Calcaneocuboid Arthritis

Calcaneocuboid (CC) arthritis is degeneration of the articulation between the anterior process of the calcaneus and the cuboid. It is a relatively uncommon cause of lateral midfoot pain, about 10-15% of midfoot arthritis, and isolated disease is rare at 5-10%. The joint is critical for lateral column stability and forefoot alignment.

It rarely travels alone. It is commonly associated with adjacent-joint disease, post-traumatic change or an inflammatory arthropathy. Before planning anything, assess the talonavicular and subtalar joints; missing concurrent disease there is the commonest viva trap.

• Peroneal tendon pathology (tears or tendinopathy) coexists in 30-40%
• Talonavicular arthritis - 60% have concurrent CC involvement
• Subtalar arthritis - a 50% association
• Cavovarus foot - chronic lateral column overload

Causes. Post-traumatic disease, after a calcaneal fracture, is the most common.

• Post-traumatic - calcaneal fractures (30-40% develop CC arthritis) and nutcracker injuries of the cuboid
• Inflammatory - rheumatoid arthritis and the seronegative arthropathies
• Degenerative - primary osteoarthritis, uncommon in isolation
• Malalignment - hindfoot varus or valgus loading the joint abnormally
• Peroneal pathology - chronic tendon dysfunction altering the mechanics

How far to trust the numbers. No population study reports the prevalence of CC arthritis, and the rates quoted for how often it follows a given injury come from surgical series of that injury.

The joint. A saddle-shaped, concave-convex articulation between the anterior facet of the calcaneus and the cuboid, forming the lateral component of the transverse tarsal (Chopart) joint. Its motion is coupled with the talonavicular and subtalar joints as part of the triple joint complex, contributing to its oblique axis of motion, and on its own it allows only about 5-10° in the sagittal and transverse planes.

What it does. It transmits power from hindfoot to forefoot, allows limited motion for adapting to terrain, and carries about 15-20% of forefoot load in stance, transmitting body weight laterally under high compressive load. It locks to stabilise the lateral column at toe-off, controls forefoot abduction and adduction, and maintains lateral column length. The dorsal calcaneocuboid and bifurcate ligaments stabilise the lateral side of the Chopart joint.

The cyma line. The normal Chopart joint forms a smooth S-shaped line across the talonavicular and calcaneocuboid articulations. A break in the contour suggests malalignment that alters lateral column loading.

View larger

When it degenerates. The articular cartilage is progressively lost, the subchondral bone stiffens and scleroses, peripheral osteophytes form and the capsule becomes inflamed. The joint loses height, and the lateral column shortens with it. Loss of lateral column length leads to abnormal load transfer, compensatory forefoot adduction and cavovarus deformity.

After trauma. Following a calcaneal fracture, CC arthritis develops through three routes:

1. Direct articular damage from the injury
2. Malunion, which loads the joint abnormally
3. Lateral column shortening, which alters the biomechanics

Nutcracker and lateral compression injuries. In the nutcracker mechanism, forced abduction compresses the cuboid between the calcaneus and the bases of the 4th and 5th metatarsals. In a lateral-compression Chopart injury, the anterior calcaneal process is driven into the cuboid while medial distraction avulses the spring-ligament complex, and residual incongruity at the CC surface predisposes to focal post-traumatic arthritis.

View larger

History. Pain sits in the lateral midfoot, inferior to the lateral malleolus: a dull ache, worse with activity, walking on uneven ground and lateral stress. Patients struggle with narrow shoes and walk less far. Ask specifically about a previous calcaneal fracture or midfoot injury.

Examination. Localise tenderness and stress pain precisely, against the CC joint, the dorsal calcaneocuboid and bifurcate ligaments and the peroneal tendons, rather than labelling it generically as lateral midfoot pain.

