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Competitive Sports: Section Articles

Diagnostic Considerations of Lateral Column Foot Pain in Athletes

Traister, Eric MD1; Simons, Stephen MD, FACSM2

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doi: 10.1249/JSR.0000000000000099
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According to the National Council of Youth Sports survey in 2008, over 44 million children aged 6 to 18 years participated in organized sports (26). Many of these kids continue to be active as adults. Foot injuries account for approximately 16% of all sports-related injuries across all ages (11). Therefore, it is not surprising that foot pain is a common complaint. The literature is robust with articles on foot pain. However, there is minimal literature specific to lateral column foot pain in athletes, and most of the limited literature addressing lateral column pain comes from podiatry. The cause of this type of pain is not always straightforward. In order to make an accurate diagnosis, one must first understand the anatomy and basic biomechanics of the lateral column. Second, one should take a detailed history that includes the age of the athlete, mechanism of injury, and sport activity. Finally, a focused physical examination and imaging, if appropriate, also aid in making an accurate diagnosis and initiating a treatment plan. This article will discuss lateral column foot pain in athletes.


Understanding anatomy and biomechanics is fundamental in diagnosing the etiology of lateral foot pain. This discussion will provide basic anatomy and biomechanical knowledge of the lateral column. The lateral column consists of the calcaneus, cuboid, fourth and fifth metatarsal, fourth and fifth phalanges, and the associated soft tissue.

The calcaneus is the largest tarsal bone. This bone adapted to accommodate considerable ground reaction forces as our ancestors acquired an obligate bipedal gait. It has an anterior facet that articulates with the cuboid and three superior facets articulating with the talus. Strong ligamentous connections traverse the talocalcaneal joints. One clinically important soft tissue connection is the bifurcate ligament. Also known as the “Y” ligament, this structure consists of calcaneocuboid and calcaneonavicular portions, and injury to the ligament is a frequently overlooked cause of traumatic lateral foot pain.

The cuboid is the cornerstone of the lateral column. Even though it is not a weight-bearing bone, it experiences compressive forces from the adjacent bones. The cuboid articulates proximally with the calcaneus, medially with the lateral cuneiform, and distally with the fourth and fifth metatarsals. The peroneal sulcus provides a groove on the lateral aspect of the cuboid through which the peroneus longus passes en route to the first metatarsal. This effectively uses the cuboid as a pulley for peroneus longus function.

The fourth and fifth metatarsals articulate with their respective phalanges. The fifth metatarsal has more mobility than the middle lesser metatarsals. The fifth metatarsal base projects a prominent proximal lateral tuberosity for peroneus brevis and tertius attachment.

In a normal weight-bearing foot, the subtalar joint is in neutral while the calcaneal plantar condyles and the metatarsal heads lie in the same plane. Uncompensated hindfoot varus, forefoot equinus, and a rigid plantarflexed first ray can all increase loads on the lateral column. During hindfoot varus, the subtalar joint compensates by pronating to maintain a “neutral” position. Uncompensated hindfoot varus caused by a tarsal coalition or kinetic chain timing issues will increase the load on the lateral column. Forefoot equinus increases dorsiflexion at the ankle during weight bearing. This position creates a rigid and plantar flexed first ray relative to the hindfoot increasing the load on the lateral column. It is important to recognize abnormal foot structure and compensatory mechanisms to determine abnormal loading patterns.

Calcaneus Problems

This article will focus on more common calcaneal fractures and their ligamentous involvement with the calcaneus. A comprehensive review of calcaneal injuries is beyond the scope of this article.

Calcaneal fractures can be divided into stress, intra-articular, and anterior process fractures.

Stress fractures

Calcaneal stress fractures are well documented in military recruits and long-distance runners (29). Patients present with insidious onset of poorly defined heel pain. The pain is initially intermittent with weight-bearing exercise and then worsens with increased activity. Clinical features that help distinguish calcaneal stress fractures from the more prevalent plantar fasciitis include pain that is diffuse and not focused on the plantar or posterior heel and pain that worsens with increased activity. Plantar fascia pain is most often worse on the first steps and then improves with walking. Examination is not specific, but a medial to lateral calcaneal squeeze is more likely tender than the focused plantar tenderness of plantar fasciitis. In addition, a single-leg hop test that reproduces calcaneus pain in the affected foot is suspicious of injury. If there is suspicion of calcaneal stress fracture, radiographs are indicated initially. The lateral view may reveal a sclerotic line obliquely oriented from the posterosuperior aspect of the calcaneus projecting inferior to anterior and perpendicular to the trabecular lines. However, radiographs are often normal. If there is sufficient clinical suspicion, magnetic resonance imaging (MRI) can confirm the diagnosis.

