Midfoot osteoarthritis (OA) is a common cause of midfoot pain, affecting 1 in 8 people aged over 50 years. Often, midfoot OA is sufficiently painful to stop people walking. Once this occurs, people descend on a spiral of disadvantage characterised not just by painful feet, but all the established negative sequelae of inactivity. Clinically, OA in the midfoot can be challenging to treat with variable effectiveness of conservative interventions. Our ability to design effective treatments for midfoot OA has been hampered by a limited understanding of the modifiable determinants of disease initiation and progression. This is underpinned by two issues. First, early structural changes in midfoot OA remain undefined and may require MRI to measure accurately and precisely. Second, while joint loading is a key factor in the development and progression of OA at other weight-bearing joints, its role in midfoot OA is not well understood. This presentation will focus on recent research being conducted to unravel the mechanisms by which midfoot OA may develop and progress. It will also cover clinical factors related to symptoms and functional impairment that are future targets for intervention in clinical practice. Ultimately, improving the treatment of midfoot OA presents an opportunity to reduce the negative downstream effects of pain and foot-related disability on physical inactivity and general health.