Essential Insights On Lateral Column Pain
Lateral column pain has a variety of possible etiologies ranging from peroneal tendon disorders and cuboid syndrome to skewfoot and postoperative symptoms after plantar fascia release. Accordingly, these authors survey the literature and offer pertinent pearls on diagnosing and treating this condition.
Lateral column pain is a descriptive term for a myriad of symptoms involving the joints and bones of the lateral column. The lateral column is comprised of the calcaneus, the cuboid and the fourth and fifth metatarsals as well as their respective joints, the calcaneocuboid, the cuboidometatarsal and the intermetatarsal joints.
Lateral column pain may be due to arthritis, biomechanical abnormalities, acute fractures secondary to trauma or stress fractures secondary to chronic overuse. Other causes include tarsal coalition, peroneal tendonitis or subluxation, extensor digitorum brevis tendonitis, plantarflexion and inversion ankle injuries, cuboid subluxation and iatrogenic causes following surgery.
In the literature, researchers have described lateral column pain with a number of names including cuboid fault syndrome, lateral plantar neuritis or cuboid syndrome, which has also been called subluxed, locked or dropped cuboid.1 The sheer number of terms used throughout the literature to describe lateral column pain can make literature review a daunting process.
The literature is divided in reference to biomechanical etiologies of lateral column pain. Various authors have suggested that lateral column pain is associated with neutral, supinated and pronated foot types. Adducted foot types can cause an increase in mechanical pressures that can result in lateral column pain.2 Increased plantar pressures on the lateral column that one may see with neutral to supinated foot types can stress the cuboidometatarsal joints. Identifying the exact biomechanical etiology of lateral column pain is an important factor in providing appropriate treatment.
A patient with lateral column pain will complain of acute or chronic pain in the area of the calcaneocuboid joint or the bases of the fourth and/or fifth metatarsal. The pain is usually greater with propulsion but may also be present during stance or non-weightbearing. Palpation should isolate the specific area of pain. Tenderness may also be present along the peroneal tendons or the origin of the extensor digitorum brevis muscle.
One typically diagnoses lateral column pain based on the physical exam as radiographs show little benefit in diagnosis. However, one should rule out stress and acute fractures. Consider tarsal coalition in the younger patient. Due to the nonspecific nature of the pain and the lack of positive radiographic results, accurate diagnosis of lateral column pain can be a difficult process. While computed tomography (CT) and magnetic resonance imaging (MRI) can be useful tools in evaluating the lateral column, they are often unnecessary.
What You Should Know About Cuboid Syndrome
Cuboid syndrome, which has been defined as “a minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint” is a common cause of lateral column pain.1
The most common proposed etiologies of cuboid syndrome are plantarflexion, inversion ankle sprains and overuse injuries. Cuboid syndrome is often difficult to diagnose as symptoms can be non-specific. Radiographs are usually negative as there is normally no osseous damage and no notable radiographic changes. Even radiographs taken under manipulation rarely show any changes in the cuboid position.
As a result, the diagnosis of cuboid syndrome is often based on history and physical findings on clinical examination. Cuboid syndrome can be a result of excessive pronation caused by conditions such as posterior tibial tendon dysfunction or pes planus. While MRI can be useful in identifying localized inflammation of capsule and ligaments, it is often not necessary.
Midtarsal joint stability plays an important role in cuboid syndrome. Newell and Woodle found that 80 percent of their patients with cuboid syndrome had pronated feet.3 In a normal foot, the subtalar joint is supinating during propulsion and the peroneus longus acts as a stabilizer of the forefoot as it assists in plantarflexing the first ray while using the cuboid as a pulley.
However, when the subtalar joint is pronating through the early phase of propulsion, the peroneus longus has a greater mechanical advantage because the foot is pronated and the midtarsal joint is unstable. Due to this pronated, unstable nature of the cuboid, the peroneus longus is able to sublux the cuboid during the propulsive phase of gait. This in turn can irritate the calcaneocuboid joint capsule and surrounding ligaments, as well as the peroneus longus tendon.