These results should be correlated with the history and physical examination since it is common for younger athletes to have asymptomatic bone marrow edema on MRI. In 1997, Lazzarini et al. (17) showed that 16 out of 20 asymptomatic runners had bone marrow edema on foot and ankle MRI. Once a diagnosis of calcaneal stress fracture is confirmed, return to activity is variable. In 1995, Fredericson et al. (10) suggested a graded classification system based on MRI. Activity recommendations were based on this MRI grade. However this study focused on tibial stress fractures. More recently in 2013, Nattiv et al. (27) prospectively studied 211 male and female track-and-field athletes at a Division 1 university. They showed that a modified Fredericson grading system, bone mineral density, and location of stress fracture sites all correlated with the time of return to activity. However, there was only one calcaneal stress fracture in their series. These grading symptoms help guide patient care, but in general, modified weight bearing, heel inserts, and restricted activity for 4 to 6 wk are needed before return to activity.

Intra-articular fractures

The calcaneus is the most commonly fractured tarsal bone, making up 1% to 2% of all fractures. Approximately 70% to 75% of these are intra-articular (5). These fractures present as acute traumatic events, usually from a high axial load to the hindfoot, such as a fall from height. Clinicians should have a high suspicion for concomitant spinal compression fractures due to the mechanism. Patients will complain of heel pain and have a positive calcaneal squeeze test. The Mondor sign, commonly seen with intra-articular calcaneal fractures, is a plantar ecchymosis that tracks distally to the sole of the foot (34). A thorough neurovascular examination should be performed with all calcaneal fractures as acute compartment syndrome of the foot can occur and is a surgical emergency. Initial radiographs may be normal and should be followed by computed tomography (CT) scan if there is suspicion of a calcaneal fracture. MRI should be considered also if the foot is unstable. Intra-articular fractures are associated with potential poor long-term outcomes for pain and function regardless of nonoperative or operative approach (7). Therefore prompt recognition of these fractures, followed by referral to a surgeon experienced with such injuries, is paramount.

Anterior process fracture

The literature describes two mechanisms for calcaneal anterior process fractures, which are a frequently overlooked source of traumatic lateral foot pain. An inversion injury to a plantarflexed foot can produce an avulsion fracture to the tip of the anterior process by traction from the bifurcate ligament. The second mechanism is an eversion abduction force on the foot that produces a compression force across the calcaneus (6). Patients will complain often of pain similar to a lateral ankle sprain. However maximum tenderness will typically occur 1 to 2 cm more distally in the region of the sinus tarsi or over the calcaneocuboid joint. The experienced clinician will recognize the swelling pattern, focal and isolated from the lateral malleolus, that is typically seen in lateral ankle sprains. Radiographs can be helpful but are often normal. A CT scan and MRI are helpful if there is a strong suspicion of calcaneal fracture if x-ray is unrevealing. Acute nondisplaced (<2 mm) small fractures can be treated conservatively with 4 to 6 wk of immobilization in a protected walking boot or cast followed by gradual return to activity. Surgery should be considered for fractures that are displaced or present with any joint instability (31).

Cuboid Problems

Cuboid syndrome

Cuboid syndrome appears in the literature by various names: subluxed cuboid, locked cuboid, dropped cuboid, peroneal cuboid syndrome, cuboid fault syndrome, and lateral plantar neuritis. The precise mechanism of injury is poorly understood. There is no definitive diagnostic test. Therefore it is not surprising that the true incidence of cuboid syndrome is unknown and misdiagnosis may be common.

The pathomechanical origin of cuboid syndrome is thought due to a disruption of the calcaneocuboid joint, specifically injury to the calcaneocuboid portion of the bifurcate ligament leading to pain and potential instability (4). This disruption may occur insidiously by repetitive stress to the ligament or acutely from a traumatic event. Although a precise mechanism is unknown, repetitive plantarflexion and inversion ankle injuries are cited commonly as potential causes. In 1992, Marshall and Hamilton (24) reported that the cuboid was involved in 17% of all ankle and foot injuries in the American Ballet Theatre. The majority of these injuries occurred in female dancers performing demi-pointe or en pointe work. Jennings (15) reports prevalence closer to 5% in the athletic population.

