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Dorsal Foot Pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Jun 29, 2009.

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    Some things, I like to see limp into clinic. A nice classical Plantar Fascitis or a child with night pains are easy to diagnose, easy to treat and generally satisfying.

    However I have a confession. I HATE treating Dorsal foot pain.

    Extensor tendonitis, dorsal exostosis and suchlike are things I cannot claim a success rate anything like what I would like.

    Of course if you use orthotics they take up room in the shoes which can cause the shoe to compress the foot more -> more pain.

    One colleague of mine blames pretty mush all dorsal pain (and about 95% of pain in the plantar metatarsal area actually) on Mortons Neuroma's. Is this something others find?

    What are others experiences with dorsal foot pain. What are the aetiology's / conditions you see most often. What treatments do you find most success with?

    Kind regards
    Robert Isaacs
  2. Robert:

    I believe you will find plenty of information on Podiatry Arena on a relatively common condition that I call Dorsal Midfoot Interosseous Compression Syndrome (DMICS).
  3. Peter

    Peter Well-Known Member

    Anecdotally, I have had modest success with periosteal acupuncture for dorsal exostoses if that helps?
  4. David Smith

    David Smith Well-Known Member


    I was about to say 'yes me too' but when I thought about it, I used to but nowadays I seem to get reasonable results. Why is this?

    Let's consider what structures are most likely to be involved and what forces that are likely to cause trauma

    Anteiror Tib - Tension forces
    Toe Extensors muscles and tendons - Tension forces
    Ligaments - Tension forces
    Nerve and their branches - Compression forces - tension forces
    Joints - Compression forces
    Retinaculum - friction forces - tension forces
    Tendon sheaths - friction forces
    Bones - bending forces
    Interosseous muscles - tension forces - compression forces

    Now consider how these forces are propagated in the dorsal foot.

    Joint Compression, Bending forces about the bones and some compression of the deep peroneal nerve will be mainly due to dorsiflexion and/or abduction moments caused by GRF at the forefoot.

    Extensor Muscle, tendon, retinaculum tension forces by the dorsiflexing action of the muscles.

    Interosseous muscles tension by the abduction of the forefoot.

    Nerve compression may have external forces of the shoe to consider

    Etc etc, but its almost always down to the effect of forces during ambulation.

    so now I would design a treatment modality that addresses those forces. This may well be an orthosis but I always mobilise the foot and ankle joints. I have taken before and after pressure mat records of these subjects and usually find drastic changes in the vertical force action on the forefoot.

    When I find trigger points I will massage them out, which works sometimes, also of course icing and rest will often be used.

    With dorsal foot pain especially I like to get an x ray of the foot to see how the joints wear and positions look. This gives me a better idea of how much improvement the customer is likely to get. If the joints are severely effected by arthritis then I often advicse that resolution of symptoms may be limited. This reduces the expectation of the patient and probably gives better reported results.

    All seems a bit obvious when you write it out and its pretty much what K.Kirby says about forefoot pain in terms of joint compression syndrome i.e. stop the forces that cause it.

    Cheers Dave
  5. Dorsal midfoot interosseous compression syndrome (DMICS) is by far the most common cause of dorsal midfoot pain that I have observed in my quarter century of treating foot and lower extremity injuries. These individuals typically have relatively large calf muscles with limited ankle joint dorsiflexion, are overweight and are normally over the age of 50. 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.

    Treatment consists of:

    1. Icing therapy, 20 minutes, 1-3 times per day.
    2. Gastrocnemius and soleus stretching exercises, 3-4 minutes, 3 times per day.
    3. Avoidance of barefoot walking or low heeled walking shoes, always wearing shoes with at least a 10 mm heel height differential, with often times heel lifts added to shoes.
    4. Make certain that patient never wears shoes that lace over or put dorsal pressure over area of maximum tenderness on the dorsal midfoot (see illustration). The constant compression force from the vamp of the shoe tends to continue the irritation of the soft tissues that are inflamed in the area.
    5. Make foot orthoses with increased heel contact point thickness and are well formed to medial and lateral longitudinal arches that are not overly flexible. The orthoses should be designed with the biomechanical goal of exerting both increased external rearfoot dorsiflexion moments that will cause decreased internal forefoot dorsiflexion moments within foot.
    6. If symptoms are initially more severe, then 4 weeks in a boot-brace walker is used to reduce forces on dorsal midfoot joints and reduce inflammation of tissues.

    There is some clinical evidence that the cause of the pain is subcortical bone edema at the dorsal midfoot joint margins where the dorsal joint ligaments originate and insert. The Forefoot Plantarflexion Test is nearly always positive and the Midfoot Compression Tests is positive in most individuals with DMICS.

    With this treatment protocol, over 90% of my patients are healed within 3 months of the initiation of treatment.

    Hope this helps.

