Dorsal midfoot

Dorsal Mid-foot Interosseous Compression Syndrome (DMICS)

Significant History and physical symptoms

Current evidence indicates that one in five people in the UK aged over 50 experience midfoot pain (Thomas et al, 2015 and Roddy et al, 2011). The most commonly identified pathology associated with this presentation is symptomatic radiographic midfoot osteoarthritis (OA), affecting approximately one in eight adults over the age of 50 in the UK and strongly associated with physical disability and foot deformity (Thomas et al, 2015 and Rathod et al, 2016).

It is important to recognise that radiographic changes do not always reflect the presence or severity of OA. Midfoot OA may be present despite normal plain radiographs. Emerging evidence demonstrates that adults with midfoot pain and normal x-rays, are likely to have structural changes consistent with OA when assessed with MRI (Halstead et al, 2025). These findings support the understanding that, in the absence of an alternative identifiable diagnosis, persistent midfoot pain in this age group is most appropriately managed as midfoot OA, even if radiographic changes are not evident. Advanced imaging is not routinely required to support this approach.

Less Common Differential Diagnoses not included in this pathway:

• Tarsal coalition
• Charcot arthropathy
• Gout
• Cuboid syndrome
• Fracture
• Mueller–Weiss syndrome
• Fracture

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

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.
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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.
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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.
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Guerreiro, F., Abdelaziz, A., Ponugoti, N. and Marsland, D., 2023. Nonoperative Management of Lisfranc injuries–A systematic Review of outcomes. The Foot, 54, p.101977.
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Halstead, J., Martín‐Hervás, C., Hensor, E.M., Keenan, A.M., Conaghan, P.G., McGonagle, D., Arnold, J.B., Jones, J. and Redmond, A.C., 2025. Association between clinical and MRI‐detected imaging findings for people with midfoot pain, a cross‐sectional study. Journal of Foot and Ankle Research, 18(1), p.e70019.
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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.
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Lim, P.Q., Menz, H.B., Landorf, K.B., Kaminski, M.R., Paterson, K.L. and Munteanu, S.E., 2025. Assessment and management of midfoot osteoarthritis by podiatrists in Australia: a cross-sectional survey of current practice. Rheumatology international, 45(6), p.141.
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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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Rathod, T., Marshall, M., Thomas, M.J., Menz, H.B., Myers, H.L., Thomas, E., Downes, T., Peat, G. and Roddy, E., 2016. Investigations of potential phenotypes of foot osteoarthritis: cross‐sectional analysis from the clinical assessment study of the foot. Arthritis Care & Research, 68(2), pp.217-227.
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Roddy, E., Muller, S. and Thomas, E., 2011. Onset and persistence of disabling foot pain in community-dwelling older adults over a 3-year period: a prospective cohort study. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 66(4), pp.474-480.
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Sadasivan, P., Cooper, L. and Currall, V., 2024. Lisfranc injuries in athletes: a review. Orthopaedics and Trauma, 38(1), pp.18-24.
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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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Suzuki, M., Kuruma, H., Kato, K., Kase, H., Fujimoto, H. And Nagashima, R., 2025. Comparing the effect of short foot exercise and toe curl exercise on plantar pressure during single-leg standing in individuals with flatfoot: A randomized controlled trial. Clinical Biomechanics, p.106693.
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Thomas, M.J., Peat, G., Rathod, T., Marshall, M., Moore, A., Menz, H.B. and Roddy, E., 2015. The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot. Arthritis research & therapy, 17(1), p.178.
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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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