Cuboid syndrome clinically can appear quite variably. Patients can present with localized pain over the cuboid, especially on the plantar aspect, but often present with generalized lateral foot pain. A subluxated cuboid may present with a slight depression over the dorsum of the cuboid, plantar cuboid prominence, and less commonly erythema, edema, or ecchymosis, if more significant trauma occurred. There may be tenderness over plantar calcaneus and the peroneus longus as it wraps around the lateral plantar aspect of the cuboid. An antalgic gait with or without pain with resisted plantarflexion and foot eversion is common. Two clinical maneuvers are described to aid the diagnosis. The midtarsal adduction test is performed by stabilizing the calcaneus with one hand and then applying a medially directed force to the forefoot with the other hand (Fig. 1). This maneuver distracts the lateral side and compresses the medial aspect of the calcaneocuboid joint. The second maneuver is the midtarsal supination test (Fig. 2). One hand stabilizes the calcaneus and the other hand inverts and plantar flexes at the midtarsal joint (15). Pain and instability constitutes a positive test; however, neither test has been validated in the literature.

Figure 1:
The midtarsal adduction test is performed by stabilizing the calcaneus with one hand and then applying a medially directed force to the forefoot with the other hand.
Figure 2:
The midtarsal supination test is performed by stabilizing the calcaneus with one hand while the other hand inverts and plantar flexes at the midtarsal joint.

Cuboid syndrome is a clinical diagnosis as there are no validated diagnostic tests. However, stress radiographs may be helpful in testing the stability of the calcaneocuboid joint by applying an adduction force to the forefoot that may cause gapping to an unstable calcaneocuboid joint. Andermahr et al. (2) reported that a calcaneocuboid gap greater than 10° may indicate a more significant injury. Furthermore, Leland et al. (21) reported in a group of 25 volunteers with no previous foot problems that the mean calcaneocuboid gap was 3.9 mm for the unstressed joint and 5.5 mm when stressed. The calcaneocuboid angles were 4.8° for the unstressed and opened to 9.7° when stressed. Subsequently Lohrer et al. (23), testing interobserver and intraobserver reliability, reported that calcaneocuboid angular measurements are not reliable but distance measurements are. Therefore while these measurements may be helpful in the diagnosis of cuboid instability, it remains unclear as to the proper application in the clinic setting. CT scan and MRI should be used to rule out fractures, dislocations, and injury to adjacent structures. Ultrasound is a newer technology that may aid in the evaluation of cuboid instability and surrounding ligamentous injury. In a case report, Adams and Madden (1) used diagnostic ultrasound to quantify the calcaneocuboid joint space in a suspected cuboid subluxation. While ultrasound has potential, it is unproven and is highly user dependent.

Treatment consists of pain management, relative rest, modified activity, potential immobilization, physical therapy, external dynamic support, and manipulation. Manipulation is appropriate if pain allows and there is no significant bruising. Two techniques are described commonly as follows: the cuboid whip and the cuboid squeeze. Patients may need multiple manipulations, but when manipulations are successful, have reported significant pain relief. After manipulation, patients may need padding to support the plantar cuboid and external taping to support the medial longitudinal arch (15). Time to recovery is variable and is based on the patient’s ability to perform pain-free activity.

Cuboid Fractures

Cuboid fractures are rare. They can occur as stress, avulsion, compression, or os peroneum fractures. They can have an insidious or acute onset. These fractures are commonly mistaken as lateral ankle sprains; thus, clinicians should have a high suspicion for cuboid etiology in lateral foot pain.

Stress fractures

Stress fractures usually present insidiously after introducing new shoes or training change. Because the cuboid is a non–weight-bearing bone, the “stress” likely comes from the peroneus longus using the cuboid as a pulley during plantarflexion and eversion. A second cause of lateral column and cuboid stress may involve pes planus and overpronation. Pain perception most commonly will be directed to the cuboid but may be felt vaguely in the cuboid or surrounding lateral midfoot. Inspection reveals localized edema, discoloration, and an antalgic gait. Precisely directed palpation over the cuboid will usually elicit tenderness, but this lacks specificity.

Radiographs are usually normal and thereby insensitive to diagnose these stress fractures. However x-rays can help rule out overt fractures and an os peroneum (discussed later). MRI, CT, or bone scan can be considered if cuboid pathology is suspected or if a patient is not improving with conservative management. MRI has several advantages since it does not expose the patient to radiation, is noninvasive, and gives additional information on soft tissue structures. Spitz et al. (43) reported that MRI, similar to bone scans, showed stress-related changes in bones several weeks earlier than radiographs. CT scans can be used to better characterize fractures if bone changes are seen on MRI or if surgery is indicated, but CT scans are often unnecessary as these are unlikely to change management.

