Dorsal midfoot

Dorsal Mid-foot Interosseous Compression Syndrome (DMICS)

Significant History and physical symptoms

Dorsal midfoot interosseous compression syndrome (DMICS) is by far the most common cause of non-specific dorsal midfoot pain. This is also referred to more simply as Midfoot Compression Syndrome. There is some clinical evidence that the cause of the pain is sub cortical bone oedema at the dorsal midfoot joint margins where the dorsal joint ligaments originate and insert. The pain is certainly caused by increased dorsal interosseous compression forces at the midfoot joints due to the relatively high magnitudes of midfoot dorsiflexion moments in these individuals.

Individuals typically have relatively large calf muscles with limited ankle joint dorsiflexion, are overweight and are normally over the age of 50.

The pain generally worsens with increased weight-bearing activities and patients report the pain from DMICS will either occur just before heel off and/or during propulsion of walking gait. Walking barefoot or in low-heeled shoes usually exacerbate the pain, while walking in shoes with an increased heel height usually eases the pain.

• Relatively sudden onset
• No history of direct trauma / injury
• Pain during or immediately after activity
• Low heeled shoes / barefoot > pain
• Higher heeled shoes < pain
• Most commonly in region of metatarsal / cuboid / cuneiform
• Palpable tenderness along the mid tarsal / tarsal-metatarsal joint line
• Minimal oedema
• Significant pain on pain on forefoot dorsiflexion, OR pain on palpation of the joint line when forefoot is plantarflexed
• Pain on dorsum of foot can occur during or immediately after activity

Less Common Differential Diagnoses not included in this pathway:

• Osteoarthritis
• Tarsal coalition
• Charcot arthropathy
• Gout
• Cuboid syndrome
• Fracture
• Mueller–Weiss syndrome
• Fracture
• Osteoarthritis of Lisfranc joint

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

Video on testing anterior compartment

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for Analgesia Advice
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
  • Avoidance of barefoot walking or low heeled walking shoes, always wearing shoes with at least a 10 mm heel height differential.
  • Avoidance of barefoot walking or low heeled walking shoes, always wearing shoes with at least a 10 mm heel height differential
  • Make certain that patient never wears shoes that lace over or exert pressure over the dorsal area of midfoot tenderness. The constant compression force from the vamp of the shoe tends to exacerbate irritation of the inflamed soft tissues in the area. Dorsal Lacing Guidance
  • Give leaflet to reinforce verbal advice - NHSGGC Footwear Advice Leaflet
  • Alternative Shoe Lacing Options
• Exercise Prescription
  • Gastrocnemius and Soleus stretching exercises
• Heel Raise
  • These should be given bilaterally so as to avoid Leg Length Discrepancy

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Corticosteroid Injection
• Acupuncture
• Therapeutic Ultrasound
• Minimal benefit and no conclusion on effective dosage parameters

If a patient is not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

Biomechanical assessment and prescription of Foot Orthosis

• Address biomechanical deficit if indicated by assessment.
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include, hallux valgus, hallux rigidus, Morton’s neuroma, lesser toe issues, tendon pathology and degenerative changes of the joints of the foot and ankle.

The indications for surgery include persistent pain, worsening symptoms, significant limited mobility or failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further Investigation

The other reason for referral to Orthopaedics is for “Further Investigations”.

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are the severity of the symptoms and whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to Orthopaedics:

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic Clinician if you are unsure whether to refer.

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Anderson, J.G., Bohay, D.R., Patthanacharoenphon, C.G. and Ertl, A.M., 2014. Midfoot injuries. In Sports Injuries of the Foot (pp. 71-85). Springer US.
Click here for Article

Burns, J., Crosbie, J., Ouvrier, R. and Hunt, A., 2006. Effective orthotic therapy for the painful cavus foot: a randomized controlled trial. Journal of the American Podiatric Medical Association, 96(3), pp.205-211.
Click here for Article

Chapman, G.J., Halstead, J. and Redmond, A.C., 2016. Comparability of off the shelf foot orthoses in the redistribution of forces in midfoot osteoarthritis patients. Gait and posture, 49, pp.235-240.
Click here for Article

Halstead, J., Chapman, G.J., Gray, J.C., Grainger, A.J., Brown, S., Wilkins, R.A., Roddy, E., Helliwell, P.S., Keenan, A.M. and Redmond, A.C., 2016. Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clinical rheumatology, 35(4), pp.987-996.
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Kirby, K.A., 1997. Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast Incorporated, pp. 165-166
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Lau, S., Bozin, M. and Thillainadesan, T., 2017. Lisfranc fracture dislocation: a review of a commonly missed injury of the midfoot. Emerg Med J, 34(1), pp.52-56.
Click here for Article

Menz, H.B., Munteanu, S.E., Zammit, G.V. and Landorf, K.B., 2010. Foot structure and function in older people with radiographic osteoarthritis of the medial midfoot. Osteoarthritis and cartilage, 18(3), pp.317-322.
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Najafi, B., Barnica, E., Wrobel, J.S. and Burns, J., 2012. Dynamic plantar loading index: understanding the benefit of custom foot orthoses for painful pes cavus. Journal of biomechanics, 45(9), pp.1705-1711.
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Shih, Y.F., Wen, Y.K. and Chen, W.Y., 2011. Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study. Clinical rehabilitation, 25(10), pp.913-923.
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Thomas, M., Peat, G., Rathod, T., Moore, A., Menz, H.B. and Roddy, E., 2014. 188. The Epidemiology of Midfoot Pain and Symptomatic Midfoot Osteoarthritis: Cross-Sectional Findings from the Clinical Assessment Study of the Foot. Rheumatology, 53(suppl 1), pp.i129-i130.
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Thomas, M.J., Roddy, E., Rathod, T., Marshall, M., Moore, A., Menz, H.B. and Peat, G., 2015. Clinical diagnosis of symptomatic midfoot osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot. Osteoarthritis and cartilage, 23(12), pp.2094-2101.
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Tuthill, H.L., Finkelstein, E.R., Sanchez, A.M., Clifford, P.D., Subhawong, T.K. and Jose, J., 2014. Imaging of tarsal navicular disorders: a pictorial review. Foot & ankle specialist, 7(3), pp.210-224.
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