Can Midfoot Pain Be a Feature of Reactive Arthritis?
Yes, midfoot pain can occur in reactive arthritis, as the condition may involve small joints of the feet, though this is less common than large joint involvement. 1, 2
Joint Distribution in Reactive Arthritis
Reactive arthritis typically presents with asymmetric oligoarthritis primarily affecting large joints of the lower limbs (knees, ankles), which is the predominant pattern. 2, 3 However, the clinical picture is not limited to large joints alone.
Small Joint Involvement
- Post-streptococcal reactive arthritis specifically can involve small joints in addition to large joints and the axial skeleton, distinguishing it from typical reactive arthritis patterns. 1
- While involvement of small joints of the hands and feet is much less common in reactive arthritis compared to other arthritic conditions, it is not excluded from the clinical spectrum. 4
- The arthritis in post-streptococcal reactive arthritis is described as cumulative and persistent, affecting large joints, small joints, or the axial skeleton. 1
Additional Musculoskeletal Features
Beyond joint involvement, reactive arthritis commonly presents with:
- Enthesitis (inflammation at tendon/ligament insertion sites), which can affect the midfoot region where multiple tendons insert. 2, 3
- Dactylitis (sausage digits), which can involve the toes and contribute to midfoot discomfort. 3, 5
- Tenosynovitis and bursitis, which may affect structures around the midfoot. 3
Clinical Pitfalls
Do not rule out reactive arthritis based solely on midfoot involvement. While large joint oligoarthritis is typical, the presence of midfoot pain—especially when accompanied by enthesitis, dactylitis, or a history of preceding genitourinary or gastrointestinal infection—should prompt consideration of reactive arthritis in the differential diagnosis. 2, 6, 5
The absence of long-term joint deformity helps distinguish reactive arthritis from rheumatoid arthritis, even when small joints are involved. 2
Diagnostic Approach
When evaluating midfoot pain with suspected reactive arthritis:
- Assess for asymmetric oligoarthritis of lower limb large joints as the primary pattern. 2
- Look for extra-articular manifestations including conjunctivitis/uveitis, urethritis, and skin lesions. 2, 5
- Identify preceding infection (typically 1-4 weeks prior) in the genitourinary or gastrointestinal tract. 3, 6, 5
- Consider HLA-B27 testing for diagnostic support and prognostic information, though negative results do not exclude the diagnosis. 4, 5