Treatment consists of pain management, relative rest, and modified activity. A protective boot, with weight bearing as tolerated, should start upon diagnosis. Arch support should be added to the cast boot as most boots have a flat insole. Sometimes a cuboid pad or taping may be utilized additionally for symptom control. Recovery time is variable. A slow, gradual return to activity is started once the patient is able to perform activities of daily living pain free in normal shoes for 2 wk. However, patients should be advised to pay close attention to any recurring pain symptoms as longer rest may be needed.

Avulsion/compression fractures

Avulsion and compression fractures are acute injuries. Avulsion fractures typically present after an inversion/adduction injury or a sudden change in direction. In this injury, the calcaneocuboid capsule and plantar calcaneocuboid ligament are torn. The fracture piece comes from the plantar posterior cuboid (30). In 1953, Hermel and Gershon-Cohen (13) described the “nutcracker fracture” as a fracture occurring from compressive forces applied to the cuboid from the calcaneus and fourth and fifth metatarsal. This fracture typically occurs during forced eversion/abduction on a plantar flexed foot. A forced forefoot adduction on a supinated foot is another proposed mechanism for compression fracture. Following injury, patients will present with lateral foot pain, swelling, possible bruising, and pain, especially with push off. If the calcaneocuboid joint is unstable, the diagnostic maneuvers described in the cuboid subluxation section may illicit pain.

Imaging should begin with radiographs. The cuboid is best evaluated on the oblique view, but avulsion fractures also may be seen on the lateral view. However, radiographs are often normal. MRI is recommended next as many cuboid fractures result in instability due to ligamentous disruption.

Treatment varies based on the degree of fracture. For stable minimally displaced fractures, the same conservative treatment used for cuboid stress fractures can be used. Avulsion fractures often result in a fibrous nonunion. Excisional surgery may be indicated for recalcitrant pain (30). Misdiagnosed tarsometatarsal injuries, especially if unstable, can have long-term consequences, such as lateral column shortening. Therefore it is imperative that proper imaging and a surgical consultation is utilized if the diagnosis or treatment is in question.

Os peroneum syndrome

The os peroneum is an accessory bone that is found within the peroneus longus tendon adjacent to the lateral plantar aspect of the cuboid. It is present in 5% to 26% of the population (16,22). As with other accessory bones, the majority of these are asymptomatic. However they can cause lateral foot pain. In 1995, Sobel et al. (42) first characterized painful os peroneum syndrome as a spectrum of conditions attributed to an os peroneum causing discontinuity within the peroneus longus tendon. This syndrome is caused by stress fracture, overt fracture, or diastasis of a multipartite os peroneum.

Patients can present with chronic or acute pain over the lateral foot. In the acute presentation, the patient will typically describe an inversion or supination ankle injury. Chronic cases often present with no inciting event but appear after repetitive actions. Physical examination will reveal pain over the lateral plantar aspect of the cuboid. Ecchymosis and swelling may be present. Resisted foot eversion should elicit pain.

On radiographs, an os peroneum can display a wide range of sizes. It usually has rounded edges and is best seen on a medial oblique view. A rare bipartite os peroneum can be mistaken for a fracture. If clinically necessary, further imaging by bone scan, CT scan, MRI, or diagnostic ultrasound can be considered. The latter two modalities can help characterize the integrity of peroneus longus tendon.

Treatment includes nonoperative and operative approaches. Nonoperative treatment includes some level of rest, icing, bracing, and corticosteroid injections if not fractured. A cast boot with arch support may be utilized if symptomatic with walking. A case report by Smith et al. (41) reported successful nonoperative treatment in a professional tennis player who sustained a minimally displaced os peroneum fracture. This patient was non-weight bearing for 2 wk followed by gradual return to activity and resumption of tennis by 8 wk. If conservative treatment fails or if there is significant displacement of the os peroneum fracture, surgical excision/treatment may be necessary.

