What Clinicians Should Know About Midfoot Osteoarthritis

How Do We Treat It?

Treatment of midfoot OA typically com­prises biomechanical approaches, exercise and education, and pharmacological treatment.

Allied Health

A recent Australian survey showed podiatrists commonly provide footwear advice on fit, support and cushioning; use low dye taping; and prescribe arch contouring orthoses and/or shoe stiffening inserts.²² Many also advise foot muscle strengthening and, if appropriate, weight loss or referral for weight loss support.²²

Evidence is limited to several case series and a randomized feasibility trial, showing immediate improvements in pain and four-week improvements in function with carbon fiber insoles, small 12-week improvements in pain with pre-fabricated arch contouring foot orthoses, and improvements in pain up to six months with custom arch-contouring foot orthoses.^23-26

Although no clinical trials have tested the efficacy of the remaining approaches used in midfoot OA, strengthening exercise and weight loss are recommended in knee and hip OA clinical guidelines and thus are reasonable to consider for midfoot OA.^27,28

Primary Care

Analysis of foot OA management shows physicians mainly prescribe medications, most commonly acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).²⁹ Although not investigated in midfoot OA, guidelines advise topical NSAIDs first for peripheral OA, and oral NSAIDs if topical preparations are ineffective or unsuitable.²⁷ Acetaminophen is generally not recommended.¹⁹

Two case series suggest imaging-guided intra-articular glucocorticoid injections for midfoot OA are effective for up to three or four months, but not longer, aligning with OA guidelines which advise consideration of these injections when other pharmacological treatments are not successful or reasonable.^27,30,31

Surgery, typically arthrodesis, is reserved for end-stage disease or recalcitrant pain, when conservative and pharmacological treatments fail.³²

What New Knowledge Will Improve Midfoot OA Care?

Evidence-based care is essential to help people with painful midfoot OA maintain employment, independence and care-giving roles. To date, research has been limited. Large, rigorous, prospective, observational data and intervention trials are needed, together with agreed clinical criteria.

• Large, population-based observational studies could help clarify the natural history and modifiable risk factors of midfoot OA across diverse and under-represented groups. Identifying distinct subgroups (phenotypes) and drivers of disease may support more inclusive, patient-centered and personalized care by recognizing both local disease features and broader systemic influence.
• Large trials are needed to test the efficacy of footwear or orthoses to improve pain while standing or walking. Devices can create a firm lever or stable arch in the shoe, but their mechanisms and potential effectiveness are unclear. Improving muscle strength, which accounts for 30% variance of midfoot OA pain, is promising, but no trials have tested its treatment potential.
• Systemic aspects of midfoot OA overlap with knee and hip pain and are linked with obesity, diabetes and female sex.
• New research studies of people with midfoot OA as part of a presentation of multiple joint OA are recommended to investigate whether new weight loss solutions can improve joint pain, and also protect musculoskeletal power because muscle weakness is linked to midfoot OA and is associated with inactivity.
• A further critical gap is the lack of clinical criteria for midfoot OA. Comprehensive criteria must reflect the symptom experience and include all midfoot joints. Currently, standing radiographs detect medial and dorsal OA, but not lateral midfoot OA, despite lateral foot injuries, such as ankle sprains, being common. A large clinical data repository paired with imaging (e.g., radiographs, MRI, ultrasound) to capture morphology and disease activity, will inform clinical criteria and support optimized treatment algorithms.

In Summary

Midfoot OA is a common presentation in rheumatology services, but it may be overlooked and under-treated. People are increasingly seeking healthcare solutions for foot pain that will be attributable to OA. Future research is needed to understand the natural history and optimize management. Foot OA, especially at the midfoot, contributes to the growing burden of musculoskeletal pain, and rheumatology services are well placed to provide support.