An inversion sprain can also cause subluxation or dislocation of the cuboid as well as stress the peroneal tendons and ligaments of the lateral column. The peroneus longus muscle may forcefully contract in response to an inversion stress in an attempt to restore medial ground contact and balance. This contraction can result in a medial rotation of the cuboid and/or disruption of the intertarsal ligaments.
A Closer Look At Peroneal Tendon Disorders
Peroneal tendon disorders are a commonly overlooked source of lateral column pain because it can be hard to differentiate them from injuries to the ligaments of the lateral ankle. Palpation of the peroneal tendons for defect or tenderness is an important part of the physical exam for a patient complaining of lateral column pain.
Peroneal tendon disorders typically fall into three categories including: tendonitis and tenosynovitis; tendon subluxation and dislocation; and tendon tears and ruptures.4
Peroneal tendonitis and tenosynovitis typically cause lateral ankle and or foot pain as a result of prolonged or repetitive activity. Anatomic variations of the lateral foot as well as ankle and hindfoot alignment can predispose patients to peroneal tendon disorders such as subluxation or tendon tears. The lateral retromalleolar groove can vary in shape and depth, which affects the stability of the peroneal tendons as they pass posterior to the fibula. A shallow or narrow retromalleolar groove can potentiate peroneal tendon subluxation and subsequent tendon pathology.
The musculotendinous junction of the peroneus brevis typically lies proximal to the superior peroneal retinaculum although it can occur more distally and posterior to the retromalleolar groove. Additionally, the peroneus quartus, an accessory muscle reported to be present in 10 to 22 percent of the population, runs posterior to the fibula. Either of these anatomical variations can cause stenosis in the retromalleolar groove and/or attenuate the superior peroneal retinaculum. A hypertrophied peroneal tubercle of the calcaneus can also result in peroneal tendon disorders as it increases mechanical stress on the peroneal tendons.
A cavovarus hindfoot creates a mechanical disadvantage for the peroneal tendons by increasing frictional forces at the lateral malleolus, peroneal tubercle and cuboid notch. The moment arm of the peroneal tendons is also lower and places the peroneal tendons at a higher risk for tendon disorders.
Why Fifth Metatarsal Fractures Lead To Lateral Column Pain
Fractures of the base of the fifth metatarsal typically result in lateral column pain and often physicians overlook this in the presence of an ankle sprain or fracture. The more common avulsion fracture has a good prognosis with non-operative treatment. An avulsion fracture occurs as a result of forced inversion with the peroneal brevis avulsing a small portion of bone at its insertion to the base of the fifth metatarsal. A true Jones fracture of the fifth metatarsal diaphysis can cause significant disability and results from vertical and mediolateral forces over the fifth metatarsal.
Depending on the severity of the injury, immobilization in a cast, CAM walker or surgical shoe is recommended. A period of non-weightbearing may be necessary. A bone stimulator may be helpful for fractures that have not responded to immobilization. If the fracture is displaced, comminuted or has failed to heal properly, surgery may be necessary. One can obtain open reduction by passing an intramedullary cannulated screw over a percutaneous drilled K-wire with fluoroscopic guidance. In one study, nearly one-quarter of patients with Jones fractures who underwent conservative treatment later required surgery due to delayed union or recurrent fractures.5
Inside Insights On Skewfoot
Skewfoot, which is a combination of the forefoot deformity of metatarsus adductus and the rearfoot deformity of flatfoot, can also cause lateral column pain. This is due to the sheer increase in pressure that transfers though the lateral aspect of the foot due to the abnormal shape. Skewfoot patients generally have a myriad of symptoms that one must address.
Conservative treatment consists of serial casting to correct the metatarsus adductus aspect of the deformity. Surgical correction should focus on treating both the metatarsus adductus and the flatfoot deformity. Mosca suggests that performing a calcaneal lengthening osteotomy with an Achilles tendon lengthening was successful in correcting the skewfoot 90 percent of the time.6
How Plantar Fascia Release Can Cause Lateral Column Pain
Symptomatology following plantar fascial release is one of the more common iatrogenic causes of lateral column pain. Lateral column pain symptomatology can at times be more painful to the patient than the initial heel symptoms. Studies vary on the occurrence rate with 4 to 11 percent of patients experiencing lateral column pain after undergoing a plantar fascial release.7-9
The amount of fascia released is directly related to an increased likelihood of developing lateral column pain, regardless of the type of procedure one performs. The exact amount of plantar fascia that one should release is a hotly debated topic. After reviewing the literature, Downey recommended releasing 33 percent of the fascia.10 Brugh and colleagues showed that lateral column symptoms increased when surgeons released more than 50 percent of the fascia.11 Due to the importance of the plantar fascia, one should take care to avoid destabilizing the foot while treating heel pain.