Fourth Metatarsal

Stress fractures

The incidence of metatarsal stress fractures is second only to tibial stress fractures in athletes. Stress fractures of the second, third, and fourth metatarsals make up 90% of metatarsal stress fractures (28). Patients normally will present with poorly defined forefoot pain. The pain is initially intermittent and then worsens with increasing activity. This presentation most commonly occurs a few weeks following a training change (25). Inspection of the forefoot reveals sometimes focal, but more often diffuse, dorsal, forefoot swelling. Subtle swelling can be appreciated by noting less distinct extensor tendon appearance of the affected foot compared to the normal foot during active toe dorsiflexion. A midshaft stress fracture is usually distinguishable with focal tenderness, but adjacent soft tissue tenderness is often present with proximal and distal stress fractures. Axial loading of the metatarsal is done by applying an in-line force to the metatarsal from the end of the bone. Pain with this maneuver eliminates the soft tissue tenderness and may be more specific for bone-related pain. Fulcrum testing, by applying a plantarflexion force to the metatarsophalangeal (MTP) joint while using the long finger as a fulcrum under the shaft of the metatarsal, is another technique. Radiographs often will be normal for 3 to 6 wk after symptom onset. If clinically necessary, MRI or bone scan can be used to confirm a stress fracture. Ultrasound also may reveal dorsal cortical disruption with certain fractures.

Stress fractures in the second and third metatarsals typically take 4 to 6 wk before return to activity. Treatment includes activity restriction, modified weight bearing, a rigid shoe plate, and possibly a walking boot with arch support. Over the past decade, there is increasing concern that proximal fourth metatarsal fractures have potential for delayed healing and nonunion similar to proximal fifth metatarsal fractures. Several case series demonstrating prolonged recovery, 2 to 9 months, have been published (14,37,40).

In 2013, Rongstad et al. (36) reported on 11 patients who presented with acute proximal fourth metatarsal stress fractures or evidence of a nonunion in the proximal fourth metatarsal. All underwent calcaneal bone autograft at the nonunion site with plate placement on the dorsolateral surface. All of the athletes were able to return to sport between 10 and 20 wk, with 7 out of 11 patients returning at 13 wk. All athletes reported they would opt for the same treatment again. Despite these studies, the literature does not provide clear evidence for best management of these fractures. Clinicians should advise patients of the potential for delayed healing and nonunion so treatment options can be discussed.

Fifth Metatarsal

The literature on fifth metatarsal injuries is robust. The majority of this literature focuses on fractures. Relevant to clinically important injuries, the proximal third of the fifth metatarsal is divided into three zones. Zone 1 is the most proximal and encompasses the tuberosity and styloid process. Avulsion fractures occur here. Zone 2 at the metaphyseal–diaphyseal junction is the site of Jones fractures. The poor blood supply in this zone contributes to the potential for delayed healing or nonunion. Zone 3 contains the proximal diaphyseal shaft of the fifth metatarsal and has a poorer blood supply and less healing potential than zone 2 as supply is proximal. Identifying the zone of injury helps guide management.

Avulsion fracture

Avulsion fractures are misdiagnosed commonly as Jones fractures. However avulsion fractures occur more proximally at the tuberosity or styloid process. The peroneus brevis and lateral band of the plantar aponeurosis is attached here. These injuries typically occur with an acute inversion injury. Patients will present with bruising and discomfort at the base of the fifth metatarsal. Radiographs are usually sufficient to make the diagnosis. Most avulsion fractures can be treated symptomatically with progressive protected weight bearing, sometimes requiring a short walking boot for 2 to 4 wk. In 2013, Shahid et al. (39) treated 23 acute avulsion fractures with either a short leg cast or with a walking boot. The walking boot group returned to activity in 9 wk, whereas the short leg cast group returned to activity at 12 wk. Uncommonly these fractures can continue to be a source of pain for patients because of nonunion. Ritchie et al. (35) reported on six elite athletes with fracture nonunion who went on to have excision of the avulsed fragment. All returned to sport with no complications within 12 wk.

Jones fracture

Fractures of the proximal fifth metatarsal at the metaphyseal–diaphyseal junction are well documented. This location is a “watershed area.” The poor blood supply on the tension-side location of the fracture is the main contributor for potential delayed healing or nonunion. Jones fractures typically present after an acute event, but many patients report antecedent lateral foot pain prior to the fracture, likely indicating micro-traumatic injury preceding macrotrauma. Tenderness, bruising, and swelling will be present at the base of the proximal fifth metatarsal. Radiographs will confirm the diagnosis. Operative versus nonoperative management is possible. Nonoperative management involved prolonged casting (2 to 3 months) with graduation to a walking cast boot over a few month period. However, due to high nonunion rates, refracture rates, and delayed return to activities, surgical fixation is generally advisable for athletic individuals. Fixation should be accomplished with the largest intramedullary cannulated screw possible to reduce refracture rate.

