What’s the Source of your Patient’s Midfoot Pain?

With so many structures packed into such a small area, differential diagnosis of foot pain can be terribly tricky.

There also tends to be more focus on rearfoot conditions, meaning many physios are more familiar with presentations like Achilles tendinopathy and plantar heel pain. But what goes through your mind when a patient presents with pain through the midfoot?

There are plenty of potential diagnoses and structures to consider. And with so much working within a relatively small space, all exposed to weightbearing load, it’s not uncommon for more than one structure to be contributing to a patient’s symptoms.

In this blog, we’ll look at some of the key things to consider when assessing midfoot pain, with insights from foot and ankle expert Dr John Osborne.

If you want to take a deeper dive into assessing and managing forefoot, midfoot and hindfoot pain, check out Dr John Osborne’s Mastering the Foot Masterclass here.

How different sources tend to present

Before jumping straight to a diagnosis, it can help to think about which type of structure might be contributing to the patient’s symptoms.

Bone-related pain
May be described as a deep ache and tends to worsen with loading. Night pain may also be reported, which should prompt further questioning.

Joint-related pain
This can be less consistent. Patients may report stiffness, particularly after rest or in the morning, and symptoms may respond to load without necessarily being consistently load-dependent.

Neural pain
May present quite differently, with burning, pins and needles, heat or other altered sensations. Symptoms can occur at rest or at night and may not have an obvious relationship with loading.

Muscle and tendon pain
Often more localised and has a clearer relationship with load. Symptoms may warm up with initial contractions or activity, before worsening again with prolonged or repeated loading.

Skin-related pain
May appear load-related at first, but closer questioning can reveal that direct contact or friction is actually the main aggravating factor.

There are also plenty of other structures to keep in mind, including ligaments, bursae, retinacula and fat pads. And don’t forget the bigger picture: age, BMI, diabetes, neurological conditions and rheumatological or arthropathic conditions such as rheumatoid arthritis and gout can all influence your differential diagnosis.

Midfoot osteoarthritis

Midfoot osteoarthritis (OA) is one diagnosis worth having on your radar, particularly in older adults, with around one in eight adults over 50 affected.

Patients may report morning stiffness lasting less than 30 minutes and reduced foot joint mobility, but their pain response to loading can be inconsistent. Multiple joints may also be affected at the same time.

Pain is commonly reported around the dorsomedial or dorsocentral aspect of the arch. Certain activities, such as walking upstairs or walking barefoot, may be particularly provocative.

Your clinical assessment might include foot posture, looking for palpable bony changes or nodules around the navicular, joint palpation, passive range of motion, strength testing and gait assessment. Imaging, including X-ray, MRI or CT, may also play a role where appropriate. See John explain in this clip from his Masterclass:

Management will depend on the individual presentation, but may include education, footwear modification, orthoses, taping and exercise, though John notes that more research is needed into the benefits of exercise for midfoot OA.

Differentials

One differential that can overlap with midfoot OA is tibialis anterior tendinopathy. Because it inserts onto the medial cuneiform and base of the first metatarsal, symptoms can be felt around the medial midfoot. Patients will often describe reasonably localised pain that warms up with initial activity or contraction, but worsens again with prolonged loading.

Some patients may report pain later in the day or at night, but closer questioning will often reveal a relationship with how much they have loaded the foot.

Assessment can include your tendinopathy usuals: functional assessment (observing gait), palpation, and resisted muscle testing.

Treatment options may include footwear or orthotic modification, alongside progressive exercise targeting dorsiflexion capacity. In some cases, pharmacological or injectable options may also be considered. Though, again, evidence is limited. See John explain in this clip from his Masterclass:

Other possibilities include bone stress. Navicular bone stress injury is an important differential, particularly where there has been a change or increase in weightbearing load.

Charcot neuroarthropathy also needs to be considered in the appropriate clinical context, particularly in patients with diabetes and peripheral neuropathy.

The key is not to assume that every midfoot presentation fits neatly into one diagnostic box. Start with the patient’s symptoms, consider which structures could plausibly produce them, look at how those symptoms respond to load, and keep systemic factors in mind.

Wrapping up

The foot can be complicated, but using symptom behaviour to guide which structures and conditions you consider can help narrow your differential diagnosis.

For a deeper look at assessing and managing forefoot, midfoot and hindfoot conditions, watch Dr John Osborne’s Mastering the Foot Masterclass here.