    Attached Files:

  6. Thanks to all. I always, as Dave suggests, try to take the systematic tissue stress approach to such cases, however the idea of DMICS had not occured to me in that form, nor had I come across it before. I'd isolated it as inflamation of the dorsal midfoot joints but not from a pivotal viewpoint. As always, the tissue stress approach rests on a knowledge of which tissues are under stress and why.

    We never stop learning!

    What are the thoughts of the community on pain in the dorsal MTA from Neuromas? Personally, to be honest, I struggle with this as a TS concept in any but the most massive of neuromas.

  7. Craig Payne

    Craig Payne Moderator

    Also keep gout in mind - I have treated a couple of dorsal midfoot gouts recently. Responded dramaticaly to colchicine with 24hrs.
  8. I'm assuming you mean intermetatarsal neuromas, where the discomfort is mostly plantar. Being neural tissue, it doesn't take much trauma to flare-up a nerve. The intermetatarsal neuroma is probably caused mainly by excessive compression forces on the nerve from tight shoegear (80+% of women), but may also be caused by excessive dorsiflexion of the digits with metatarsal head loading causing a traction injury to the nerve, since the nerve lies plantar to the deep intermetarsal ligament. It is amazing how simply getting the individuals out of shoes that have too high of a heel height differential and out of shoes that squeeze the metatarsal heads from medial to lateral helps improves symptoms with this condition.
  9. Yeah, that was an interesting one, wasn't it Craig??
  10. Craig Payne

    Craig Payne Moderator

    As Kevin knows, this case had everything that said "DICS" ... except for the night pain from it which was enough to say something else going on. One dose of colchicine and they had the best nights sleep in years and the pain was gone!
  11. Craig:

    I was thinking that the evening pain was a little unusual for DMICS. But without seeing the patient, I didn't know what to think. I thought your colchicine idea was excellent...right on the money! That's why you make the big bucks.;)
  12. David Smith

    David Smith Well-Known Member

    Craig, Kevin

    Is Colchicine the first drug of choice for gout treatment in USA and Aus? In UK it appears to be Alipurinol. Alipurinol seems much safer in terms of potential side effect or poisoning with overdose but not so dramatic it its action in terms of symptom relief.

  13. Dave:

    Allopurinol is not indicated for acute gouty attacks since initiating allopurinol during an acute gouty attack may make the symptoms worse. Allopurinol is one of the drugs of choice for management of chronic gout.

    Colchicine is one of the medicines that can be used, along with non-steroidal anti-inflammatory drugs, such as indomethacin, to calm an acute gouty attack. However, these medicines do not lower serum uric acid levels, they only reduce the inflammation from the uric acid crystallization within the joint/tissues of the body.

    Therefore, colchicine and allopurinol are used for two different purposes in individuals who suffer from gout.

  14. Craig Payne

    Craig Payne Moderator

    No. BUT, its very specific for gout. If it works within 24hrs (maybe 48hrs), then its gout --> awesome diagnostic drug; I get it for that purpose and have diagnosed a number of atypical midfoot and rearfoot cases this way. It can be a bit toxic to the liver in many people if used >24hrs, so need to be moved on to another drug, depending on the reason for the higher uric acid levels - usually allopurinol or a probenecid (although Febuxostat is a newie that looks promising)
  15. musmed

    musmed Active Member

    Dear All

    Colchicine as craig says works like magic.
    The correct dosage for acute gout is:
    at first warning take 2 0.5mg tablets
    every 2 hours take 1 tablet until either diarrhoea or relief of pain occurs.
    drink litres of water to increase excretion of uric acid
    Maximum daiy dosage is 8mg.

    found on the web to cut down typing time
    In gout, uric acid crystals are deposited in the joints. Immune cells called leukocytes try to engulf the uric acid crystals, which they recognize as foreign. The leukocytes then become hyperactivated, and they release inflammatory agents that cause the characteristic joint damage (and pain) associated with gout.

    In order for the phagocytosis to occur, the leukocyte cell has to drastically change its shape to be able to engulf the uric acid crystals. Cytoskeletal elements called microtubules must dissemble and reorganize to allow the leukocytes to do this. That is alter its tensegrity structure. Colchicine inhibits this reorganization of the microtubules, and thus prevents phagocytosis of the uric acid crystals by leukocytes.

    This is how it works.

    from sunny Sydney 21C today
    As Craig says, a great diagnostic tool.
  16. Graham

    Graham RIP

    From a sagittal point of view I often see a Dorsal midfoot interosseous compression syndrome / dorsal exostoses presentation, more often in Ave to Ave/high arch presentations and a Functional Hallux Limitus.

    I assume that with restricted/late timing of Hallux dorsiflexion there is a compensation at the next available joint/joint complex creating a dorsiflexion moment of the forefoot through the mid tarsal joint as the heel atteps to raise as the first mtpj remains stiff.

    FHL/First ray cut aways some lateral ff posting seems to take care of this nicely.

