DOC » #439 Cuboid pain with running after flatfoot surgery

#439 Cuboid pain with running after flatfoot surgery

Today on the Doc On The Run Podcast, we’re talking about cuboid pain with running after flatfoot surgery.

Now look, you’ve got to have frequent follow-up and seeing your doctor once a month is not frequent follow-up. I do live coaching calls with course members and recovering runners who are staying strong, starting to run again, and ramping up for the next event, without getting re-injured.

Now, today’s episode comes from a recent group coaching call for recovering runners. All of the runners on these calls have been injured and they’re getting back to running, and today’s call will help you understand several things. Even if you don’t have cuboid pain, even if you didn’t have flatfoot surgery, this will help you think about your pain differently and help you look for opportunities to maintain your running-specific strength as you continue to recover from your overtraining injury. So let’s go ahead and listen into the call.

Jessie:
My name is Jessie, and I had surgery in November on my ankle to replace my posterior tibial tendon. It was completely damaged, and so I got a new tendon grafted on, and then my heel bone was shifted over, and then also I had my calf lengthened, and the whole works.

Dr. Segler:
Okay. So it sounds like so basically, you had posterior tibial tendon problems. You have flat feet?

Jessie:
Well, apparently. I didn’t think they were that bad, but it was just… Yeah.

Dr. Segler:
Okay. So, what you described to me sounds like a combination of three procedures that’s pretty common for somebody that has posterior tibial tendon weakness, damage, tears, whatever. So one of them is called a Kidner procedure, where we actually detach the posterior tibial tendon, drill a hole in the navicular bone and kind of reinsert it in a place that provides more leverage. And then it sounds like you also had a thing called a calcaneal osteotomy or calcaneal slide procedure. So it sounds dramatic, but what we do is we basically cut the heel bone in two pieces, and then we take the bottom piece that’s under your foot toward the ground, and slide it over a little bit to shift and supinate your foot to hold it in a corrected position, which makes you stand in a way that immediately relieves a lot of the tension and stress, and work that the posterior tibial tendon has to do.

And it also sounds like you had a thing called a gastroc recession, where we actually make an incision kind of halfway up your leg on the inside of the leg, and release part of the gastroc, the big muscular attachment to the Achilles tendon, and leave the soleus part intact, so it actually reduces a lot of stress and strain that could pull those repairs apart, because when you have flat feet, you get tight Achilles tendons, and those tendons oftentimes can actually literally rip the surgical repair apart, because there’s so much force on it. So, let’s see, so about seven months ago is when you had the surgery?

Jessie:
Yeah, yeah, and I recovered really well, and I actually got back into running about March or so, but my tendon felt great, the whole inside of my ankle felt great, but I’ve been having some pain or sensation on the outside of my foot, like around the cuboid bone. And so, I got back into running, I kind of had to stop, then I got back in again, and I was up to like five miles every other day. But then, and it was getting better, it kept feeling better, but then about four weeks ago it just was like, “Oh no, it doesn’t feel good,” and so I stopped.

I haven’t run for four weeks. I just tested it out this morning, ran a couple minutes. I still feel that kind of weird pain around my cuboid bone, and everything else feels great home. It’s a lot better, but I just, I don’t know if it’s scar tissue. My PT and doctor think it’s just the ligaments getting used to the different position of my foot. But yeah, I just don’t know what that weird pain on the outside of my foot is. It’s very weird.

Dr. Segler:
Okay. So what do you think? So your doctor and your physical therapist have told you essentially that it’s the ligaments and stuff kind of relaxing or getting used to this new positioning that your foot’s in since you had the surgical repair.

Jessie:
Yeah, just pulling on a different position. Yeah.

Dr. Segler:
Right. Yeah, so when you have what we call a flatfoot reconstruction, which is basically the combination procedure you had is one form of flatfoot reconstruction. We have reconstructed your foot, we put it in a different position, and put it in a completely different configuration, specifically designed to start to change the stresses and strains on your foot, right?

Jessie:
Mm-hmm (affirmative). Yeah.

Dr. Segler:
So, the question then is, is that wrong or not? And I would say probably not. I think it’s not really abnormal, it is normal. And you have to think about, well, what really is happening here? And so, if you look at your foot, I don’t know if you can see this, but… And are you on video? Can you see? We’ve got a foot model here. Jessie?

Jessie:
Oh yeah.

Dr. Segler:
Yeah, yeah. Okay.

Jessie:
I can’t see it, I’m on the phone.

Dr. Segler:
Oh, okay. Well, I’ll see if I can send some of this to you, so you can see later.

Jessie:
Okay.

