How To Manage Isolated Lateral Column Pain
The lateral column of the foot includes the calcaneus, the cuboid, the fourth and fifth metatarsals as well as the calcaneocuboid (CC), cuboido-metatarsal and intermetatarsal joints. Injuries to the midtarsal joints are relatively uncommon. However, when these injuries do occur, there is a debate on the best way to approach the treatment.1 Traditionally, patients with CC joint arthrosis in combination with midtarsal or subtalar joint pain have undergone a triple arthrodesis. The notion of performing isolated fusions has previously been disregarded since the general belief is the surrounding joints would break down over time. Over the past 20 years, bone block distraction arthrodesis of the CC joint has been popularized for flatfoot reconstruction. There has been little written in the literature on addressing isolated lateral column pain. In my experience, one can have success with fusion of the calcaneocuboid joint but it is not usually beneficial to fuse the fourth and fifth cuboido-metatarsal joints. Accordingly, let us take a closer look at these clinical scenarios.
A Guide To Lateral Column Pathologies
The typical patients who may present to your office with lateral column pain are those who have a neutral to supinated foot type. These patients generally apply more weight to the lateral column during the gait cycle. Patients with a forefoot or midfoot adductus will also stress the lateral column with mechanical pressures to the lateral portion of the foot. This often affects the fourth and fifth metatarsocuboid joints. You may also see a patient with a significantly pronated foot type secondary to the instability of his or her midtarsal joint. Excessive instability will also result in hypermobility of the CC joint and subsequent joint pathology. One unique presentation of lateral column pain has been described as cuboid syndrome. Cuboid syndrome is a disruption or even subluxation of the structural congruity of the calcaneocuboid joint.2 The talonavicular joint together with the calcaneocuboid joint acts to lock the midtarsal joint in order to allow for a rigid foot at push-off and a flexible foot at heel strike. The cuboid is secured in the lateral column by many dorsal and plantar ligaments that are stronger dorsomedially than plantar laterally. The biomechanical considerations of the foot contributing to this pathology are well documented by Blackeslee and Morris.2 This allows the calcaneocuboid joint to rotate about a medially positioned axis. After either direct or indirect trauma to the lateral column, the proximal aspect of the cuboid on the calcaneus medially everts, falls out of place and can partially sublux. It is also important to remember the influence of the peroneus longus tendon that travels within the peroneal groove plantar to the cuboid. As the peroneal muscle contracts in the middle of the midstance phase and into the late propulsive period, depending on its course and degree of contraction, this can also contribute to the syndrome. Conversely, chronic recurrent subluxation of the cuboid can bring irritation to the peroneal tendon, leading to a secondary tendonitis. Many concurring factors can lead to the occurrence of cuboid syndrome. These can be external forces as well as internal forces of the peroneous longus tendon and the anatomy of the joint. When an incongruent calcaneocuboid joint is coupled with excessive ground reaction forces, it can lead to overstress of the joint, its ligaments and capsule, leading to a subluxation. Cuboid syndrome is simply a minor disturbance in the position of the joint that leads to inflammation.2 There may be acute or chronic plantar pain in the area of the calcaneocuboid joint. Patients will consistently have discomfort with longitudinal midtarsal joint supination.2 Often, the patients relate significant pain with direct plantar palpation of the calcaneocuboid joint. Palpation of the fourth and fifth metatarsal base-cuboid joints is also important in the clinical exam. At times, there may be moderate pain with or without crepitus during evaluation. Plain radiographs are usually not helpful in the diagnosis as one cannot often appreciate the dislocation. Pure subluxation or dislocation of the joint is very rare. Mcharo and Ochsner described only one case of bilateral recurrent dislocation.4 Most are actually fracture dislocations from direct impaction on the calcaneocuboid joint. Those that are intraarticular fractures are of the most concern. Specific injury to the calcaneocuboid joint ligaments, although rare, has been reported.3 These usually occur in supination type injuries. Andermahr, et. al., describe a classification system for calcaneocuboid joint ligament injuries. They use a “four-stage” system that evaluates the specific ligament that is disrupted and the presence of a bone flake or fracture. Leland, et. al., attempted to define normal stability of the calcaneocuboid joint and the ligamentous contributions using stress radiographs.1 Some patients will present with chronic lateral column pain that cannot be associated with a specific etiology. A patient may subjectively complain of a generalized ache, joint pain or tendon pain as the peroneal tendon passes under the peroneal groove. In these cases, it is important to evaluate the possibility of a biomechanical contribution. Another subset of patients has had extensive plantar fascial releases with a complete lateral band release. These patients may present with lateral column pain. This is usually secondary to excessive stress placed on the lateral column from the extra strain on the calcaneocuboid joint in the absence of a supporting plantar fascia. Even if the lateral band of the fascia is left intact during surgery, it is recommended to offload the involved extremity for two to three weeks before resuming weightbearing. If not, then the possibility of lateral column pain is dramatically increased due to overwhelming stress in this location.
