Calcaneocuboid joint capsule tear

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Had a patient yesterday whose ultrasound scan suggests an unusual injury.

FINDINGS There is a significant effusion of the lateral aspect of the transverse tarsal joint. There is a small amount of fluid in the tendon sheath of peroneus brevis. There is visibility of the joint capsule which appears to have been stripped off the bone at the calcaneocuboid joint, but no definite avulsion fracture is associated.​

XR showed soft tissue swelling only.

She's a 27 year old recreational netball player of quite high BMI (approx. 35) no meds, no chronic conditions.
She doesn't recall any trauma on either occasion and has no history of inversion sprains. She's had two painful episodes, one last September and one in December. On the most recent occurrence she had played netball as usual without incident then the following morning was getting into a car and heard a pop from her foot and had ongoing pain from then.

Mechanically she has genu and tibial valgum and a foot posture index of about 4. She'd also previously been provided with some neutral prefab orthotics which had then been modified by a podiatrist with some rear foot varus wedging. Obviously all this together with her weight would combine to generate some fairly high peroneal tendon loads.

There's a few things I'm wondering;

1) would we expect the cuboid to displace sufficiently to strip the joint capsule without there having been a severe inversion injury?
2) What's the natural progression of this kind of injury to a joint capsule likely to be, self resolution? rapid progression to DJD?
3) anyone managed a similar injury previously?
​

thanks
Ben

 

I can't speak from any experience on this, but seeing more and more of these types of unusual problems with the sensitivity of diagnostic ultrasound.

All I can suggest is go back to basics: what motion make it hurt --> are there any strapping or orthotic design features that can stop that motion?

 

If this is the case, it would be very rare, especially with no significant trauma. All scans are useful to aid with diagnosis but it is important to remember that that they interpretation is the opinion of the radiologist. The report does not indicate where on the joint the damage has occurred. In this instance I might be tempted to arrange an MRI but I would treat this as a capsular injury in the interim although suspect there is a degree of cuboid compression syndrome - an MR will provide more information and indicate if there is any bone oedema. There is nothing to suggest that the specific injury will cause DJD but clearly, she is loading the lateral aspect and thus this could predispose to DJD in the long term.

In the short term, I might be tempted to immobilise for 2-4 weeks for some stability and symptom relief. I find a modified low dye strapping very good for cuboid problems but, from the description of this foot, you need to reduce the medial tension. This foot type is always a challenge to manage with orthoses as one would want to try and offload the lateral border yet it is likely they are functioning towards end range given the tibial and genu valgum. What it really requires is some splinting along the lateral border to reduce motion around the cuboid articualtions and is often aided by a heel lift for any equinus component - these sorts of patients often pivot around the cuboid.

We have started experimenting with orthoses that have minimal control in terms of traditional posting but have a stiff lateral border with a flexible arch. More difficult with the standard approach to orthoses but more achievable with cad cam and certainly achievable with laser sintered orthoses - recently taken this approach with a patient with 5th MTPJ symptoms - this did also include some lateral forefoot control on the device but the results were very impressive both in terms of symptom relief and inshoe analysis.

 

Interesting case, MRI might be a great idea.

1st step would be remove the device she has, I would try some Lateral Ankle strapping with Low Dye that the " cross straps" that normally you would start laterally and pull medially, do the opposite Start medially and pull laterally. And look her shoes and make sure she is not wearing anything too laterally warn or broken down