Release of the plantar fascia reduces its ability to support the arch, which allows a drop in the medial and lateral columns of the foot. The plantar fascia, plantar ligaments and the spring ligament all lend support to the longitudinal arch. Sectioning of the entire plantar fascia can cause an equinus rotation of the calcaneus and a drop in the cuboid.12 This drop in the cuboid creates a strain on the capsular and ligamentous structures of the plantar calcaneocuboid joint, which is acutely painful.
What About Lateral Column Overload?
Another proposed etiology of lateral column pain is overloading of the lateral column while the patient attempts to avoid weightbearing through the medial column during the postoperative course. This cause is usually self-limiting and will resolve with a return to normal gait.
Lateral column overload is a frequent complication with lateral column lengthening procedures for the correction of deformities such as posterior tibial tendon dysfunction or pes planus.13 Researchers have noted lateral column symptomatology with both the traditional Evans osteotomy as well as the calcaneocuboid distraction arthrodesis.14
There is concern for osteoarthritis of the calcaneocuboid joint with an anterior calcaneal osteotomy. Degenerative arthritis in adjacent joints is a known sequelae of joint arthrodesis with several reports of fifth metatarsal stress fractures.13,15-17 Compressive forces increase eightfold in the calcaneocuboid joint following an Evans calcaneal osteotomy.16 In response, many surgeons have advocated lateral column lengthening through the calcaneocuboid joint with simultaneous fusion despite a high incidence of calcaneocuboid nonunion.15
Postoperative subluxation of the talocalcaneal and talonavicular joints due to over- or under-correction may explain postoperative pain and loss of motion.18 Sands and colleagues showed that motion in the subtalar joint is strongly influenced by the position of the foot when surgeons fuse the calcaneocuboid joint. Hindfoot mobility is preserved only when one maintains the foot in neutral position.17
Can Conservative Treatment Have An Impact?
Treatment options include both conservative and surgical modalities depending on etiology, severity and course. Conservative methods usually produce satisfactory patient results but surgical corrections may be required in some instances.
Conservative treatments consist of physical therapy, strapping, neutral orthotics, rest and nonsteroidal anti-inflammatory drugs (NSAIDs). Supportive padding with a cuboid pad decreases strain on the calcaneocuboid joint and supports any mild dislocation. Custom-molded orthotics may help distribute weight more evenly between the medial and lateral columns of the foot. A diagnostic injection into either the tarsometatarsal joint or calcaneocuboid joint can isolate the specific area of pain.
Conservative treatment is generally successful in treatment of cuboid syndrome. Physical therapy, strapping, manipulation and neutral orthotics are all useful treatment modalities. Prolotherapy is an option when recurrent subluxation occurs with other treatments. This involves an injection of approximately 1 cc of a solution into the calcaneocuboid joint. This solution usually contains anesthetic, dextrose and occasionally phenol. The objective is to cause sclerosing of the joint capsule in a sort of pseudarthrosis to decrease mobility and subluxation of the joint.2 For patients with more resistant conditions, especially those demonstrating calcaneocuboid joint degeneration, an isolated calcaneocuboid fusion may be indicated.
Manipulation to realign the calcaneocuboid joint occurs by using a maneuver known as the “black snake heel whip.”1 To perform this procedure, position the patient in stance in front of you with the knee on the affected side flexed 90 degrees. Patients can use a chair or countertop to stabilize themselves while physicians hold the forefoot with their fingers and place their thumbs over the plantar and medial aspect of the cuboid. Then manipulate the cuboid to a more dorsal and lateral position with a single, whip-like downward motion.
