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Dorsal interosseous compression syndrome after heel lift

Discussion in 'Biomechanics, Sports and Foot orthoses' started by markjohconley, Oct 3, 2012.

  1. markjohconley

    markjohconley Well-Known Member

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    How do you decrease forefoot dorsiflexory moments after heel lift?
  2. Mark:

    It would be helpful if you provided a little more information. Is "heel lift" a thing you put inside a shoe or an event of the gait cycle?

    DMICS is a pathological condition and does not only occur during one part of gait.

    Would you also ask, "what do you do for proximal plantar fasciitis that occurs at heel contact"?
  3. Craig Payne

    Craig Payne Moderator

    The only way is with strapping.
    The only other option is hoping that the reduction in the moments before the heel lifts off the ground with orthotics is sufficient to allow healing to happen.

    See: Taping for DMICS and "Top of Foot Pain" from Barefoot Running
  4. RobinP

    RobinP Well-Known Member

    I suppose it depends on whether you are trying to reduce external forefoot dorsiflexion moments across the whole forefoot or more locally at medial and lateral columns.

    If, for example, the objective was to reduce external FF dorsiflexion moments at the 1st metatarso cunieform joint, then a lateral forefoot post would shift the COP laterally and increase the external 1st ray plantarflexion moment, thus reducing the dorsal compression force. Admittedely, that force may not be much but we are talking about zones of stress and that small force may be the difference between enough compression at the dorsal midfoot to cause bony bruising that exceeds the zone of optimal stress for that tissue, and having little enough force to allow healing

    Even after the heel rises from the ground, the orthotic will still be adjacent to the anatomy and must be having some kinetic effect, regardless of how little

    My thoughts only
  5. markjohconley

    markjohconley Well-Known Member

    Goodaye Kevin, got me again, "heel off"

    Forgot the 'midfoot'

    Can the symptoms occur after heel off if i've adhered a temporary midfoot 10 mm felt pad (bevelled) that extends distally to the tarso-metatarsal joints

    Its would be from a compressional rather than a tensional force so I'd TRY strapping about the heel to reduce the amount the heel fat pad 'squashed' and add a poron (PPT) heel cushion and then start a thread on PA

    Thanks Robin, I have a patient, SPECT-CT imaging (weightbearing) demonstrates an obvious uneven joint space at 1st metatarsal-medial cuneiform (narrow dorsally), and report states there are various anomalies at 2,3,4 tarso-metatarsal joints but I can't identify them visually.

    Seems I think the same automatically nowadays thanks to PA

    ..this bit is my problem accepting/comprehending
  6. RobinP

    RobinP Well-Known Member

  7. Mark:

    Now I think I know what you are asking.

    Dorsal midfoot interosseous compression syndrome (DMICS) is a pathological condition that I first described 15 years ago which affects the dorsal joint surfaces of the midfoot. Please see the following thread which includes my original Precision Intricast Newsletters from 1997 where I describe the condition.

    Dorsal midfoot interosseous compression syndrome

    Patients with DMICS will often complain of pain with walking only after heel-off when the forefoot is plantarflexing on the rearfoot. In fact, patients with DMICS also may complain that even swimming is very painful presumably due to the force of the water on the dorsal forefoot which plantarflexes the forefoot on the rearfoot.

    Even though the mechanism of the etiology of DMICS is forceful dorsiflexion of the forefoot on the rearfoot (increased forefoot dorsiflexion moment) during the latter half of the midstance phase of gait, the best way to diagnose DMICS is the Forefoot Plantarflexion Test, where the examiner manually plantarflexes the forefoot on the rearfoot. This is likely due to the fact that forefoot plantarflexion increases the tension forces on the dorsal capsular ligaments of the midfoot joints which then pull on the "bruised" dorsal joint margins of the dorsal midfoot.

    I have described these items previously along with illustrations in my newsletters and in the thread on DMICS. Hope this helps.:drinks
  8. This illustration shows how the Forefoot Plantarflexion Test (FPT) will stretch the dorsal joint ligaments in the area of the suspected area of bone edema from the excessive dorsal midfoot compression forces seen in dorsal midfoot interosseous compression syndrome (DMICS). The FPT will reproduce the pain that the patient feels after heel-off, during the early propulsive phase of gait.

