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