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Dorsal Midfoot Interosseous Compression Syndrome

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Apr 19, 2006.

  1. admin

    admin Administrator Staff Member


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    I am grateful to Kevin Kirby and Precision Intricast for permission to reproduce this February 1997 Newsletter (you can buy the 2 books of newsletters off Precision Intricast):

    DORSAL MIDFOOT INTEROSSEOUS COMPRESSION SYNDROME


    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 “Essentials of Practice” 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. Palladino’s 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.


    [​IMG]

    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.


    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.


    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.]
     
  2. In any beam that is subjected to vertical loading forces from above, compression stresses will exist on the top side of the beam and tensile stresses will exist on the bottom side of the beam. Even in the human foot, which has a much more complex load-bearing structure than a simple beam, compression stresses will exist on the dorsal aspect of the internal foot architecture and tensile stresses will exist on the plantar aspect of the internal foot architecture.

    The human foot derives its load-bearing capacity to resist longitudinal arch collapse during weightbeaing activities by being composed of compression-bearing elements (i.e. bones), which resist dorsal compression forces, that are elegantly combined with plantar tension-bearing elements (i.e. plantar ligaments, plantar aponeurosis, plantar intrinsics and plantar extrinsic muscles)which resist plantar tensile forces. Therefore, just like the simple beam, the human foot has compression stresses within the dorsal edges of the compression-bearing elements and tensile stresses within the plantar tension-bearing elements of its longitudinal arch structure.

    The illustration that follows represents a closer look at how ground reaction force (GRF) acting on the plantar first metatarsal head-sesamoid causes a first metatarsal dorsiflexion moment that is resisted by the compression forces between the dorsal joint surface of the first cuneiform-first metatarsal joint and the tensile forces within the plantar ligaments of the first cuneiform-first metatarsal joint. These interosseous compression forces acting at the dorsal midfoot joints that result from the bones, ligaments and muscles resisting longitudinal arch collapse during weightbearing activities is the cause of Dorsal Midfoot Interosseous Compression Syndrome.
     

    Attached Files:

  3. gold

    gold Member

    excellent Kevin
    its great to see a name put to a condition that is so very common. At least now when I'm describing what is causing the pain I can give the patient a name to go with it. It's not always easy to describe the compression and tensile forces to the public
     
  4. Forefoot Plantarflexion Test

    When the Forefoot Plantarflexion Test is performed on the patient with DMICS, this plantarflexion of the forefoot relative to the rearfoot will cause a sharp pain on the dorsal joint line of the affected midfoot joint. This test is nearly diagnostic for DMICS. I believe that the cause for this Positive Forefoot Plantarflexion Test is that the insertion points for the dorsal capsular ligaments of the midfoot are at the exact same areas on the dorsal margins of the midfoot bones where there is also subchondral "bruising" of the bone. In turn, this subchondral bruising of the bone at the dorsal midfoot joint edges is due to excessive magnitudes of interosseous compression forces at the dorsal midfoot joint edges during weightbearing activities. This subchondral bruising likely also causes the pain with forefoot plantarflexion and the tenderness with direct manual palpation of these joint edges.

    Illustrated below is another one of my drawings that shows how the Forefoot Plantarflexion Test causes increases tensile force on the dorsal capsular ligaments of the first metatarsal-first cuneiform joint and may cause pain at the points of attachment of these dorsal capsular ligments into the bone that has been previously damaged by the excessive magnitudes of dorsal interosseous compression forces at the dorsal midfoot joints.
     

    Attached Files:

  5. admin

    admin Administrator Staff Member

    I am grateful to Kevin Kirby and Precision Intricast for permission to reproduce this March 1997 Newsletter (you can buy the 2 books of newsletters off Precision Intricast):


    DORSAL MIDFOOT INTEROSSEOUS COMPRESSION SYNDROME Part 2

    In last month’s newsletter I described a condition, Dorsal Midfoot Interosseous Compression Syndrome (DMICS), which to my knowledge had not been described previously in the literature. This condition is the result of excessive compression forces within the dorsal aspects of the joints of the midfoot causing an inflammatory condition in the dorsal joint surfaces and dorsal joint capsules. Since DMICS is a relatively common condition which can cause quite significant disability, I have decided to devote another newsletter just to the biomechanics and treatment of the condition.​

    As mentioned in last month’s newsletter, DMICS can cause pain along the dorsal joint capsules of the joints of the medial column (i.e. metatarsal-cuneiform joints, navicular-cuneiform joints, and less frequently in the talo-navicular joint) and in the joints of the lateral column (i.e. metatarsal-cuboid joints or calcaneo-cuboid joint). As also mentioned in last month’s newsletter, pain along the dorsal joints of the lateral column has already been described clinically by Dr. Steven Palladino which he calls Lateral Column Overuse Syndrome (LCOS). In other words, DMICS affecting the lateral column is the same condition as Dr. Palladino’s diagnosis of LCOS.​

    Whether DMICS is found in either the dorsal joints of the medial or lateral columns is dependent on many biomechanical factors. However, in the patients that I have seen with this condition, it is clear that the location of the pain from DMICS is strongly affected by position of the subtalar joint (STJ) axis (i.e. whether the STJ axis is medially or laterally deviated).​

