing necrotic core with rim enhancement

MRI Arthrogram Appearance

  • Contrast outlines intercuneiform and cuneometatarsal joints

  • Lisfranc ligament injury: contrast tracks abnormally between medial cuneiform and base of 2nd metatarsal

  • Subtle cartilage defects and intra-articular fractures highlighted by intra-articular contrast

CT Appearance

Non-Contrast CT:

  • Excellent cortical bone visualization

  • Fractures: clear cortical disruption and displacement

  • Stress fractures: subtle cortical breaks, periosteal reaction

  • Degeneration: sclerosis and osteophyte formation in cuneometatarsal joints

CT Arthrogram Appearance:

  • Contrast outlines cuneometatarsal and intercuneiform joints

  • Lisfranc injury: contrast extension into Lisfranc interval

  • Osteochondral lesions or small fractures better defined

CT VRT 3D image

Medial cuneiform bone 3d

MRI image

Medial cuneiform bone MRI axial cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000

MRI image

Medial cuneiform bone MRI coronal cross sectional anatomy 3T MRI AI enhanced radiology image-img-00000-00000

CT images

Medial cuneiform bone ct axial

X Ray image

Medial cuneiform bone