Lateral Column Compression Syndrome - PowerPoint Presentation

Slide1

Lateral Column Compression Syndrome

Slide2

Cuboid Syndrome

A minor disruption or subluxation

of the structural congruity of the

calcaneocuboid

joint.Poorly understoodFrequently misdiagnosed and mistreated High incident of repeat injuries

Patterson S.

Cuboid

syndrome: a review of the literature. Journal of Sports Science and Medicine (2006) 5,597-606

Slide3

Etiology

Extrinsic trauma:Isolated fractures

MOI is usually

plantarflexion

of the hindfoot and midfoot against a fixed forefoot“Nutcracker fracture”Plantar flexion/inversion sprains

Greaney

RB, Gerber FH, Laughlin RL, et al (1983)

Distribu- tion and natural history of stress fractures in US marine re-

cruits. Radiology 146:339–346

Slide4

Etiology

Intrinsic traumaRepeated

microtrauma

injuries

Yu et al. retrospective study: incidence of cuboid stress fractures in the 4% range over a 19 year periodReported hypotheses on the causes of cuboid

stress fractures: Repeated pull of peroneus

tendons Malalignment and altered biomechanics

Insufficiency fractures from loss of bone density Overpronation Calf muscle inflexibility

Yale J (1976) A statistical analysis of 3,657 consecutive fatigue fractures of the distal lower extremities. J Am

Podiatr

Assoc 66:739–748

Yu S et al. MRI of isolated

cuboid

stress fractures in adults. AJR: 201, 2013

Slide5

Prevalence

Reported incidence of

cuboid

fractures: 4% of all foot problems in athletes 17% of foot or ankle injuries in ballet dancers

7% in patients following inversion ankle sprains

Newell SG, Woodle

A. Cuboid syndrome. Phys Sports Med. 1981;9:71-76. Marshall P and Hamilton WG. Cuboid

subluxation in ballet dancers. The American Journal of Sports Medicine Vol 20 No 2 1992Patterson S. Cuboid

syndrome: a review of the literature. Journal of Sports Science and Medicine (2006) 5,597-606

Slide6

Predisposing Factors

Reported predisposing factors: Mid-tarsal

hypermobility

Changes in exercise intensity, frequency and duration

Training on uneven surfaces

Overpronation of the foot

Durall, C. Examination and treatment of

cuboid syndrome: a literature review. Sports Health Vol 3 No 6 2011

Slide7

Differential Diagnosis

Tarsal coalition Stress fracture 5

th

metatarsal

Peroneal tendon subluxation

Peroneal tendonopathy

Anterior

calcaneal process fracture

Slide8

Imaging

MRI and technetium

bonescan

are considered the gold standard imaging tools to identify fractures and bone stress injuries.

I

maging has little value in the diagnosis of “

cuboid

syndrome” since bony anomalies are common in the midfoot and joint dysfunctions are, as a rule, undetectable on imaging .

Slide9

Treatment

Reported treatments include:

Joint manipulation

Low grade mobilizations

Taping Orthotics, including a cuboid

pad Graded load bearing activities

Slide10

Matthews LG and Claus AP. Two examples of “

cuboid

syndrome” with active bone pathology: why did manual therapy help? Manual Therapy 19 (2014) 494-498

Case Study

Matthew and Clause (2014) identified bone pathology with

cuboid

dysfunction

Insidious onset of the bone pathology inferred to as a systemic problem, contributing to the chemical stimulus for

nociception

and of sensitization of the nervous system.

Conclusion

: No direct link between

cuboid

dysfunction and the bone pathology.

Slide11

Current Treatment Approaches

Fixes the symptoms, not the underlying movement impairment

I

nsufficient knowledge of pathophysiology and

arthrokinematics

to explain the occurrence of

cuboid dysfunctions and stress fractures

Similar situation to treatment of SIJ dysfunctions until 20 years agoA different frame of reference is needed to fix the cause of the cause of cuboid dysfunctions

Slide12

Lateral Column Compression Syndrome

Bone pathology and

cuboid

dysfunction are not separate entities, but are in fact closely related.

Causal factor of both bone stress and joint dysfunction can be explained by a movement impairment syndrome: “lateral column compression syndrome.”

Slide13

Lateral Column Compression

Collection of signs and symptoms that occurs when the patient is not able to sufficiently stabilize the foot in standing.

The foot is not able to absorb normal loading during

weightbearing

.

The midfoot overpronates, and the forefoot ends up in a

valgus position.

Slide14

Lateral Column Compression

Causes the medial column of the foot to elongate and the lateral column to compress.