Dr. Segler:
So basically, when we have your foot and you have a flatfoot, and we try to do something to reposition it to create more of an arch and tilt you over, well, it obviously is going to tilt you over onto the outside of the foot. And so, you can get pain either at the base of your fifth metatarsal bone, you can get pain in the cuboid, you can get pain on the outside of the heel. You can get pain in any of those areas, but that’s part of the goal actually, is to actually put you in a corrected position where you can alter the stresses and strains, and actually remove a lot of that force on the outside of the foot. That’s actually the goal.

And so, it can be that as you supinate your foot and you tilt it over, that those structures on outside of the foot are actually starting to relax, and change, and improve, but that’s not always the case. Sometimes what it is you start to develop this thing called cuboid syndrome, where you supinate the foot so much that it’s really and truly compressing this little cuboid bone right here, and that cuboid is getting sort of squeezed between the heel bone and the fourth and fifth metatarsal bones, and causing discomfort.

So, the important thing is to make sure that you obviously follow your doctor’s advice. I mean, you’ve had what most people would consider a pretty good outcome, when you are only seven months out from a big procedure like that, where you’ve had a complete reconstruction of the shape and positioning of your foot, and you’re already back to running. But then if you take four months off and you go out and run and you have discomfort immediately when you run, one thing that that kind of suggests is that you don’t really have a stress fracture in that bone, right? Because if you had a stress fracture and you took four weeks completely off and all of your pain was gone, and then you just went out and ran a couple of miles, it would be unlikely that you would have pain just from that.

And so, although we can guess, I mean, I can guess, your doctor can guess, your physical therapist can guess on what’s really going on with you, it’s up to you as the runner, really, to try to figure it out, to make sure that you know exactly what’s going on. And unfortunately, and this is one of the things I teach at medical conferences to doctors over, and over, and over is I just say, “Look, you’ve got to do more frequent follow-up,” and the people that I talk to that are in your situations, where you have these questions that are not really answered, and they say, “Okay, well, how are you doing? Okay, you’re doing great, so we’ll see you in another three months.”

That far out from surgery, a lot of times, truthfully, with a flatfoot reconstruction, a fairly common routine, not every doctor does this, but a fairly common routine and reasonable routine is say, “Okay, we’ll see you like two days after your surgery to remove a pain pump, if you have a pain pump. We’ll see like a week later to change the bandage. We’ll see you at two weeks to take out your stitches. We’ll see you at three or four weeks to see how you’re doing, and x-rays, check your healing, and see you again at six weeks, do some more x-rays to see if the osteotomy’s healing appropriately,” and then you have these intervals that are kind of three months, four months, six, nine months, 12 months, 18 months. And those are all normal routines, but I mean, they’re not perfect for everybody, because everybody has different timelines and different things going on.

And so, if you have the surgery and you feel like you’re improving and everything’s great, then that’s awesome. I mean, it’s good to go back and check in with the doctor, but when something goes sideways, these normal routines don’t work, and you as a runner, frankly, you’re not a normal patient, you’re somebody who’s trying to do a whole lot more than 90% of the people who will ever have a flatfoot reconstruction, most of them just want to walk.

In fact, I remember my son was asking me one time about patients and when you can really tell that they’re happy and that kind of stuff, when he was really little, and I told him a story about this one woman who was in her 70s, who I did a flatfoot reconstruction on, and every time she came into the office, she would actually hug me and just tell me, she was elated that she could walk down the aisle at the grocery store. And that was really her goal, was to be able to walk down the aisle at the grocery store without pain. Well, she’s never going to run a mile in the rest of her life, but that’s a huge difference in activity that you’re talking about.

And so, you are not really normal and you’re not like most people most doctors see, because what you’re doing is an extreme level of activity, by most people’s standards. It’s probably not extreme for you, it’s not extreme for me, but you have to really kind of put that in the right perspective, and if you feel like you’re concerned that maybe something else is going on, that you’re getting cuboid syndrome, or you’re getting a cuboid stress fracture or something like that, or a fifth metatarsal stress fracture, it’s really important to figure that out.

So a lot of times, you can try to push on the bone and tell like, is that tenderness actually on the bone, or is it on something else? Because the change in position of your foot can put a lot of stress and strain on other structures. So you even have on your foot, you’ve got on the outside of the foot where the cuboid is, there’s this little groove over here, and the peroneus longus tendon comes down behind the fibula, and then it curves through this groove on the outside of the cuboid and goes across the bottom of your foot. And when you supinate the foot with a flatfoot reconstruction and it’s in a new position, even the peroneus longus tendon that goes around the cuboid can actually get stretched, overstressed, and strained, so that you get either true tendonitis or you get tenosynovitis, where the sort of tube that surrounds the tendon, the tendon sheath gets inflamed, and it can cause that kind of discomfort.

