tl;dr: Â I'm causing too much metatarsal-cuboid joint pressure, which is causing a tendonitis. Â The prescription is RICE, using a heel-foot strike (which isn't an option for me), and strapping. Â I'll do the RICE and strapping and see how it goes.
For the last eleven years in my practice, I have been noticing a gradual increase in the number of patients who complain of pain along the dorsal aspects of their midfoot during weightbearing activities. Thinking that this relatively common dorsal midfoot pain syndrome must have been described in the medical literature somewhere before, I did my own literature review and could only find references regarding midfoot pain caused by trauma. However, Steven Palladino, DPM, recently lectured on a clinically related entity on November 22, 1996 at the âEssentials of Practiceâ seminar at the California College of Podiatric Medicine which he calls Lateral Column Overuse Syndrome (LCOS). In his practice as Chief of Podiatry at the Santa Rosa Kaiser, Dr. Palladino performed a four month study and found that about 4% of his patients complained of pain along the dorsal aspects of the calcaneo-cuboid or cuboid-metatarsal joints which was consistent with LCOS.
Due to a lack of adequate terminology to describe the relatively common clinical entity where patients have pain along the dorsal joint lines of either the medial or lateral midfoot, I have elected to name this entity Dorsal Midfoot Interosseous Compression Syndrome (DMICS). I consider Dr. Palladinoâs clinical entity of LCOS to be a part of DMICS, but confined to the lateral column. DMICS describes the painful syndromes located in both the medial and lateral columns of the midfoot.
Upon taking the history, patients with DMICS point to the area of the metatarsal-cuneiform joints, navicular-cuneiform joints, and sometimes to the area of the metatarsal-cuboid joint as the source of most of their pain. Much less frequently, the pain is noted more proximally, in the dorsal aspects of either the talo-navicular or calcaneo-cuboid joints. 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. There is usually no history of trauma even though patients with blunt trauma to the dorsal midfoot have very similar symptoms.
On physical examination, there is discrete tenderness along the dorsal joint lines of the affected midfoot joints but no tenderness along the dorsal aspects of the extensor tendons with dorsiflexion resistance applied at the digits. Edema is never present plantarly and minimal edema is only detected dorsally in the most painful cases. There is no pain with forceful manual dorsiflexion of the forefoot on the rearfoot. The hallmark in the physical examination of patients with DMICS is that they all have very significant pain with plantarflexion of the forefoot on the rearfoot. This test of plantarflexion of the forefoot on the rearfoot is a remarkably sensitive indicator of the level of severity of DMICS.
The reason that manual plantarflexion of the forefoot on the rearfoot during the clinical examination causes such significant and consistent pain in patients with DMICS is that the dorsal capsular ligaments along the joints of the midfoot are inflamed. The cause of the inflammation in the dorsal capsule of the joints of the midfoot is the chronic excessive interosseous compression force (ICF) in these joints during weightbearing activities.Â
Figure 1. An increase in either the ground reaction force (GRF) on the forefoot, the force of body weight and/or Achilles tendon tension will lead to an increase in the interosseous compression forces in the dorsal midfoot which increases the likelihood of dorsal midfoot interosseous compression syndrome (DMICS).
The combination of three forces act together on the foot during late midstance to cause an increase in the ICF across the dorsal joint surfaces of the midfoot (Fig. 1). First, the weight of the body exerts a plantarly directed force through the tibia onto the talar dome. Second, due to the requirements of the gastrocnemius and soleus muscles to be active during late midstance, the Achilles tendon in under great tension causing a plantarflexion moment on the rearfoot. Lastly, since the center of mass of the body is over the metatarsal heads during late midstance, ground reaction force (GRF) is at its peak on the metatarsal heads which causes a dorsiflexion moment on the forefoot.Â
The net result of these three forces acting together is a very strong flattening force or moment on both the medial and lateral longitudinal arches of the foot. The stronger the flattening moments on the medial and lateral longitudinal arches, the greater is the ICF across the dorsal joint surfaces of the midfoot. The flattening moments on both the medial and lateral longitudinal arches are increased by such factors as increased body weight, low heeled shoes and a tight Achilles tendon. Weak plantar ligaments and weak plantar intrinsic and plantar extrinsic muscles also increase the dorsal ICF at the midfoot since these ligaments and muscles help prevent medial and lateral longitudinal arch collapse.Â
It is the repetitive trauma at these dorsal midfoot joint surfaces with each step which causes the pain from DMICS. Treatment revolves around both reducing the inflammation to the dorsal midfoot joints and trying to eliminate the mechanical factors causing the increased flattening moments on the medial and lateral longitudinal arches. Local treatment to reduce inflammation may include icing and non-steroidal anti-inflammatory drugs and even cortisone injections in resistant cases.
Mechanical treatment involves, first of all, having the patient stretch their Achilles tendons and either adding a heel lift to their shoes or getting them into a slightly higher heeled shoe. Most helpful is to prevent the medial and lateral longitudinal arches from collapsing during gait as much as possible with either padding, strapping or generic or prescription foot orthoses. The foot orthoses must be stiff enough to support the medial and lateral longitudinal arches and should be well contoured to the foot. I find that if the initial treatment of the patient with temporary insoles or padding is helpful, the patient is very happy to proceed further with the more corrective and much more beneficial prescription foot orthoses since DMICS can be quite a painful and debilitating condition.
[Reprinted with permission from: Kirby KA.: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, AZ, 1997, pp. 165-166.]  (And then reprinted WITHOUT permission by me)
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