Recently, additional anatomic conditions are proposed to affect Jones fracture healing. Raikin et al. (32) proposed that hindfoot varus could lead to greater fracture risk and ultimate treatment failure because this alignment overloads the lateral column of the foot. In their study, 16 out of 21 Jones fractures treated operatively had a clinical hindfoot varus and 18 had radiographic hindfoot varus. All of the Jones fractures were treated postoperatively with orthotics to correct alignment. Mean follow-up was 49 months, and there was 100% union rate with full return to activity and no refractures. Other observed anatomic factors thought to predispose Jones fracture include the following: a prominent tuberosity, increased calcaneal pitch, and increased curvature of the fifth metatarsal (18,19).

In 2011, Lee et al. (20) proposed that a plantar gap at the proximal fifth metatarsal site could provide prognostic clues to healing propensity. The plantar gap is defined as the widest distance between the fracture margins as best seen on the oblique view radiographs. They found that a plantar gap greater than 1 mm significantly increased average union time of the fracture. This gap measurement was independent of the Torg classification. For a plantar gap less than 1 mm, the average union time was 71 d and 126 d for a plantar gap greater than 1 mm. Union was determined by visualization of callous on CT scan. None of the above studies have been validated and should be used with caution to help guide the treatment process with the athlete.

Zone 3 fractures

Fractures in the distal metaphysis and proximal 1.5 cm of the diaphysis occur in zone 3. The zone is located immediately distal to the strong ligamentous attachments between the fourth and fifth metatarsal. These strong ligamentous attachments help prevent dislocation at this articulation but consequently transfer lateral bending forces to zone 3. Pain in this zone is frequently due to a stress fracture (9). Radiographs are often negative. MRI is useful when radiographs are negative. Treatment is dependent on the activity level of the patient. This zone has the poorest blood supply of the three zones and the poorest healing potential. Surgical fixation should be considered for active patients who participate in cutting sports. For less active patients, conservative management consists of metatarsal functional bracing, modified weight bearing, and restricted activity, but runs the risk of delayed healing and nonunion.

Shaft/spiral fracture

Fifth metatarsal spiral fractures are the most common acute fracture seen in dancers and normally occurs during an inversion injury from dancing en pointe (38). Radiographs will confirm the diagnosis. These fractures are typically managed nonoperatively. Aynardi et al. (3) followed 142 acute oblique spiral fractures displaced less than 5 mm. All were treated with weight bearing as tolerated in a fracture boot or hard soled shoe for 6 wk. Patients were transitioned to full weight bearing as soon as pain allowed. Two patients with persistent fracture nonunion eventually required surgery. However, 140 out of 142 had excellent functional outcomes with nonoperative treatment.

Tailor’s bunion

A tailor’s bunion or bunionette is an osseous or soft tissue prominence on the lateral aspect of the fifth metatarsal head. It is caused by a combination of excessive pressure and friction between the fifth metatarsal head and footwear and chronic varus force to the fifth toe. The bunion develops gradually, and the patient may not notice it until it is symptomatic. There will be an obvious lateral MTP deformity with tenderness at the MTP joint. Erythema, tissue thickening, and adventitial bursal swelling may be present. Radiographs are rarely indicated unless surgery is contemplated. Conservative management includes modified activity and footwear (e.g., wide or punched out toe box), orthotics, donut pads, ice, and pain management. Topical NSAID may relieve swelling and pain acutely. If conservative management fails, Vienne et al. (44) published a prospective study with excellent outcomes on modified Coughlin procedures for symptomatic Tailor’s bunions.

Other considerations

The fifth metatarsal apophysis appears between ages 8 and 12 years and normally fuses by the age of 17 or 18 years (12). It is misdiagnosed commonly as a proximal fracture in pediatric patients who present with lateral foot pain. In a retrospective review, Riccardi et al. (33) found that up to 47% of x-rays in an orthopedic clinic with radiographically open apophyses were misinterpreted as proximal fifth metatarsal fractures. The apophysis is typically parallel to the metatarsal shaft along the lateral aspect of the proximal fifth metatarsal. This orientation contrasts with the usual avulsion fracture, which is oblique or transverse to the shaft. Contralateral views can be helpful to assess open apophyses. Although usually symmetric, occasionally anomalous physeal orientation may cause confusion as with this symptomatic unfused physis in a teenage soccer player (Fig. 3).

Figure 3:
Unfused proximal fifth metatarsal apophysis in an 18-yr-old soccer player.