But in my mind, if the discomfort you have is like a stress fracture, then you get pain that sort of crops up very slowly. It goes from sort of just vaguely aching once in a while after you exercise or the day following exercise, to aching more consistently, and sometimes even while you’re running. And at that point, generally, if you push on that specific bone, it’s tender, and if you have a tendon issue or a ligament issue, it’s more likely to kind of be aggravated while you’re doing the activity, almost immediately. It’s a lot more responsive than the stress fractures. At least, that’s the way I look at it. And so, if you go take four weeks off and then you go for a short run, I think it’s more likely to be a soft tissue issue, but that doesn’t mean you can’t treat it, and the important thing is that obviously, you took a month off and it didn’t fix your issue, correct?

Jessie:
Hello?

Dr. Segler:
Yeah. So, sorry, I couldn’t hear you there.

Jessie:
Sorry.

Dr. Segler:
So if you took a month off and it didn’t resolve it, then you go back and you run again, it’s important to treat it, right? So at this point, you have to do something. So if you go back to the doctor and you say, “Look, I still have this weird pain. What can you do about it?” There are actually lots of things they can do about it. So sometimes some stretching exercises, and the physical therapist can help you stretch those things out, but also sometimes you might need, not necessarily custom orthotics, but some kind of orthotic support, or even a modification like padding in the inserts in your shoes in different places, to shift some of those stresses away from that area, or to support you better, so your peroneus longus tendon isn’t working as hard, if that’s the issue. But you have to do something to reduce those stresses and strains that are actually causing the irritation, because obviously, I mean, you can’t go run two miles and take another month off, right?

Jessie:
Right.

Dr. Segler:
So at this point, what do you actually think it is?

Jessie:
It just feels sort of like the cuboid is kind of getting squished. That’s what it feels like. I mean, it’s significantly better after taking the four weeks off. It feels a lot better, but I still feel a little lingering pull, sort of. It’s not achy at all, it only hurts when I’m basically running, so.

Dr. Segler:
Well, it is, when you have a flatfoot reconstruction and again, we take your foot that is really pronated, and there’s not a lot of stress on the cuboid, and then we supinate your foot and we twist it over into this other supinated position, it really does compress the cuboid and can put lots of stresses on it, and your foot is also tilted over to where you’re actually standing more with more weight and pressure on the cuboid.

And so, it could be that the cuboid Cuba is kind of getting squished, but most of the time, what I have found is that most patients are right most of the time. And there was actually a study, so like when I was the chief resident in my surgical residency, students who were on the rotations would have to present patients to us as senior residents or whatever, before we’d let them do anything to the patient. And so, I would have people come in and somebody like, okay, let’s say you came in, and the student would go talk to you, they would all these questions or try to figure out what’s going on, then they’d come up with a treatment plan.

And the student would come to me and say, “Okay, I just talked to Jessie. I think Jessie has cuboid syndrome. I want to give her a cuboid pad,” and I would say, “Okay, why do you think it’s cuboid syndrome?” And they would tell me why they think it’s cuboid syndrome, and then I would always say, every time I would say, “Well, what does Jessie think is going on?” And they would usually say something like, “Well, Jessie is a plumber,” or “Jessie is a tech engineer. She’s a software engineer. She doesn’t know anything about feet. She’s not a doctor,” and I would say, “Well, I mean, no offense, but you’re not really a doctor yet either. You’re here on a rotation trying to learn how to be a doctor.”

Then I would give them a copy of this study that actually showed that 80 something percent of patients all across all specialties in this study, when the doctors literally at the end of their interview just asked the patient, “What do you think is wrong with you?” Almost all the time, like 80 something percent of the time, the patients were actually right. Even though they didn’t know the anatomy or the medical terms, or whatever, and most of the time, you’re right. So your intuition is actually pretty good.

And so, if you feel like the cuboid is getting squished and you go in and you describe that to them, then the doctor may try some simple things, something like a cuboid pad or something, just some simple pads to actually shift your positioning a little bit, to try to redistribute some of those forces, so that it’s not actually squishing the cuboid so much, and see if that makes a huge improvement. And a lot of times, you can do that.

I mean, I see patients all the time, either on webcam calls, or house calls, or whenever, and I will, a lot of time I’m going to do this with patients where I show them. I mean, I take some felt or something, take an insert out of one of my running shoes, put it on there, show them how to change the forces, and then that can actually give you a way to try it, because if you do some simple things and then it suddenly shifts just enough of that pressure away that it’s not really squishing the cuboid so much, and you start to improve, then you’re out of the woods, and that’s really what you’re after, right?

Jessie:
Yeah. Yeah. Yeah.

Dr. Segler:
Okay. So, all right, Jessie.

Jessie:
Cool. Perfect.

Dr. Segler:
So I’m glad to hear that you’re doing better after your surgery. Sorry you’re having that issue now, but hopefully you’ll start moving in the right direction.

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