    One must remember, that after heel-off, during the early propulsive phase of gait, the forefoot plantarflexes on the rearfoot due to the forefoot plantarflexion moment generated by the windlass effect, first described by Hicks (Hicks JH: The mechanics of the foot. II. The plantar aponeurosis and the arch. J Anatomy. 88:24-31, 1954). This plantarflexion of the forefoot on rearfoot during early propulsion will stretch the dorsal ligaments of the midfoot, thus causing an increase in tension force on the dorsal capsular ligaments that originate and insert onto the dorsal margins of the midfoot joints, which, in turn causes the pain in the dorsal midfoot at heel-off.

    In other words, even though probable etiology of DMICS is excessive and chronic maginitudes of forefoot dorsiflexion moments causing high dorsal midfoot joint pressures and microfractures and bone edema of the dorsal midfoot joint margins, most of the symptoms from DMICS come from the dorsal midfoot capsular ligaments pulling on these injured areas of bone. In addition, dorsal compression forces from shoegear also exacerbates the inflammation and pain.

    One of these days, I will need to formally publish this.....in my next life.:cool:
  9. markjohconley

    markjohconley Well-Known Member

    Thanks Kevin, Craig and Robin, been off for a few days, will wait till i'm thinking straight before i read the posts properly, thanks again, mark
  10. RobinP

    RobinP Well-Known Member

    This has vexed me for a couple of days now and I have thought about it quite a bit. However, this statement doesn't quite sound right with respect to the period just after heel off

    Although I completely concur with the forefoot plantarflexion test and the mechanism of pathology, I would have thought that the pain in the dorsal midfoot that is created immediately after heel off is compressive in origin.

    Perhaps if I explain my thought process then once everyone has had a good laugh you can all take me to school on it!

    1. Immediately after heel rise, is the Windlass effect great enough to create a large forefoot plantarflexion moment? As the heel rises further and the hallux dorsiflexes further, the Windlass mechanism increases and this is the point at which there will be a greater external forefoot plantarflexion moment. But is this the case just after heel off?

    2. Immediately after heel rise, I would have thought that the lever arm to the midfoot from the metatarsals would be great enough to create an external forefoot dorsiflexion moment that would be stronger than the external forefoot plantarflexion moment created by the Windlass mechanism

    3. Bearing in mind that the tendo-achilles is contracting and causing a rear foot plantarflexion moment, I would have thought that this would increase the compression over the dorsal midfoot

    4. Clinically, what I see is lack of Windlass "engagement" allowing lowering of the medial longitudinal arch. Addition of a heel raise or a 1st metatarsal head cut out improves Windlass mechanism and reduces symptoms

    5. I don't understand why taping the foot to reduce MLA lowering forces has a symptom reducing effect if, in effect it is creating an external forefoot plantarflexion moment and this is what is causing the pain, according to the statement above

    6. A test that I use, in addition to the forefoot plantarflxion test is heel raise(double stance or single stance) Most times, the initiation of heel rise is the most painful part. As the heel rises further and the windlass mechanism has a greater effect, the symptoms reduce.

    Now, it could be that we are talking about different parts of mid to late stance. I am referring to the very first point of heel off.

    I look forward to any feedback. These are just my observations

  11. The time of maximum dorsal midfoot joint compression force is likely at the end of midstance phase, just before heel off occurs. The dorsal midfoot compression force is caused by the Achilles tendon tension force creating a rearfoot plantarflexion moment which, in turn, increases the ground reaction force (GRF) plantar to the forefoot. The increase in forefoot GRF causes a forefoot dorsiflexion moment, which, when combined with the rearfoot plantarflexion moment, creates a dorsal midfoot interosseous compression force and a longitudinal arch flattening moment.

    At the time of heel off, the hallux will start to dorsiflex which will cause an increase in tension within the plantar fascia. This increase in plantar fascia tension force just after heel off causes an internal rearfoot dorsiflexion moment and an internal forefoot plantarflexion moment, which will, in turn, decrease the compression force on the dorsal midfoot joints due to the resultant increase in longitudinal arch raising moment. In addtion, as the foot progresses into propulsion, the center of mass of the body is advancing anterior to the forefoot which will also lessen the GRF on the forefoot.

