06/02/2026
Dorsal Midfoot Interosseous Compression Syndrome (DMICS)
Over 29 years ago, in February 1997, I first coined the term "Dorsal Midfoot Interosseous Compression Syndrome" (DMICS) to describe a midfoot pathology that I frequently saw, but no one had previously described within the medical literature. Now, DMICS is recognized by many podiatrists around the world as a relatively common cause of dorsal midfoot pain (Kirby KA.:Dorsal Midfoot Insterosseous Compression Syndreome, February 1997 Precision Intricast Newsletter, in: Kirby, KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, AZ, 1997, pp. 165-166).
Patients with DMICS complain of pain along the dorsal aspects of their midfoot joints during weightbearing activities. 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 weightbearing activities and patients report the pain from DMICS will either occur just before heel off and/or at the initiation of propulsion of walking gait. Walking barefoot or in low-heeled shoes usually exacerbates the pain, while walking in shoes that are loosely tied with an increased heel height (i.e., heel drop) usually eases the pain. There is usually no history of trauma even though patients with blunt trauma to the dorsal midfoot area of the foot may complain of very similar symptoms.
On physical examination of the patient with DMICS, 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 detected at the dorsal midfoot in only the more severe cases of DMICS.
There is no pain with forceful manual dorsiflexion of the forefoot on the rearfoot. However, there is very significant pain with plantarflexion of the forefoot on the rearfoot. This test, the Forefoot Plantarflexion Test (see illustration below), is the key examination finding in patients with DMICS. All patients with DMICS have very significant pain with plantarflexion of the forefoot on the rearfoot. The Forefoot Plantarflexion Test is a remarkably sensitive indicator of the level of severity of DMICS.
The most likely reason that manual plantarflexion of the forefoot on the rearfoot during the Forefoot Plantarflexion Test causes such significant and consistent pain in patients with DMICS is that the dorsal margins of the midfoot joints have, over time, developed microfractures and/or bone edema due to the excessive compression forces within their dorsal midfoot joints (see illustration below).
I predicted the MRI finding of "bone bruising" and subchondral bone injury in the dorsal midfoot joints in 2010 (Kirby KA: "Prescribing Better Foot Orthoses: Lateral-Dorsal Midfoot Pain", June 2010 Precision Intricast Newsletter, in: Kirby KA: Foot and Lower Extremity Biomechanics IV: Precision Intricast Newsletters, 2009-2013. Precision Intricast, Inc., Payson, AZ, 2014, pp. 95-96).
15 years after I predicted subchondral bone injury in patients suffering from DMICS, the MRI finding of dorsal midfoot joint bone edema was finally confirmed in patients with DMICS (i.e. dorsal midfoot pain) by Jill Halstead, PhD and coworkers in 2025, (Halstead J, Martín‐Hervás C, Hensor EM, Keenan AM, Conaghan PG, McGonagle D, Arnold JB, Jones J, Redmond AC. Association between clinical and MRI‐detected imaging findings for people with midfoot pain, a cross‐sectional study. Journal of Foot and Ankle Research. 2025 Mar;18(1):e70019). See the MRI image from the paper by Halstead et al below.
The dorsal capsular ligaments which attach to these damaged area of dorsal midfoot joint bone will pull on these areas of damaged bone which causes pain during propulsion, when the forefoot is plantarflexing on the rearfoot due to the windlass effect. Again, the cause of the bone damage within the dorsal articular margins of the midfoot joints is the chronic excessive interosseous compression force (ICF) in dorsal surfaces of these midfoot joints during weightbearing activities.
The combination of three main forces act together on and within the foot during late midstance to cause an increase in the ICF across the dorsal joint surfaces of the midfoot (see illustration). First, the weight of the body exerts a plantarly directed force through the tibia onto the talar dome at the ankle joint. This ankle joint compression force is increased by any tension forces within the Achilles tendon, tendons of the deep posterior compartment muscles and peroneal muscle tendons.
Second, due to the biomechanical requirements of the gastrocnemius and soleus muscles to be active during late midstance, the Achilles tendon has large tension forces which cause a rearfoot plantarflexion moment which, in turn, has a tendency to flatten the longitudinal arch of the foot. 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 "arch-flattening 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 arch-flattening moments on both the medial and lateral longitudinal arches are increased by such factors as increased body weight, low heeled shoes and limited ankle joint dorsiflexion. 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.
Repetitive micro-trauma at these dorsal midfoot joint surfaces with each step is the likely etiology for 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 relacing shoes to form a "lace-gap" over the symptomatic area of the dorsal midfoot (see illustration below). Choosing shoes that do not cross dorsally over the affected area of the dorsal midfoot also is helpful for these patients. In addition, icing and non-steroidal anti-inflammatory drugs and even cortisone injections may be necessary in resistant cases. The worst cases are treated initially with cam-walker brace boot walkers for 3-6 weeks.
Mechanical treatment involves, first of all, having the patient stretch their Achilles tendon 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 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. Proper conservative treatment, outlined above, is routinely very effective.