    When the STJ axis is medially deviated, the STJ tends to be maximally pronated in stance and gait and the medial longitudinal arch tends to be more flattened. This is caused by the talar head being internally rotated on the calcaneus so that the STJ axis (which travels closely with the talar head during weightbearing activities) now passes medial to the first intermetatarsal space. When the STJ axis is laterally deviated, the STJ tends to be in neutral position or supinated slightly from the neutral position in stance and the medial longitudinal arch tends to be increased. A foot with a laterally deviated STJ axis is caused by the talar head being externally rotated on the calcaneus so that the STJ axis now passes lateral to the first intermetatarsal space (Kirby, K.A.: Methods for determination of positional variations in the subtalar joint axis. J. American Podiatric Medical Assoc. 77:117, May 1987).​

    Those patients who develop DMICS symptoms in the joints of the medial column invariably have quite significant medially deviated STJ axes. The medial deviation of the STJ axis causes the STJ to maximally pronate which leads to excessive ground reaction force (GRF) on the medial metatarsal heads during weightbearing activities. During walking, this excessive GRF on the medial metatarsal heads reaches its peak during the late midstance phase when the center of mass of the body passes directly over the metatarsals. The increased GRF on the medial metatarsal heads causes an increased magnitude of dorsiflexion moment on the joints of the medial column. The result is a greater interosseous compression force along the dorsal aspects of the joints of the medial midfoot during late midstance which, when repeated step after step, leads to the inflammation and pain of DMICS.​

    However, if an individual which has symptoms consistent with DMICS has a STJ axis which is laterally deviated, the pain is more likely to occur along the joints of the lateral column (i.e. LCOS). Those individuals which develop pain along the dorsal joints of the lateral midfoot are often those that have both a laterally deviated STJ axis and who also have a large degree of metatarsus adductus deformity. Other individuals who commonly develop DMICS in the lateral midfoot may have a partially compensated rearfoot varus deformity in which their calcaneus is inverted and their STJ is maximally pronated during relaxed calcaneal stance position. (These clinical observations have also been confirmed by Dr. Palladino.) Both the feet with laterally deviated STJ axes and metatarsus adductus and the feet with partially compensated rearfoot varus deformities will tend to have increased GRF on the lateral metatarsal heads during the late midstance phase of gait which causes increased dorsiflexion moments across the calcaneo-cuboid and cuboid-metatarsal joints. The result is excessive interosseous compression forces, inflammation and pain along the dorsal joint surfaces of these joints.​
    Because the biomechanical etiology differs between patients with DMICS in the joints of the medial midfoot and DMICS in the lateral midfoot, then treatment of these conditions differs somewhat also. If the patient has pain along the dorsal joints of the medial midfoot, then the increased dorsiflexion moments on the medial column must be reduced in order to reduce the increased dorsal interosseous compression forces which cause the inflammation and pain. Initially I usually add an adhesive felt varus heel and arch wedge to the shoe insole (shaped like the medial half of a cobra pad) in order to decrease the pronated position of the STJ. This is often combined with a 1/8” felt pad plantar to either the 4th and 5th metatarsal heads or 2nd through 5th metatarsal heads (see November 1993 Precision Intricast Newsletter). The combination of these two pads helps reduce the GRF on the medial metatarsal heads during late midstance by transferring the GRF to the lateral metatarsal heads.

    Foot orthoses must be made of a relatively rigid material which will not flatten significantly during late midstance. I recommend a 3/16” polypropylene plate with a 40 /40 rearfoot post, the heel contact point made to a 1/8” thickness, a 2-3 mm medial heel skive, a 16-18 mm heel cup, balanced 2-40 inverted with or without a valgus forefoot extension. I may also add a 1/8” to 1/4” heel lift under the orthosis and/or get the patient into a shoe with increased heel height differential and relatively firm, stable sole such as a running shoe and/or hiking boot to decrease the excessive GRF on the metatarsal heads during the late midstance phase of gait which may be caused by even a mild equinus deformity.​
    Biomechanical treatment of patients with the symptoms of DMICS in the joints of the lateral midfoot is generally much different. I will start the patients on aggressive gastrocnemius and soleus stretching exercises and add heel lifts inside the existing shoes since they nearly always have some degree of an equinus deformity. Next, I recommend the patient start wearing a higher heeled shoe and avoid barefoot walking. Foot orthosis treatment is more difficult in many of these individuals especially if their STJs are maximally pronated during standing. I will usually make a relatively rigid orthosis of 3/16” polypropylene, balanced close to vertical, with a 40 /40 rearfoot post and a heel lift if the equinus deformity is very significant. The orthoses must go into a higher heeled shoe, not a flat shoe. In addition, those patients with more intense pain in the joints of the lateral midfoot often need to go into a walking brace or walking cast for a two to four week period since this is often the only treatment method which allows the very symptomatic patient to walk comfortably.