    Since heel off doesn't normally occur without hallux dorsiflexion (and what many call "activation of the windlass"), and since hallux dorsiflexion will tend to "open" the dorsal midfoot joints, then it is likely that the greatest compression forces in the dorsal midfoot joints occurs in late midstance, just prior to heel off and just prior to hallux dorsiflexion occurring.

    I have attached a PowerPoint slide of a lecture I am giving at Paul Scherer's Napa Seminar on October 20th on the etiology of hallux limitus which outlines the findings from a cadaver gait simulator at Penn State University in 2004 on Achllles tendon and plantar fascia tension during gait.

    Hope this helps.:drinks
  12. markjohconley

    markjohconley Well-Known Member

    Thanks Kevin.
    Would the patient be likely to feel pain from tension (load) applied to the dorsal ligaments when wearing foot orthoses short-term. Though decreasing net forefoot dorsiflexion moments and thus decreasing the pathological dorsal joint compression wouldn't there likely be load applied to the dorsal ligaments at some stage of gait with the foot orthoses. Would you warn the patient that a 'little pain for overall gain'?

    In regards to gastrocnemius and plantar soft tissue stretching, is there any way to avoid medial ankle/foot soft tissue stretching at the same time?

    Thanks, Mark (presently surrounded by a fistula of nurses (not many people realise this is the collective noun for a grouping of nurses, unbelievable what did they study at school))
  13. RobinP

    RobinP Well-Known Member

    Good question Mark.

    I gave the example earlier that I couldn't fathom why low dye taping was so instantly pain relieving. I can't seem to get my head around the mechanics of it.

    My thought was that the dorsal ligament load with taping/orthoses would be more progressive ie same final load but applied over a longer time frame and reaching max tensile length with less force
  14. markjohconley

    markjohconley Well-Known Member

    Thanks Robin, hadn't thought of that, Mark
  15. RobinP

    RobinP Well-Known Member

    I'm not saying that is the case...I don't know, is the truth. I'm just guessing.

    Hopefully someone more clever than me will come along and give the correct answer!
  16. No, the patient should not feel more pain at heel-off in the dorsal ligaments when wearing the orthosis short-term or long-term. However, if the orthosis increases the tightness of the shoe laces (or other shoe enclosure system) across the dorsal midfoot (an increase in external compression force on the dorsal midfoot), then the pain will be increased. That is why I always relace the patient's shoes when I treat a patient with dorsal midfoot interosseous compression syndrome (DMICS) with foot orthoses....to avoid increased dorsal shoe pressure on the dorsal midfoot joints.

    No. If they are having more pain with orthoses, it is possible that they are undergoing more propulsion with the orthosis than without the orthosis. However, by decreasing the dorsal interosseous compression force at the mdfoot joints and the probable bone edema at these dorsal midfoot joints, the foot orthoses will likely cause the dorsal ligaments to cause less pain in the foot during propulsion.

    Yes. Have the patient adduct the foot about 5-10 degrees during the stretch which should minimize stretching of the soft tissue structures of the medial ankle and medial foot during the stretch.

    By the way, Mark, if a patient has more severe pain across the dorsal midfoot I will initially treat them with four weeks of a cam-walker boot-brace after I cast them for the orthoses so that, at the end of four weeks, they are sufficiently less symptomatic to allow the orthoses, shoe relacing, icing therapy and stretching therapy to work more effectively at resolving their DMICS.

    Hope this helps.
  17. Robin:

    The low-Dye taping works in a very similar fashion to foot orthoses: they both exert a rearfoot dorsiflexion moment and forefoot plantarflexion moment on the foot which will tend to decrease the interossous compression force across the dorsal edges of the midfoot joints, and decrease the pain from dorsal midfoot interosseous compression syndrome (DMICS).

    My attached drawing illustrates this concept.
  18. markjohconley

    markjohconley Well-Known Member

    Yes, as always, a fully comprehensive articulate reply, thanks Kevin

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