Key Insights On Conservative Treatment Options
When treating lateral column pathologies, a conservative approach is always preferable over surgical intervention. The support of padding in the form of a cuboid pad seems to alleviate the strain on the joint and also supports any mild dislocation that may exist. One technique is applying a circular or rectangular piece of 1/4- to 1/2-inch felt padding directly under the cuboid. One may use this alone or in conjunction with a well-constructed custom molded orthotic to take pressure off the lateral column and distribute the weight more medially. If there is excessive loading occurring along the lateral column biomechanically, then one can also plantarflex the lateral column slightly when taking the orthotic impression cast. One can achieve manipulation to realign the calcaneocuboid joint into a more normal position at times by using the “black snake heel whip” maneuver.2 You can do this by positioning yourself behind the patient, who is in stance with the knee flexed to 90 degrees on the affected limb. The patient stabilizes him- or herself with the hands on a countertop or chair. The physician then holds the forefoot with the fingers, and places his or her thumbs, one over the other, on the plantar medial aspect of the cuboid. The patient must be in a completely relaxed state with the affected lower extremity. In a single rapid downward movement, manipulate the foot like a whip. The physician will want to move the cuboid in a more dorsal and lateral direction with respect to the calcaneus. Often, one will hear an audible “pop” or the physician may feel subtle movement of the cuboid. Gentle massage of the foot with forefoot distraction for one to two minutes prior to performing this maneuver may prove to be helpful in relaxing the splinting of the intrinsic and extrinsic musculature. Afterward, clinicians can utilize a good low-Dye type strapping to help maintain the alignment following the procedure. Multiple manipulations can be helpful. In cases of chronic recurrent subluxations, clinicians can achieve strengthening of the ligaments and capsule of the joint with proliferant therapy. Also referred to as prolotherapy, this solution usually contains anesthetic, dextrose and, rarely, phenol. This is a small volume, often less than 1 cc. After a sterile prep, one would inject this solution directly into the joint capsule of the calcaneocuboid joint in an effort to cause internal sclerosis of the capsule and tighten them. The idea is to sclerose and irritate the area in order to increase blood flow to the area. The end result is a form of pseudoarthrosis that minimizes the excessive mobility and the subluxation of the joint.
Pertinent Pearls On Performing Isolated Calcaneocuboid Fusion
When conservative measures have failed, fusion of the site may be warranted. Utilize standard fusion techniques using screws or staples. I have performed isolated fusion of the calcaneocuboid joint over the last 10 years with predictable success. The standard approach involves joint distraction and curettage in an attempt to avoid excessive shortening of the lateral column. As these patients often have a neutral to supinated foot type, no grafting is utilized for this procedure. Surgeons may consider grafting if they note hindfoot collapse in the preoperative scenario. The patients never continue to sublux their cuboid after this procedure nor does it seem to affect the patient’s function in a negative way. Some patients will exhibit some abduction of the affected foot after a fusion due to the “closing down” of one joint on the lateral column. This abduction does not seem to affect the adjacent talonavicular joint, and the patients appear to accommodate the abduction easily without any noted clinical sequelae. I have performed over 25 isolated calcaneocuboid fusions, over five isolated fourth and fifth metatarsal base cuboid fusions, and a few complete lateral column fusions. Of the isolated fourth and fifth metatarsal cuboid joint fusions, some of the patients have residual pain in the calcaneocuboid joint after surgery. Yet those patients with isolated calcaneocuboid joint fusions have not had problems at the more distal joint.