1. Inspection, standing - lateral column alignment, swelling, skin changes and overall foot posture; gait for a lateral foot stress pattern
2. Palpation - localise tenderness to the CC joint (anterior to the lateral malleolus) and compare it with the TN and subtalar joints
3. Range of motion - forefoot abduction and adduction with the hindfoot stabilised, reduced in CC arthritis; compare with the other side
4. Special tests - single heel rise for associated tibialis posterior dysfunction, peroneal strength, and the Coleman block test if cavovarus is suspected
5. Adjacent joints - the TN, subtalar and ankle joints, systematically, for concurrent disease

View larger

Differential Diagnosis of Lateral Midfoot Pain

Weight-bearing radiographs first. Standing AP, lateral and oblique views of the foot. Judge the CC joint, the alignment (lateral column length and forefoot position) and the TN and subtalar joints on the same films. The features of CC arthritis are:

• Joint space narrowing
• Subchondral sclerosis and cysts
• Osteophytes, especially dorsal; on the lateral view, look for dorsal osteophytes impinging on the extensor tendons
• Lateral column shortening, judged against the contralateral foot

CT is for surgical planning and deformity: bone stock, subchondral change and the fusion plan, and it identifies occult fractures and coalition. After a calcaneal fracture, multiplanar CT is required to decide whether the fracture actually enters the CC joint or loads it incongruently.

View larger

The occult Chopart injury. In the case below, standard views were initially negative despite persistent pain, and cone-beam CT revealed an anterior calcaneal-process fracture and a separate dorsal CC fracture. It shows why cross-sectional imaging matters after an occult Chopart injury.

View larger

MRI is selective. It assesses the peroneal tendons, cartilage and soft tissues, showing tendon tears, bone marrow oedema and synovitis, and it earns its place in pre-operative planning when tendon pathology is suspected.

Why inject. CC arthritis rarely occurs in isolation and lateral midfoot pain has many mimics (peroneal tendinopathy, sinus tarsi syndrome, subtalar arthritis, cuboid or nutcracker pathology, an os peroneum), so radiographic CC degeneration does not by itself prove the CC joint is the source of the pain. An image-guided intra-articular injection of local anaesthetic, with or without corticosteroid, is the single most useful confirmatory test before committing to an irreversible fusion.

How to do it.

• Guidance is essential - fluoroscopy or ultrasound; the saddle joint is small, and blind injection frequently misses or spills into adjacent structures
• Small volume - about 1 mL of local anaesthetic keeps the response joint-specific
• Document the response - a pain diary with a defined task (walking, single-leg stance) recorded during the anaesthetic window
• Positive test - substantial, temporary relief during the anaesthetic window localises the pain generator to the CC joint

Reading the result. Good relief supports the CC joint as the target and, with normal adjacent joints, an isolated CC fusion; it can inform the extent of the fusion. Absent, partial or equivocal relief should stop you proceeding straight to a CC fusion and prompt reassessment of the adjacent joints (a separate subtalar or TN injection), the peroneal sheath, injectate placement and mixed pain sources, though it is not an absolute veto. A separate response pattern may redirect surgery to a double or triple arthrodesis or to tendon surgery. Including corticosteroid adds therapeutic value in the conservative phase.

Its limits. Anaesthetic can diffuse into the adjacent subtalar joint or peroneal sheath, which reduces specificity. A good response supports localisation to the CC region, but it does not guarantee that fusion will relieve the symptoms or unite.

Conservative first. Non-operative care succeeds in about 60-70% of patients with mild to moderate CC arthritis. The aim is to minimise abnormal loading of the degenerate joint.

• Initially - activity modification to reduce lateral column stress; supportive footwear with lateral posting
• Weeks 0-6 - orthoses to redistribute load and support the lateral column: custom orthoses with lateral forefoot support, or off-the-shelf lateral wedge insoles
• Ongoing - NSAIDs; corticosteroid injection under fluoroscopic or ultrasound guidance, which improves accuracy, to a maximum of 2-3 a year
• Weeks 6-12 - physiotherapy: peroneal strengthening, ankle stabilisation exercises and gait retraining, addressing any associated peroneal weakness or dysfunction

When to operate. Failed conservative management for a minimum of 6 months, moderate to severe arthritis and functional limitation. The choice between isolated CC fusion and triple arthrodesis depends primarily on the status of the adjacent joints, assessed clinically and radiographically.