Iselin’s disease is also specific to the pediatric population. It is a traction apophysitis that occurs in pediatric patients after repetitive traction injury. As with other apophysitis, with a sentinel event and swelling absent, Iselin’s disease can be diagnosed clinically most of the time. Radiographs are taken to confirm an open apophysis and to rule out fractures or displaced avulsion fractures. Comparison views of the asymptomatic foot are important in the evaluation of possible avulsion fractures. Modified activity, arch supports, ice, and anti-inflammatories are the mainstays of treatment. Occasionally, a cast boot is needed for a few weeks.

There are many accessory bones common to the feet. One that deserves attention is the os vesalianum, which is a lateral accessory bone proximal to the fifth metatarsal with a reported incidence of 0.1% to 0.4% (8). It usually has rounded edges and well-corticated margins differentiating it from other proximal fifth metatarsal fractures. Although usually asymptomatic, it can become painful following an acute event or repetitive overuse. Radiographically, it can be mistaken for an acute fracture much like other accessory bones.

Other diagnostic considerations for lateral column pain include peroneal tendon pathology, sinus tarsi syndrome, and tarsal coalitions. Distal peroneal pathology includes tendinitis, tenosynovitis, and partial tears. Sinus tarsi syndrome presents with pain over the anterior lateral aspect of the ankle. It often presents in patients with a history of chronic lateral ankle sprains. Tarsal coalitions commonly occur between the calcaneus and navicular or the calcaneus and talus. However, other joints may be affected and can be a common cause of lateral column foot pain.


Diagnosing the etiology of lateral column foot pain in athletes can be challenging. The clinician needs to have an understanding of anatomy and biomechanics. That knowledge, combined with a high suspicion of commonly missed diagnoses, will facilitate correct diagnosis. This is especially important in the athlete who does not respond to standard treatment. A quick and accurate diagnosis aids in reducing morbidity for the athlete and allows a safe return to activity.


