Calcaneocuboid Arthritis Rx

Solution to a Challenging Diagnosis 

 Our primary goal for treating calcaneocuboid arthritis is to limit motion of the calcaneocuboid joint, and transfer pressure from the lateral column to the medial column. Here is the prescription that we recommend for calcaneocuboid arthritis following subtalar joint fusion:
 
Direct-milled polypropylene shell with polypropylene rearfoot post. We want to ensure that we use a rearfoot post that will not compress laterally. Over time EVA will compress laterally, and likely increase pressure on the lateral column. The polypropylene will never compress. We will use a flat (0/0) post to encourage rapid pronation at heel contact to help keep the patient off of the lateral column.

Standard heel cup
. Since he has had a subtalar joint fusion, we do not need to worry about limiting subtalar joint motion. In this situation, the heel cup really does not play much of a role. So, a standard or even shallow heel cup would be fine.

Wide width
. We want the orthosis to be wide so that we can transfer as much pressure as possible from the lateral column to the medial column.

Minimum cast fill
. A minimum fill will conform closely to the arch of the foot on the medial column to help transfer pressure from the lateral column. I did warn the doctor that there is a possibility that this could push the patient too far laterally. If the patient feels like he is excessively supinating then the device can be thinned in the medial arch to increase flex. This modification is easy to perform and only takes a few seconds.

Full length top cover to the toes
.

In some situations a forefoot extension can be helpful. Some patients with calcaneocuboid arthritis find that there is less motion at the calcaneocuboid (CC) joint, and thus less pain with an extension (such as a piece of 3 mm Korex) under the fourth and fifth metatarsal heads. Other patients find that it is more comfortable to transfer pressure off of the fourth and fifth metatarsal heads in order to let those metatarsals plantarflexed. In this situation, a piece of Korex would go under metatarsal heads two and three. I advised the client not to prescribe either of those modifications. Instead, let the patient wear the orthosis for a few weeks. If he is still having pain, then use sticky felt to create a lift under metatarsal heads four and five. See how the patient does for a week or two, then remove that felt and put felt under metatarsal heads two and three and let the lateral column plantarflex. If one of those modifications improves symptom then that modification would be added permanently. In general, a CC joint with most of the arthritis dorsally will fare better when allowed to plantarflex which opens the joint dorsally. A CC joint with more arthritic changes plantarly will do better by preventing plantarflexion of the fourth and fifth metatarsals by putting the Korex under metatarsal heads four and five.


 

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