A Closer Look At Essential Biomechanical Considerations
There have been several biomechanical studies measuring triplanar motion out of the Lisfranc’s joint. Ouzounian and Shereff showed statistically more sagittal and frontal plane movement along the lateral column versus the medial three joints.5 Nester, et. al., also demonstrated significant triplanar motion out of the lateral Lisfranc’s area, especially in the sagittal plane.6 Given these findings, the distal lateral joint is the main source of triplanar motion along the lateral column. This is now recognized as an “essential” joint for maintaining mobility. Accordingly, surgeons should leave this joint open rather than fusing it when end stage arthrosis is present. In regard to the surgical approach for this clinical scenario, one would usually make a linear incision for dorsal lateral access to the fourth and fifth metatarsocuboid joints. Surgeons should preserve the sural nerve when possible. Leave the attachment of the peroneus brevis alone on the styloid process laterally. After facilitating exposure of the two joints, resect approximately 1 cm of the metatarsal base. I have found it is helpful to preserve the subchondral bone of the cuboid. This will provide more stability of the joint and prevent subsidence of the implants. Shawan and Anderson have described both an “extensor tendon anchovy” interposition as well as the Orthosphere (Wright Medical). The latter is an inert ceramic spacer that has been designed to help maintain joint spacing and movement to the joint. The only exception to this may be for Charcot arthropathy. The basic tenet in Charcot surgery is to provide stability when possible. Since the majority of these patients are neuropathic, I recommend leaving these two joints alone when possible. As long as the medial column is stable, the lateral column should not pose a problem. In the rare situation in which a distal fusion is preferred or required, one should also consider evaluation of posterior equinus. The Achilles can become a significant force along the lateral column on these patients and should be lengthened when necessary.
Final Thoughts On Distal Lateral Column Fusion
It is well understood that instability of a proximal joint can effect the distal articulations. In patients with chronic calcaneocuboid joint pain, there can also be pain at the fourth and fifth metatarsal base-cuboid joint. Often when the patient presents with isolated lateral column pain, performing a diagnostic injection into one of these two joints of the lateral column is useful to isolate the pain. A focus on the joint that is more symptomatic is warranted. We have seen over the years that patients with Lisfranc’s dislocations appear to have a better functional outcome when the three medial joints are fused in comparison to a complete arthrodesis of metatarsals one through five. Due to the anatomical contour of the lateral Lisfranc’s joint, it would make sense that an isolated fusion of this joint may be problematic. This is due to the more proximal calcaneocuboid joint being a saddle shaped joint that does not allow triplanar motion. Relying on this joint in the lateral column to absorb all the motion in the column is difficult.The majority of lateral column motion comes out of the fourth and fifth metatarsocuboid joint in the sagittal plane, much more so than the proximal calcaneocuboid joint. Some orthopedic literature discusses fourth and fifth metatarsal base resection arthroplasty for end stage arthrosis of the metatarsal cuboid joint. Since 2001, I have only performed resection arthroplasty of this joint with good early results. The patients are clearly much more functional at an early stage since no osseous healing has to occur. After longer follow-up and better evaluation, we can report prospective studies evaluating the outcomes of resection arthroplasty for isolated fourth and fifth metatarsocuboid arthrosis. There is a considerable amount of literature on the treatment of the medial column. The lateral column is sometimes as difficult and can also pose biomechanical challenges. The distinction of medial or lateral column pain is dependent on the patient’s foot type. We have observed that lateral column pain is much more prevalent in a neutral to supinated foot. Clinicians can treat chronic pain and end stage arthrosis of the lateral column joints successfully with the aforementioned approaches. As the Achilles tendon is important in medial column collapse, one should also consider its contribution to lateral column pathology. Dr. Chang is the Chief of the Department of Podiatric Medicine and Surgery at the Sutter Medical Center in Santa Rosa, Ca. He is a Clinical Professor at the California School of Podiatric Medicine at Samuel Merritt College. Dr. Chang is a Fellow of the American College of Foot and Ankle Surgeons, and is a faculty member of the Podiatry Institute.
References 1. Leland R, Marymont J, Trevino S, et. al. Calcaneocuboid Stability: A Clinical and Anatomic Study. Foot Ankle Int, 22:11, 2001, 880-884. 2. Blakeslee T, Morris J. Cuboid Syndrome and the Significance of Midtarsal Joint Stability. JAPMA, 77:12, 1987, 638-642. 3. Andermahr J, Helling HJ, et. al. The Injury of the Calcaneocuboid Ligaments. Foot Ankle Int, 21:5, 2000, 379-384. 4. Mcharo C, Ochsner P. Isolated Bilateral Recurrent Dislocation of the Calcaneocuboid Joint. JBJS, 79:4, 1997, 648-649. 5. Ouzounian TJ and Shereff MJ. In vitro determination of midfoot motion. Foot Ankle, 10:140-146, 1989. 6. Nester CJ, Findlow AF, Bowker P, Bowden PD. Transverse plane motion at the ankle joint. Foot Ankle Int 24(2):164-8, 2003.