  17. cpoc103

    cpoc103 Active Member

    Dave I have to admit I am slightly amazed at this, in the south of Eng the first drug of choice would be Colchicine, as Allopurinol will only inflame the affected area. Allopurinol is more for the chronic management of Gout and to help to TRY and prevent reoccurance.....

  18. David Smith

    David Smith Well-Known Member


    I was only going by my experience, and searching my patient database prescribed medications list, no one has ever reported being prescribed colchicine. This may be because the oral prescription only last for a few days. The patients that I refer for gout have always been prescribed NSAIDs or steroid injection or Allopurinol but I can see that this may either be because they already are in the chronic gout stage or that NSAIDs/steroid are preferred to Colchicine. CKS NHS http://www.cks.nhs.uk/home seems to advise NSAIDs as first option. http://www.nhs.uk/nhschoices/flashcont/altflash/c_gout.htm

    Acute Gout
    Colchicine and Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in the treatment of acute gout and are much superior to paracetamol or aspirin. In addition, NSAIDs are superior to colchicine in terms of speed of onset of action. Thus, despite having been used for centuries, colchicine is usually reserved for patients in whom NSAIDs are contraindicated. http://www.arthritis.co.za/gout.html

    So when does Acute Gout become chronic in terms of prescription choice?
    Is Colchicine used more often that NSAIDs and streoid injections in the UK?


    Researching shows that many health authorities or rheumatologists seem to prefer NSAIDs to Cochicine and some have no preference

    Thanks for your kind attention

    Dave Smith
  19. Craig Payne

    Craig Payne Moderator

    NSAID's are usued way more often for acute presentations. I not actually sure I can recall colchicine ever being used for a typical 1st MPJ gout ... the diagnosis of gout there is easy to do clinically. Its just the midfoot and rearfoot ones that are not typical ... thats when the specificty of colchicine come into it own as a really remarkable diagnostic drug.
  20. efuller

    efuller MVP

    I have to quibble with the "is specific for gout." comment. Biochemically colchicine inhibits microtubule formation in the cells. The microtubules are necessary for cell division. To continue an inflammatory process cells need to divide and proliferate. Therefore, colchicine is going to inhibit inflammation regardless of the cause of the inflammation.

    I'm sure the patient is happy that the pain stops, but is colchicine better than NSAID? Do you really want to take a medication with the instructions of taking a pill every couple of hours until the pain stops or you puke or have diarrhea? The colchicine is also stopping cell division in the lining of the gut which needs to be replaced constantly.

    If I ever get something that really looks like gout, I'm going to try the NSAID first. We know that gout hurts becasue of the inflammatory response to the uric acid crystals. I know all drugs have some side effects, but we should be giving our patients informed consent.


    Eric Fuller
  21. Craig Payne

    Craig Payne Moderator

    You right, it not specific, it just incredibly effective in gout.
  22. naoglesby

    naoglesby Welcome New Poster

    Do you prescribe this or do you refer the patient via their GP?
    As far as I know, I thought this was an S4 drug - or does it come in other forms?
  23. Craig Payne

    Craig Payne Moderator

    Its on the Vic S4 list for podiatrists (see here)
  24. Mart

    Mart Well-Known Member

    By far the most common diagnostic features of dorsal foot pain I see have evidence with sonography of synovitis of midfoot joint(s) +- osteophytosis, elevated midfoot peak pressures and force/time integrals measured with pressure mat and concurrent observable mid tarsal joint dorsiflexion at HO. This fits pattern described by KK, of excessive joint compression. If in doubt I usually do quick 0.2 mls infiltration of lidocaine into joint space to nail diagnosis for joint root of pain and gait exam for hint at underlying cause.

    The thing I most hate treating are the infected bites my cat gets after a night wresting racoons on my garage roof.


    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
  25. Mart

    Mart Well-Known Member

    Hi Peter

    I am curious about how you see this works




    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
  26. I have not observed gout to affect the tarsometatarsal joints but do see lots of osteoarthritis resulting in dorsal foot pain. Try the "Piano-Key Sign". Press down on the metatarsal head and if the tarsometatarsal joint is involved the patient will report focal dorsal pain and this will help you isolate the joint(s) involved.

    X-rays will show dorsal osteophytes, subchondral sclerosis and joint-space narrowing. In-situ arthrodesis of involved joints are a reliable fix in difficult and disabling conditions.
  27. DBannerman

    DBannerman Member

    Hey I've just taken the lower extremity active release course. Expensive but completely worth it as a soft tissue treatment option. I'd likely pair it with orthotics to prevent recurrence but it works really well.
  28. markjohconley

    markjohconley Well-Known Member

    My rheumatologist (for feet and knees) and orthopod (when it's my knees) both use prednisolone, obviously one oral the other intra-articular for my acute episodes
    ...AND KNEES!!!

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