C

uboid then gets caught between the hammer (calcaneus) and anvil (MT4-5) during normal weight bearing

Subsequently, drops down in dysfunction (“dropped cuboid

”) or sustains a stress fracture

Slide15

Contributing Factors

Multitude of factors contribute to developing lateral column compression

Each factor needs to be evaluated to determine the cause of the syndrome

Contributing Factors:

Anterior glide/medial rotation of the femurGenu valgus – increased Q angle

Loss of talocrural extensionSoft tissue restrictions in distal calf muscle

Poor mid and hindfoot strengthPoor calf strength

Poor structural stability of the foot

Image from http://

valleyorthocare.ca

/

Slide16

Lateral Column Compression

U

nderlying movement impairment syndrome that drives many seemingly unrelated foot and ankle overuse injuries including:

Joint dysfunction medial cuneiform/MT 1

Lateral impingement of the

calcaneus

Achilles

tendinopathy

Plantar fasciopathy

Medial

tibial

stress syndrome

Tarsal tunnel syndrome

J

ust wait to see where the weakest link in that particular patient’s body is, and that is where the breakdown will occur.

Slide17

Lateral Column Compression

Slide18

Hindfoot/midfoot Neutral

Slide19

Patient’s Preferred Posture

Slide20

Hindfoot/midfoot Neutral

Slide21

Patient’s Preferred Posture

Slide22

Patient’s Preferred Posture

Slide23

Hindfoot/midfoot Neutral

Slide24

Hindfoot Mechanics

Key players

:

The

hindfootNeed 15-20 degrees of ankle extension for running and walkingThe body will have to find a different way to bring the body weight forward during the gait cycle if TC extension is limitedCompensatory tibial internal rotation,

calcaneal eversion

and midfoot pronation

occurs, causing lateral column compression. Image from http://lermagazine.com/

Slide25

Hindfoot Mechanics

Foot needs to be able to transition from a torque converter during stance phase to a rigid lever during toe off during gait

Main driver: Subtalar joint

C

alcaneus everts during heelstrike, unlocking the

midtarsal joints Foot becomes a torque converterCalcaneus

inverts during toe off, locking the midtarsal

jointsFoot becomes a solid lever necessary for efficient toe offImage from http://sportalignment.com/en/running.html

Slide26

Hindfoot Mechanics

Subtalar joint in dysfunction:Unable to convert from

eversion

to inversion

Midtarsal joints will stay unlockedDrives foot in midfoot overpronation/forefoot abduction during toe off

Slide27

Assessment

Things to consider during assessment:Standing posture

Single

leg

stanceSingle leg stance ¼ squatTarsal

mobility testing: TC joint, subtalar joint, midtarsal

jointsMMT: gastrocnemius,

soleus, FDL, FDB, lumbricals/interosseiImage from http://www.sicfit.com

Slide28

Treatment

Joint manipulation:Restore proper joint function in affected joints

A

llows for restoration of normal hind/midfoot mechanics

Subtalar Joint

TC Joint

Cuboid

TC Joint

Slide29

Therapeutic Exercises

The patient needs to be taught to find subtalar

/midfoot neutral

Superimpose LE/trunk activities

Similar to rehab principles in low back pain patientsTeach them to find lumbar spine neutral, superimpose UE/LE activities to increase degree of difficulty

Image from http://commons.wikimedia.org/wiki/File:Ankle_Pronation_Position.png

Slide30

Therapeutic Exercises

Towel crunches Stretching Heel raises

Single leg presses/curls kickback

Golfer’s Squat

Standing TKE

Stagger Stance

Slide31

References

Mazerolle, S. (2007).

Cuboid

syndrome in a college basketball player: a case report.

Athletic Therapy Today, 12(6):9-11.Durall, C. (2011). Examination and treatment of cuboid syndrome: a literature review.

Sports Health, 3(6):514-519.Jennings J, Davies G.(2005). Treatment of cuboid

syndrome secondary to lateral ankle sprains: a case series. Journal of Orthopedic and Sports Physical Therapy, 35(7):409-415.

Newell SG, Woodle A. (1981). Cuboid syndrome. Phys Sports Medicine. 9:71-76. Marshall P, Hamilton W. ((1992).

Cuboid subluxation in ballet dancers. The American Journal of Sports Medicine, 20(2):179-175 Matthews LG, Claus AP. (2014). Two examples of “

cuboid

syndrome” with active bone pathology: why did manual therapy help?

Manual Therapy,

19:494-498

Patterson S. (2006).

Cuboid

syndrome: a review of the literature.

Journal of Sports Science and Medicine

, 5:597-606

Miller T, Pavlov H, Gupta M, Schultz E,

Greben C. (2002). Isolated injury of the

cuboid bone. Emergency Radiology, 9:272-277Yu S, Dardani M, Yu S. (2013). MRI of isolated

cuboid

stress fractures in adults.

AJR

, 201:1325-1330.