Isolated, double or triple. Triple arthrodesis is the more common operation. When disease or deformity extends beyond the CC joint, the subtalar, talonavicular and calcaneocuboid surfaces are prepared to bleeding bone, grafted and compressed together. Where the CC and TN joints are both involved and the subtalar joint is spared, a double (CC and TN) arthrodesis is the subtalar-sparing alternative (Clain and Baxter, in the evidence below).

View larger

Approach. The CC joint is reached laterally.

1. Set-up - supine with a bump under the ipsilateral hip, thigh tourniquet and C-arm; ensure adequate access to the lateral foot with the hip externally rotated
2. Incision - oblique, over the CC joint anterior to the lateral malleolus, 6-8 cm long, following Langer's lines to minimise scar contracture
3. Superficial dissection - secure the sural nerve, then elevate the peroneal tendons carefully
4. Deep dissection - incise the capsule and expose the articular surfaces; inspect the peroneal tendons systematically for tendinopathy and for tears requiring repair

Joint preparation. Given the higher nonunion rate of isolated CC fusion, adequate preparation is critical.

• Cartilage - remove it completely with osteotomes and burr, preserving subchondral bone; fish-scaling exposes bleeding bone without excessive bone loss
• Surfaces - create bleeding bone on both calcaneus and cuboid, with multiple drill holes to enhance vascularity, maintaining lateral column length
• Graft - consider autograft or allograft, harvested from the calcaneus or iliac crest; graft is particularly important in revision cases or with risk factors
• Alignment - position the cuboid to maintain lateral column length, avoiding shortening or excessive abduction; confirm with provisional K-wires before definitive fixation

Fixation. Fluoroscopic confirmation of screw position and joint compression is mandatory.

Aftercare. Radiographic union typically occurs by 10-12 weeks, but may take longer in patients with risk factors.

• Weeks 0-2 - below-knee cast, strict non-weight-bearing; elevation, ice and DVT prophylaxis; wound check and suture removal at 2 weeks
• Weeks 2-8 - non-weight-bearing in the cast, with radiographs at 6 weeks to assess fusion; watch for wound problems, infection and hardware problems
• Weeks 8-10 - transition to weight-bearing in a CAM boot if radiographic union is progressing, increasing as tolerated
• Weeks 10-12 - wean from the boot to supportive footwear and begin physiotherapy for range and strength; expect full weight-bearing by 12 weeks if union is confirmed

Who fails to unite. Smoking is the strongest predictor of CC fusion nonunion. The others are diabetes mellitus, inadequate fixation, poor bone contact, peripheral vascular disease, immunosuppression and revision surgery. Pre-operative smoking cessation for a minimum of 4 weeks is recommended.

Why this joint. Isolated CC arthrodesis carries the highest nonunion rate of the individual hindfoot and midfoot fusions (see the complications table), against 10-15% for talonavicular fusion. The reasons are specific to the joint: a small cancellous contact surface, high compressive and rotational loads across the lateral column, and a frequently scarred or relatively avascular post-traumatic bed. Salvage is a predictable examiner question.

Diagnosis. Not every nonunion is symptomatic, and a stable fibrous nonunion in a comfortable patient can be observed. Persistent lateral pain, hardware loosening or lucency and progressive lateral column collapse suggest a symptomatic one. CT is the reference test, because plain films over-call union across the small saddle joint. Exclude low-grade infection, and correct host factors, before revising.

Salvage.

• Correct the cause - confirmed smoking cessation, optimised vitamin D and metabolic status, treatment of any infection
• Prepare a fresh bed - take the fibrous interface down to bleeding bone
• Restore lateral column length - structural autograft or allograft, or a distraction bone-block if shortened
• Upgrade fixation - from screws alone to a rigid compression plate, with or without a lag screw, adding biologic or autologous graft

Where the CC joint is heavily scarred and the adjacent joints are themselves degenerating, extending to a double or triple arthrodesis gives a larger, more reliable fusion surface; the technique is covered in the dedicated arthrodesis topics. Structural graft that restores lateral column length follows the distraction-arthrodesis principle and prevents the forefoot adduction that follows lateral column shortening.