The patient should be totally relaxed in order for this procedure to work. Gentle massage of the foot can assist in relaxing the patient. When performing this exercise correctly, the physician may feel a subtle movement of the cuboid and can sometimes hear an audible “pop” as the cuboid is realigned. A low-Dye strapping can be helpful in maintaining alignment after correction. Multiple manipulations over several weeks can be helpful.
Lateral column pain associated with plantar fascial release is usually self-limiting and resolves with return to normal gait. One can easily treat more resistant forms with conservative care. Wyatt found patients had relief of symptoms after undergoing a series of chiropractic manipulation sessions along with plantar fascia stretching.19 Fourteen of 15 (93 percent) patients had moderate to significant improvement of pain with eight or fewer visits.
Weighing The Surgical Treatment Options
When conservative treatments fail, surgical treatment may be necessary. The use of isolated fusion of the lateral column joint(s) is a debated topic.
Some authors argue that triple arthrodesis is necessary to avoid arthritis of adjacent joints. Isolated calcaneocuboid fusions have had nonunion rates as high as 25 to 30 percent.
However, Chang has found isolated fusion of the calcaneocuboid joint to be a successful stabilizing procedure that eliminates subluxation of the cuboid.2 He notes that some isolated fourth and fifth metatarsal cuboid joint fusions have resulted in pain at the calcaneocuboid joint but patients with isolated calcaneocuboid fusions did not experience pain at the tarsometatarsal joints. While some authors have reported performing resection arthroplasty of the fourth and fifth metatarsal bases, long-term results are pending. Avoid lateral column shortening in all fusions.
Case Study: When A Hiker Has Recurrent Lateral Column Pain
A 27-year-old male presents with a chief complaint of lateral foot pain for several weeks. His pain is worst with normal weightbearing although he has some pain all the time. The patient does not recall any trauma to the area but he says it started after being on his feet all day on a hiking trip. He wore sneakers on the trip and denies any change in shoegear from his normal footwear. He works for a pest control agency and wears boots to work on a daily basis.
The patient has not been taking anything for pain. His past medical history is negative and there is no notable past surgical history. He does not take any medications. He is a social drinker and a non-smoker.
During the physical exam, I noted pain with palpation around the cuboid. The pain radiates to the medial arch area. There is minor swelling in the area of the cuboid. Active and passive range of motion are mildly limited and painful in comparison to the non-affected extremity. The foot is painful on passive inversion and during active plantarflexion and eversion. His DP and PT pulses are palpable 2/4. The X-ray was negative for fractures and MRI of the area was unremarkable.
I diagnosed cuboid syndrome based on the clinical findings. I manipulated the calcaneocuboid joint in the office using the black snake heel whip technique. The patient experienced some immediate pain relief on weightbearing and received low-Dye strapping to help maintain the positioning. I offered the patient physical therapy but due to work and time restrictions, he turned it down on the initial visit. On a follow-up visit two weeks later, his pain was much improved. He turned down neutral position orthotics at this time.
He presented again several months later with the same symptoms. I again manipulated the calcaneocuboid joint and had the patient use a low-Dye strapping. At a two-week follow-up, his symptoms had improved but were still persisting. I re-manipulated the joint and used a low-Dye strapping. The patient then agreed to physical therapy for stretching of the peroneus longus and triceps surae, strengthening of the intrinsic and extrinsic muscles of the foot and proprioception.
At a second two-week follow-up, the patient was pain-free and wore neutral position orthotics. He has since been wearing neutral position orthotics in his work boots. At six-month and one-year follow-ups, the patient has been pain-free in the area.
Little research exists on the pathology of lateral column. This is due, in part, to the nonspecific nature of lateral column pain ranging from vague patient complaints, multiple etiologies and the number of terms representing pain in the lateral foot. The mainstay of treatment remains conservative care with support and stabilization of the lateral foot being paramount. Surgical treatment options include isolated or multiple joint fusions as necessary.
Dr. Grossman is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery and the American Board of Podiatric Orthopedics. Dr. Grossman is a member of the teaching faculty at the Pinnacle Health System and is in private practice in Harrisburg, Pa.
Dr. Nakai is a second-year resident at Pinnacle Health System in Harrisburg, Pa.
Dr. Sweeley is a second-year resident at Pinnacle Health System in Harrisburg, Pa.
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