Lateral Column Dysfunction | Sports Medicine June 2011

Lateral column pain can be very disabling to any athlete and it should not be overlooked. Runners are especially prone to this kind of pain, as are ballet and clog dancers.

Lateral column pain refers to pain on the lateral (outside) of the foot. The problems are centered in an area made up of the fourth and fifth metatarsals, and the associated tarsal joints. Pain in the lateral column may involve the calcaneocuboid joint or the fourth and fifth metatarsal-cuboid joints. As with so many areas in the foot, the problems can be very complex. I think of the foot as a clock filled with gears for movement to measure time. If one set of gears fails to function properly, the whole clock mechanism is affected. The foot is composed of 26 bones, 33 joints, and hundreds of ligaments. Just like the clock, there are a lot of gears interacting.

Symptoms include pain on weight bearing in the area of the base of the fifth metatarsal, but more on the top of the foot. If you draw an imaginary line back from your fifth toe, on the side of the foot, you will find a boney prominence. At this point travel up about one inch onto the top of the foot. This roughly locates the cuboid/metatarsal joints and is basically at the epicenter of the lateral column.

Causes of Lateral Column Dysfunction
The short list includes arthritis, biomechanical abnormalities resulting in chronic plantar fasciitis, fracture (including stress fracture), overuse, tendonitis, and ankle sprains.

• Osteoarthritis is very common of the base of the fourth and fifth metatarsals, the lateral cuneiform, and the cuboid bone. Trauma is thought to be the cause of arthritis, but in this joint, it may be the trauma of overuse secondary to hyperpronation. Hyperpronation affects 85 percent of the population and can be easily treated.
• Stress fracture of the cuboid bone is not a common injury, but in the running athlete’s foot that is hyperpronating, the pressures mount rapidly and the cuboid can fracture. This is a very elusive injury. The best examination to establish a diagnosis of stress fracture of the cuboid is the MRI. Symptoms of lateral column pain secondary to cuboid fracture will have an acute onset; they will subside with rest and exacerbate with activity.
• Inversion ankle sprain may result in lateral column syndrome by causing a disruption of the complex cuboid/metatarsal joint with a minor dislocation of the joint called subluxation. Symptoms are often nonspecific, but will usually be excited with activity. Diagnosis is also very difficult, and though the MRI may be useful, it is best that a detailed history and clinical exam be performed.
• An often overlooked cause is chronic tendonitis and associated dysfunction of the peroneus longus and brevis tendons. This can cause joint stress in the lateral column and may result in pain and joint inflammation called capsulitis. The peroneal tendons pass through a notch in the heel bone and are held in place by a strong ligament, but a ligament subject to injury in a lateral ankle sprain. The ligament tears, causing the tendons to separate from the notch and this will result in tendonitis, stiffness, and pain. Even walking becomes difficult. The sufferer will compensate with altered gait patterns that can put stress on the lateral column.
• A common complication of surgery to the plantar fascia can affect the lateral column. The plantar fascia is made up of three distinct bands. Surgery for recalcitrant plantar fasciitis must be limited to the medial two bands to prevent a destabilizing of the lateral column. When this surgical complication occurs, it will result in increased stress on the tarsal-metatarsal joints within the lateral column and result in pain.

Establishing a Diagnosis
A detailed clinical history of the injury processes and a thorough examination are imperative. Very important information that will help your provider establish a diagnosis includes the symptom onset and complexity. Did these symptoms begin suddenly or gradually? Does pain intensify with activity or subside? A sudden onset often results in bone or joint pathology. If pain subsides with activity and returns after rest, I would be thinking of tendon pathologies. X-rays are the first most important imaging process that should be completed. MRI combined with X-ray usually is necessary to completely establish a diagnosis and treatment plan.

Treatment
Lateral column pain often responds to a treatment plan that includes rest, control of faulty biomechanics, occasionally injection therapy, and casting. Early identification and treatment usually result in an excellent outcome and early return to sport.