1. Adams E, Madden C. Cuboid subluxation: a case study and review of the literature. Curr. Sport Med. Rep. 2009; 8: 300–7.
2. Andermahr J, Helling H, Maintz D, Monig S. The injury of the calcaneocuboid ligaments. Foot Ankle Int. 2000; 21: 379–84.
3. Aynardi M, Pedowitz DI, Saffel H, et al. Outcome of nonoperative management of displaced oblique spiral fractures of the fifth metatarsal shaft. Foot Ankle Int. 2013; 34: 1619–23.
4. Baravarian B. Diagnostic dilemmas: a guide to understanding and treating lateral column pain. Podiatry Today. 2005; 18: 100–5.
5. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. Fractures of the calcaneus. Orthop. Clin. North Am. 2002; 33: 263–85.
6. Berkowitz M, Kim D. Process and tubercle fractures of the hindfoot. J. Am. Acad. Orthop. Surg. 2005; 13: 492.
7. Buckley R, Tough S, McCormack R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized controlled multicenter trial. J. Bone Joint Surg. Am. 2002; 10: 1733–44.
8. Coskun N, Yuksel M, Cevener M, et al. Incidence of accessory ossicles and sesamoid bone in the feet: a radiographic study of the Turkish subjects. Surg. Radiol. Anat. 2009; 31: 19–24.
9. Dameron T. Fractures of the proximal fifth metatarsal: selecting the best treatment option. J. Am. Acad. Orthop. Surg. 1995; 3: 110–4.
10. Fredericson M, Bergman G, Hoffman K, et al. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am. J. Sports Med. 1995; 23: 472–81.
11. Garrick JG, Reque RK. The epidemiology of foot and ankle injuries in sports. Clin. Sports Med. 1988; 7: 29–36.
12. Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr. Sport Med. Rep. 2010; 9: 265–68.
13. Hermel MB, Gershon-Cohen J. Nutcracker fracture of the cuboid by indirect violence. Radiology. 1953; 60: 850–4.
14. Hetsroni I, Mann G, Dolev E, et al. Base of fourth metatarsal stress fracture, tendency for prolonged healing. Clin. J. Sport Med. 2005; 15: 186–8.
15. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. J. Orthop. Sports Phys. Ther. 2005; 35: 409–15.
16. Kruse RW, Chen J. Accessory bones of the foot: clinical significance. Mil. Med. 1995; 160: 464–7.
17. Lazzarini K, Troinano R, Smith R. Can running cause the appearance of bone marrow edema on MR images of the foot and ankle? Radiology. 1997; 202: 540–2.
18. Lee K, Park Y, Jegal H, et al. Factors associated with recurrent metatarsal stress fracture. Foot Ankle Int. 2013; 34: 1645–53.
19. Lee KT, Kim KC, Park YU, et al. Radiographic evaluation of foot structure following fifth metatarsal stress fracture. Foot Ankle Int. 2011; 32: 796–801.
20. Lee KT, Park YU, Young KW, Kim JS. The plantar gap. Another prognostic factor for fifth metatarsal stress fracture. Am. J. Sports Med. 2011; 39: 2206–11.
21. Leland RH, Marmount JV, Trevino SG, et al. Calcaneocuboid stability: a clinical and anatomic study. Foot Ankle Int. 2001; 22: 880–4.
22. Le Minor JM. Comparative anatomy and significance of the sesamoid bone of the peroneus longus muscle (os peroneum). J. Anat. 1987; 151: 85–9.
23. Lohrer H, Nauck T, Arentz S, Scholl J. Observer reliability in ankle and calcaneocuboid stress radiography. Am. J. Sports Med. 2008; 36: 1143–9.
24. Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. Am. J. Sports Med. 1992; 20: 169–75.
25. Montelone GP. Stress fractures in the athlete. Orthop. Clin. North Am. 1995; 26: 423.
26. National Council of Youth Sports. Report on trends and participation in organized youth sports 2008. Accessed April 15, 2014.
27. Nattiv A, Kennedy G, Barrack M, et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play. Am. J. Sports Med. 2013; 41: 1930–41.
28. O′Connor F, Wilder R. Textbook of Running Medicine. 1st ed. New York (NY): McGraw-Hill, 2001, p. 218–19.
29. Pester S, Smith P. Stress fractures in the lower extremities of soldiers in basic training. Orthop. Rev. 1992; 21: 297–303.
30. Porter DA, Schon LC. Baxter’s The Foot and Ankle In Sport. 2nd ed. Philadelphia (PA): Mosby Elsevier, 2008, p. 303–5.
31. Porter DA, Schon LC. Baxter’s The Foot and Ankle In Sport. 2nd ed. Philadelphia (PA): Mosby Elsevier, 2008, p. 100–2, 305–308.
32. Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction. Am. J. Sports Med. 2008; 36: 1367–72.
33. Riccardi G, Riccardi D, Marcarelli M, et al. Extremely proximal fractures of the fifth metatarsal in the developmental age. Foot Ankle Int. 2011; 32: 526–32.
34. Richman JD, Barre PS. The plantar ecchymosis sign in fractures of the calcaneus. Clin. Orthop. Relat. Res. 1986; 207: 122–5.
35. Ritchie JD, Shaver C, Anderson RB, et al. Excision of symptomatic nonunions of proximal fifth metatarsal avulsion fractures in elite athletes. Am. J. Sports Med. 2011; 39: 2466–9.
36. Rongstad KM, Tueting J, Rongstad M, et al. Fourth metatarsal base stress fractures in athletes: a case series. Foot Ankle Int. 2013; 34: 962–8.
37. Saxena A, Krisdakumtorn T, Erickson S. Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury. Foot Ankle Int. 2001; 22: 603–8.
38. Shah S. Caring for the dancer: special considerations for the performer and troupe. Curr. Sport Med. Rep. 2008; 7: 128–32.
39. Shahid MK, Punwar S, Boulind C, Bannister G. Aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal: a comparative cohort study. Foot Ankle Int. 2013; 34: 75–9.
40. Shearer CT, Penner Murray J. Stress fractures of the base of the fourth metatarsal: 2 cases and a review of the literature. Am. J. Sports Med. 2007; 35: 479.
41. Smith JT, Johnson AH, Heckman JD. Nonoperative treatment of an os peroneum fracture in a high-level athlete. Clin. Orthop. Relat. Res. 2011; 469: 1498–501.
42. Sobel M, Pavlov H, Geppert MJ, et al. Painful os peroneum syndrome: a syndrome of conditions responsible for plantar lateral foot pain. Foot Ankle Int. 1994; 15: 112–24.
43. Spitz D, Newberg A. Imaging of stress fractures in the athlete. Radiol. Clin. North Am. 2002; 40: 313–31.
44. Vienne P, Oesselmann M, Espinosa N, et al. Modified Coughlin procedure for surgical treatment of symptomatic tailor’s bunion: a prospective followup study of 33 consecutive operations. Foot Ankle Int. 2006; 27: 573–80.
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