A Guide To Understanding And Treating Lateral Column Pain

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A Guide To Understanding And Treating Lateral Column Pain
Here one can see a typical calcaneocuboid fusion with staples.
Here one can see degenerative joint disease of the fourth and fifth metatarsocuboid joint seven years after a calcaneocuboid fusion. Be cautious in fusing the joints since the rate of nonunion is high and patients can experience postoperative pain.
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Author(s): 
By Babak Baravarian, DPM

   Problems with the lateral column are more common than we believe. Although there is a great deal of understanding of medial column problems and their solutions, there is not as much information on lateral column symptoms, causes and treatment options. With this in mind, let us take a closer look at these potential symptoms and treatment options that our institute has found helpful for such problems.

   A typical patient may have an equinus and pain in the lateral foot and ankle. The pain is localized to the rearfoot and lateral ankle with tenderness along the peroneus longus, calcaneocuboid region and, in certain cases, the fourth and fifth metatarsal base-cuboid region.

   Pain can develop for many reasons. One common reason is a lateral ankle sprain, in which there is often an inversion injury and torsion with the injury. The peroneal tendons can be strained or receive enough stress to have a peroneal longitudinal tear. In most cases, one will find the peroneus brevis is more commonly affected. There is mild pain along the posterior fibula with an increase in pain at the posterior fibular bend. The peroneus longus is less affected. If the pain is localized to the cuboid region, one may find a peroneus longus tear lateral or plantar to the cuboid. Clinicians may see cuboid subluxation although this is rare. In my opinion, the subluxation can be due to the peroneus longus tendon tension on the cuboid.

   In newly active patients with lateral column pain, the most common cause of pain is a varus rearfoot with overstress of the peroneal tendons and cuboid region. There is often a chronic subluxation of the cuboid region that requires conservative care.

   The last and most troublesome cause of pain is when one performs a plantar fascia release, either complete or partial, and there is added stress of the lateral column with less support. This leads to overstress of the cuboid region, partial subluxation and pain. Most patients are very unhappy with the initial care and often see another doctor. In these cases, it is important to avoid making the patient feel this is a mistake on the initial doctor’s part as it will happen to you at some point. I have seen this occur among patients with high and low arches, those who are heavyset, those who are very thin, and among patients with complete and partial fascia releases. There is no reason to think there was something that caused the problem other than the fact that it happens.

   The pain in all of these cases is very strange and poorly localized. One will usually note tenderness along the peroneal tendons, especially the longus with pain plantar to the cuboid and pain along the lateral aspect of the foot. These patients will rarely have pain in the ankle or subtalar joint. The pain is often more distal and more lateral than one would expect with extensive diffuse pattern or distribution. There is also mild to moderate inflammation but no extensive edema and usually minimal to no pitting.

Pertinent Points On Conservative Care

   Initial treatment in all cases is based on conservative care. The mainstay of conservative care is providing additional stability of the cuboid and control of the tension and stress on the peroneal tendon. Diagnostic testing can be very helpful in determining initial treatment. One should obtain radiographs to rule out fracture, stress fracture or bone tumor. Keep in mind that it is difficult to diagnose a dislocated cuboid unless it is severe.

   Ultrasound testing is excellent for peroneal tendon pathology. One can check the peroneal tendon for tears and gliding function. If there is poor gliding or subluxation tendency of the peroneal tendon, ultrasound testing is ideal for diagnosis prior to therapy. Obtaining a MRI is very useful in these cases if one notes tendonitis, a peroneal tendon tear or cuboid subluxation. If there is a subluxation of the cuboid, clinicians may note global edema of the plantar and, sometimes, dorsal calcaneocuboid and/or cuboid in the fourth or fifth metatarsal base region.

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