    [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. 167-168.]​
     
  6. Kerrie

    Kerrie Active Member

    Hi All,
    Kevin, I just thought that I would take the opportunity to thank you for your input on this! I have had a patient that I have just started seeing who complained of all these symptoms and had had fellow pods completed stumped! Now I know what is wrong with him it is refreshing to know also how to go about solving the problem and actually give a name to it, I have actually put him in a simple insole similar to the perscription you have stated to see if it provides relief before I make the full custom orthoses so fingers crossed
    Once Again, thank you so much for the contribution
     
  7. Kerrie:

    You are welcome. Please keep us all informed of your patient's progress. I strongly recommend custom orthoses to my patients for this condition since having excellent plantar longitucinal arch contour with the orthosis is one of the keys to getting optimum therapeutic results.
     
  8. Kerrie

    Kerrie Active Member

    Kevin,
    I am pleased to inform you that the patient came into me the other day to report complete success with the insoles and reported that the pain has since gone and that he can walk normally for the first time in many years and actually play golf which he is very happy about. I have made him the custom orthoses in the exam same design and again he loves them
    I am actually going to write a brief but indepth case study on this for my portfolio, would you like me to send it to you for a more concise report on the patients progress?
     
  9. Kerrie:

    Good to hear your patient is doing so well. If you don't mind, when you write your case study, please post it up here on Podiatry Arena so everyone can learn from it.:drinks
     
  10. Kerrie

    Kerrie Active Member

    Consider it done :)
     
  11. RobinP

    RobinP Well-Known Member

    I feel that this confession is warranted on the grounds that others may benefit. A good lesson that one shouldn't be afraid to ask the obvious questions

    Until today, I had never read these two newsletters........the shame!

    For a good many years(until joining Podiatry Arena)I have been seeing conditions that I was treating - successfully on the whole - but with no concept why treatment was successful and with even less understanding of the biomechanics and anatomy behind it.

    DMICS is a perfect example of the type of condition that I was providing effective orthoses for but couldn't really work out the reason for it. Another example would be the patient coming in with their fairly low arched prefabs in the wrong shoes claiming astounding reduction in plantar fascia problems. The point being, that I could, in no way, justify the reduction in symptoms as a result of the biomechanical changes.

    Having started looking on Podiatry Arena, I was quickly able to understand kinetics over kinematics and the concept of centre of pressure changes having effects on lever arms and determine why patients wearing insoles in the wrong shoes would work for some plantar fascia problems.

    However, the symptoms versus the examination of DMICS always perplexed me. Why, when the compression of the dorsal aspect of the tarsal bones seemed to be the problem in stance, did I find that FF plantarflexion on RF was more painful onthe couch?

    Thanks to this newsletter and Kevin's excellent diagrams, I can now identify this problem and treat more effectively and definitively than before. Moreover, I can explain to the patient why they have the problem and the causal factors involved. It was always something I wanted to ask but felt that I couldn't as it showed a lack of basic anatomical/biomechanics knowledge. The only stupid thing was not asking. The biggest thing about knowing more is that it makes you ask more questions

    Kevin, thanks for allowing this to be put on Podiatry Arena. I owe you (another) beer

    Regards,

    Robin
     
  12. Craig Payne

    Craig Payne Moderator

    Robin, its also remarkable how common this condition suddenly becomes when we have a name for it!

    Its like the vague 'metatarsalgia' --> not useful 'capsulitis' --> then it became called 'plantar plate dysfunction' .... ever notice how common it became when we started calling it that?
     
  13. RobinP

    RobinP Well-Known Member

    Yes.

    It's sort of like when you see a patient who is less than easy to deal with.

    All of a sudden, you become aware of their existance and they start popping up everywhere from the gym to the supermarket. I live on a small island so the effect is magnified.

    Plantar plate problems - another thing I was blissfully unaware of until joining the Arena.
     
  14. Robin:

    Thanks for the kind note. BTW, I'll be collecting my beer payments in Manchester on June 24 and 25 then in Llanfairfechan, North Wales for the week following.:drinks
     
  15. RobinP

    RobinP Well-Known Member

    I'm hoping to be there and pay my beer debts to you and others

    What takes you to Llanfairfechan? More to the point, can you pronounce it? Some nice walks round those parts

    Robin
     
  16. elysia_pike

    elysia_pike Welcome New Poster

    I have a patient presenting with these symptoms on her left foot which has been on-going for around 5 months. She reports there was a little bit of swelling but that and the discomfort has settled. She thinks it was after her daily commute to work where she was sat in a lot of traffic and constantly using the clutch.

    No pain along extensor tendons, AT tendon or PT tendon against resistance. Discomfort with plantarflexion of the forefoot to rearfoot. She also has to be careful of footwear as some lace ups cause discomfort in the area.

    Can DMICS develop from constant use of the clutch and do patients report discomfort with compression from footwear?

    It doesn't bother her too much and she can still do her usual sports/exercise. I've advised footwear with a slight heel and given her calf stretches to do (gastroc/soleus were a little tight).

    As you can tell I'm newly qualified and do not specialise in MSK so my knowledge around this area is pretty poor!

    Thanks for any advice :)
     
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