What is the treatment for dorsal midfoot pain that worsens with extension and flexion?

Dorsal Midfoot Pain Worse with Extension and Flexion

For dorsal midfoot pain exacerbated by extension and flexion, begin with conservative management using shoe modifications and orthotic inserts to stabilize the affected joints, as this is the mainstay of treatment for midfoot arthritis. 1

Initial Conservative Management

The primary goal is to provide pain relief by enhancing midfoot stability and modifying loads sustained at the inflamed joints. 2

First-Line Interventions

• Shoe modifications and orthotic inserts are the cornerstone of nonsurgical management for midfoot arthritis, which is the most likely diagnosis given dorsal pain with flexion/extension movements. 1
• Successful orthotic management requires achieving adequate joint stabilization while still allowing function. 1
• Proper footwear that fits well and provides adequate support should be recommended. 3
• Orthotic support should be considered if foot deformities are present. 3

Diagnostic Corticosteroid Injection

• Steroid injections are invaluable in conservative management and have diagnostic value in guiding surgical treatment decisions. 4
• A diagnostic local anesthetic injection block of the deep peroneal nerve (DPN) can provide significant pain relief, with studies showing a mean of 92.1% improvement in patients with dorsal midfoot osteoarthritis. 5
• This diagnostic injection helps confirm that dorsal midfoot nociceptive pain is transmitted by the DPN and can guide further treatment. 5

Anatomic Considerations

The dorsal midfoot pain pattern you describe is consistent with midfoot arthritis affecting the tarsometatarsal (TMT) joints. 1, 2

• The medial TMT joints provide less than 7 degrees of sagittal plane motion, while the lateral fourth and fifth TMT joints are more mobile. 1
• These constrained TMT joints translate forward propulsion motion from the hindfoot to the forefoot during gait. 1
• Posttraumatic degeneration is the primary cause of midfoot arthritis, though primary osteoarthritis and inflammatory conditions can also affect this area. 1
• The DPN consistently innervates the second and third tarsometatarsal joints and the naviculocuneiform joint, explaining the dorsal pain pattern. 5

When Conservative Management Fails

If conservative treatment with orthotics and injections fails after an adequate trial period:

• Surgical intervention typically involves arthrodesis (fusion) of the medial midfoot joints. 1
• The arthrodesis should be limited to the symptomatic joints, though identifying which specific joints cause symptoms can be challenging. 2
• A precise anatomic preoperative diagnosis is essential to determine the extent of arthrodesis needed. 2
• Successful union rates are approximately 90% following careful patient selection, preoperative planning, adequate joint preparation, and stable fixation. 4

Common Pitfalls

• Do not proceed to surgery without an adequate trial of conservative management, as shoe modifications and orthotics can effectively manage many cases. 1, 2
• Ensure proper identification of the affected joints before surgery, as unnecessary fusion of unaffected joints can limit function. 2
• Be aware that the lateral column (fourth and fifth TMT joints) requires different treatment considerations due to its greater mobility. 1
• Rule out inflammatory causes and neuropathic etiology before finalizing the treatment plan. 4