Lateral Foot Pain
Feet are complex. They are made up of 26 bones, 33 tiny joints and over 100 muscles, tendons and ligaments that all act on this dextrous and mobile articulation. There is so much movement that occurs in the foot that it can sometimes be difficult to determine exactly what is going on when an injury occurs.
Similarly as with any structure that is mobile and moveable, there can also be a lot of compensation, so when you find small niggles and pains presenting, it can often be a case of ‘chasing the monkey’ to determine exactly where the origin of the issue is originating.
So when you have some pain presenting that has come ‘out of nowhere’, any amount of research and reading can lead you in an indeterminate circle of cases, symptoms and prognosis. If we look at one particular area then sometimes you can have a variety of issues that could be concurrent with pain or lack of movement.
This week I had two clients present with the same type of symptom of pain radiating along the lateral side of the foot and some issues with pain to the touch as well as bruising. With this type of pain there were three main issues that could have been presenting and it can often take x-rays or scans to completely determine which of the cases was in actual fact the presenting pain. Three of the conditions that are not as normally diagnosed as stress fracture or ligament tears can mimic the conditions and have specific pain patterns.
JONES FRACTURE
This is a fracture that can occur in the base and middle portion of the 5th metatarsal. The metatarsal is the bone that forms the length of the midfoot before extending into the toes. The Jones Fracture occurs on the outside edge of the foot and is a sudden onset injury that results from trauma or a particular landing. It is most often caused when the toes are pointed and the foot bends inward. Pain can be mild or severe owing to the severity of the fracture. Bruising may also occur but this is not always the case. A Jones fracture can appear as a stress fracture which would illicit pain in a slow onset and over time (as in the case of a runner). Recovery can take anywhere from 4 weeks to 3 months depending on the severity and the degree of the fracture.
CUBOID SYNDROME
The cuboid is a bone that lies on the lateral side of the foot proximal (closer to the ankle bone) than the 5th metatarsal. Cuboid syndrome is a partial dislocation of the alignment of the cuboid and ensuing pain in the lateral foot near the ankle. The pain can be a sudden onset or come from overuse. The pain can be worse when weight bearing and can create some difficulty walking. Hopping or landing from a jump can also become very difficult as well as in the take off phase of a leap or jump where the heel lifts and the weight transfers to the toes. It often accompanies an inversion sprain of the ankle where the alignment of the foot and ankle rolls inwardly (say in pushing to the side quickly as in a tennis or football player). Tension in the peroneus longus muscle that inserts onto the cuboid affects the cuboid alignment and can be attributed to the onset of this condition. Those with pronated feet are more likely to be affected by this condition.
PERONEAL TENDONITIS
This condition is very common amongst runners and comes from an irritation and friction of the tendons of this very important muscle on the lateral metatarsal bone (peroneus brevis) and on the medial side of the cuneiform and 1st metatarsal (peroneus longus). Both these muscles make up the peroneals and are important for stabilising the ankle in weight bearing, everting the foot and stabilising the longitudinal arch when walking. As the insertion point of the peroneus brevis is on the lateral 5th metatarsal, it can also be presenting when diagnosing Jones Fracture or Cuboid Syndrome. It is more often a slow onset issue that comes from increase in training and loading such walking, jumping and running with possible incorrect foot strike or landing technique.
Those with higher foot arches are more prone to this condition and can often occur after improper rehabilitation from an ankle sprain. Damaged tendons in the peroneals can lead to thickening of the tendons and the formation of scar tissue which ultimately leads to more tears and issues as the tendons become weaker and less pliable. The pain can also radiate along the muscles as they appear behind the lateral malleolus of the ankle. Generally if an acute onset has occurred the chances of complete recovery are higher providing a client adheres to the rehabilitation schedule and active stretching and lengthening of the affected muscles. Chronic conditions are more slow onset and indicate an adaption of the muscles and these are perhaps more difficult to rehabilitate due to the adaptive nature of poor technique or adequate strength in the foot and ankle itself. This is where adequate analysis of gait and possibly introducing specific balancing exercises and barefoot work make a huge impact on recruiting these muscles.
Retinaculum Strains
Retinaculums are like elastic bands that hold tendons in place and keep them located in their specific groove or location. We have them in articulations that require movement but need to keep tendons and muscles in place functioning correctly. The most widely known is the flexor retinaculum in the wrist that is indicated in Carpal Tunnel syndrome. The tendons for the muscles that work on the hand all pass through this canal which keeps them contained and out of the way whilst the wrist moves.
There are two structures that help to hold the tendons of the peroneals in place at the lateral malleolus (bony protusion on the outside) of the ankle, known as the Peroneal Retinaculum. They are divided into superior and inferior bands (above and below) that attach from the malleolus to the calacaneus (heel of foot). The inferior structure is an extension of the cruciate ligament of the foot that crosses the arch on the dorsal side (upper surface = think dorsal fin on a dolphin) of the foot. The Peroneal Retinaculum keeps the muscles in place and travelling posterior (behind) the bony lateral malleolus. If these muscles do ‘snap’ out of place then this is known as a peroneal sublaxation and creates instability and lack of motion in eversion as well as inability to stand on the foot.
Another term that may be referred to this structure is the annular ligament of the toes. Annular means ‘shaped like a ring’ and there are many annular ligaments in the body at the elbow, shoulder, fingers, toes and even in the trachea. It refers to the structure on a much broader level as the wide sheath that encloses the whole mid foot area in a supportive bandage.
This injury is often misdiagnosed as a lateral ankle strain/sprain. It presents similarly with eversion and weakness in the ankle but the ligaments involved are not the talofibular/calcaneofibular ligaments that act directly on the fibula and calcaneus articulation. The difference between a retinaculum and a ligament is that the retinaculum doesn’t attach bone to bone but moreso keeps tendons/muscles in place. In this instance, after recovering from the initial pain and instability of an injury, the client may still present with a ‘snapping’ ankle where weakness and inability to perform still ensues. The strain of the retinaculum requires slightly different approaches and could require surgery for re-attachment. Whilst not as severe as the ligament tear/strain the symptoms are similar and normal function of the ankle cannot be achieved without rehabilitation.
So as you can see, there are a number of different and varying components of issues that can present with lateral foot issues. Sometimes these issues can be minor and heal in 2-3 weeks, but sometimes they require more aggressive treatment, rehabilitation and care. Succinct diagnosis is always best and understanding exactly what type of injury you have can often affect how you approach your recovery. Getting the right assessment is vital and understanding the complexities of each symptom can help you to target and ultimately bounce back from an injury be it major or minor.
