Midfoot pain

What is midfoot pain, and how common is it?

Midfoot pain is pain in the arch area of your foot, between the heel and the toes¹. It affects 20% of people over 50, more women than men, and more people in manual jobs¹. Midfoot osteoarthritis (wear-and-tear damage to the joints that form the arch) is the most common cause in this age group¹².

It helps to note where the pain sits (top of the foot, in the arch, or on the inner or outer side) and what brings it on, such as walking, standing, a twist or a fall. That gives a podiatrist a head start in working out the cause.

What can cause midfoot pain?

Several things can, and they tend to feel a little different:

• Osteoarthritis causes an aching pain with walking and standing. There may be a bony lump on top of the foot and soreness where shoes press¹³.
• Ligament injuries, including a Lisfranc injury (damage to the ligaments that hold the midfoot bones together), usually follow a twist, a fall or a blow to the top of the foot. They can feel like an ankle sprain and are often overlooked¹⁴. Bruising on the sole is an important sign⁵.
• A stress fracture causes very localised pain over one spot on a bone¹.
• Tendon pain is sore when you lift your foot or toes against resistance³.
• Gout and other inflammatory arthritis can make the foot painful and inflamed¹.
• Charcot foot (a foot damaged and inflamed because of nerve damage, mostly linked with diabetes) looks swollen and warm¹⁶.

Don't assume midfoot pain after a twist or fall is just an ankle sprain: it can be a ligament or bone injury⁷. See a podiatrist or your GP if the midfoot is tender or painful when squeezed. If you can't put weight on the foot after an injury, see your GP or a podiatrist the same day.

How is the cause found?

A podiatrist starts with your story: how the pain began, your usual footwear and activity, and any diabetes, numbness or joint conditions. They'll watch you walk, compare both feet, press on painful areas and may squeeze the midfoot⁸⁹⁷. That's a normal part of assessment.

For pain that came on gradually, the diagnosis is mostly made from your history and examination³. After an injury or overuse, X-rays are usually the first images, often taken standing and of both feet⁹⁷. X-rays can miss a Lisfranc injury, so a CT or MRI scan may follow if it's still suspected⁷. A normal X-ray doesn't rule one out⁵. If an X-ray is arranged, ask whether it will be taken standing.

What helps first?

Simple care is the first step³⁶:

• Choose a fairly stiff, supportive shoe with a firm sole, laced securely⁸. Avoid flat slip-on shoes³. Roomy, low-heeled shoes with soft soles also help¹⁰.
• Cut back on what aggravates it for now.
• Try insoles. They can ease pain by limiting movement across the midfoot joints. They don't cure the problem and work best in supportive shoes⁸.
• Ask a pharmacist about pain relief such as paracetamol.

A podiatrist or physiotherapist can add exercises, taping or orthoses (shoe inserts), chosen together with you⁶. Most of this rests on guidance rather than strong trials, so how much each step helps isn't clear yet. Stable Lisfranc injuries in athletes did well without surgery¹¹.

These steps are for pain without a significant injury. If you can't put weight on the foot after an injury, or you think a bone may be broken, see your GP or a podiatrist the same day rather than treating it yourself.

What helps if that isn't enough?

If simple care hasn't helped, ask your podiatrist or physiotherapist whether referral to an orthopaedic service is right for you. Referral is usual when an injection is being considered, the cause is uncertain, or pain is severe or getting worse⁶.

For midfoot arthritis, injections, orthotics and joint fusion surgery are widely used, but little research backs how well they work¹². Lisfranc injuries that are unstable or displaced are often fixed with surgery⁵. Delay in treating a Lisfranc injury is linked with more complications, so don't put off review if pain persists after an injury⁴. If surgery is planned, ask what it involves and how long you'll need to stay off the foot.

Will it get better, and how can I stop it coming back?

Athletes with stable Lisfranc injuries treated without surgery mostly returned to sport within about 6–10 weeks⁷. How long other causes take, such as midfoot arthritis, isn't clear yet, so ask your podiatrist what to expect.

No approach has been shown to prevent it returning. Strengthening exercises for the foot muscles may reduce the chance of re-injury, though how well they work for midfoot arthritis isn't firmly established¹. Support with weight management is part of care¹, and it's worth asking your doctor if that suits you. Keep wearing supportive, firmly laced shoes⁸, and build back to sport or heavy activity gradually, following your clinician's advice.

See a podiatrist or your GP if pain keeps coming back or doesn't improve, because missed injuries can lead to persistent pain and arthritis⁸.