OBJECTIVE: Hallux valgus, flatfoot, and rearfoot eversion are well-known major complications of knee osteoarthritis (OA). However, there is no consensus on the association between these foot malalignments and knee symptoms or function. Thus, this study aimed to examine the association between foot alignment and knee symptoms or function in patients with knee OA. METHODS: Female patients aged ≥ 50 years with symptomatic knee OA participated in this study. Knee symptoms and function were assessed using the Knee Society Scoring System (KSS). Hallux valgus, navicular/foot ratio, and leg heel alignment were used as the forefoot, midfoot, and rearfoot alignment indices, respectively. The navicular/foot ratio was defined as the ratio of the navicular height to the total foot length. We performed multiple linear regression analysis to examine the associations between foot alignment and knee symptoms or function. RESULTS: Seventy-eight participants participated our study. KSS symptom score was significantly associated with navicular/foot ratio (regression coefficient [β], -0.30; 95% confidence interval [CI], -109.2 to -20.5; P = 0.005), knee extensor strength (β, 0.32; 95% CI, 0.02 to 0.09; P = 0.004), and age (β, 0.24; 95% CI, 0.01 to 0.32; P = 0.036). KSS function score was not associated with foot alignments but with knee extensor strength (β, 0.40; 95% CI, 0.10 to 0.33; P = 0.001) and body mass index (β, -0.35; 95% CI, -2.82 to -0.66; P = 0.002). CONCLUSIONS: Knee symptoms were significantly associated with midfoot alignment in patients with medial knee OA. This suggests that lower navicular height in patients with medial knee OA may relate with the alleviation of knee symptoms. Key Points • In patients with medial knee OA, midfoot alignment was significantly associated with knee symptoms in patients with medial knee OA; however, knee function was not associated with foot alignment. • Lower navicular height in patients with medial knee OA may relate with the alleviation of knee symptoms.