Essential Insights On Lateral Column Pain

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Author(s): 
Allan Grossman, DPM, FACFAS, Ann Nakai, DPM, and Jason Sweeley, DPM

   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

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