Global epidemiology. Symptomatic radiographic midfoot OA affects roughly 12% of community-dwelling adults over 50 (Keele Clinical Assessment Study of the Foot), rising with age, female sex, obesity and prior foot/ankle injury - but that definition scored the cuneometatarsal, naviculocuneiform and talonavicular joints and did not include the calcaneocuboid, so it is the risk profile that transfers, not the number. No population study reports the prevalence of CC arthritis, and the figures on this page for how often it follows a given injury come from surgical series of that injury, which are ascertained from the cases that reached an operating theatre. Isolated CC arthritis is uncommon; most CC degeneration is post-traumatic (after calcaneal or cuboid/nutcracker fractures) or part of broader midfoot/hindfoot OA. There is no dedicated arthroplasty registry for the CC joint because management is fusion-based, not implant-based.

Side-by-side guidance. No society publishes a CC-arthritis-specific guideline; recommendations are extrapolated from foot OA and hindfoot fusion principles.

Registry and outcome evidence. Calcaneal fracture registries and the Buckley RCT show that articular malreduction (step-off over 2 mm) drives post-traumatic subtalar and CC arthritis — the dominant route to symptomatic CC disease worldwide.

High- versus limited-resource practice. In well-resourced systems, weight-bearing CT, MRI for peroneal assessment and rigid plate/screw constructs with biologics are standard. In limited-resource settings, plain weight-bearing radiographs and screw-only fixation predominate, late presentation of malunited calcaneal fractures is more common, and accommodative orthoses with footwear modification carry a larger share of definitive care. Smoking cessation for a minimum of 4 weeks before fusion is a universal, low-cost intervention that reduces nonunion.

Isolated CC fusion or a longer fusion. Whether truly isolated CC arthritis exists often enough to justify isolated fusion is debated. Given its nonunion rate, some surgeons favour double or triple arthrodesis for more predictable union; the counter-argument is preservation of TN and subtalar motion. The evidence is limited to small retrospective series.

Motion preservation. Interposition arthroplasty and joint-preserving distraction for early CC arthritis rest on sparse, low-quality data, with no validated implant or established role. Fusion remains the reference standard for end-stage disease.

How much motion does the CC joint really lose? Beimers' CT helical-axis study (2012) suggests fusing the CC joint may reduce global hindfoot motion less than once feared, since the CC contributes a small share, which challenges the historical reluctance to fuse it within lateral column lengthening. It had five patients in each arm and measured the ankle and subtalar joints rather than the transverse tarsal joint, so it is an absence of evidence of a motion penalty, not evidence that there is none.

Biologics and fixation. The best fixation (parallel screws, plate or combined) and whether routine autograft, allograft or orthobiologics meaningfully lower nonunion are unresolved. Recommendations are extrapolated from general hindfoot fusion data rather than CC-specific trials.

1. Thomas MJ, Peat G, Rathod T, et al. The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults. Arthritis Res Ther. 2015;17(1):178. PMID 26166410. doi:10.1186/s13075-015-0693-3

2. Saltzman CL, Fehrle MJ, Cooper RR, et al. Triple arthrodesis: twenty-five and forty-four-year average follow-up of the same patients. J Bone Joint Surg Am. 1999;81(10):1391-402. PMID 10535589.

3. Clain MR, Baxter DE. Simultaneous calcaneocuboid and talonavicular fusion: long-term follow-up study. J Bone Joint Surg Br. 1994;76(1):133-6. PMID 8300657.

4. Sangeorzan BJ, Swiontkowski MF. Displaced fractures of the cuboid. J Bone Joint Surg Br. 1990;72(3):376-8. PMID 2341430. doi:10.1302/0301-620X.72B3.2341430

4a. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84(10):1733-44. PMID 12377902. doi:10.2106/00004623-200210000-00001

4b. Reddy V, Fukuda T, Ptaszek AJ. Calcaneus malunion and nonunion. Foot Ankle Clin. 2007;12(1):125-35. PMID 17350514. doi:10.1016/j.fcl.2006.12.004

4c. Beimers L, Louwerens JWK, Tuijthof GJM, et al. CT measurement of range of motion of ankle and subtalar joints following two lateral column lengthening procedures. Foot Ankle Int. 2012;33(5):386-93. PMID 22735280. doi:10.3113/FAI.2012.0386

4d. Rammelt S, Marx C, Swords G, Swords M. Recognition, treatment, and outcome of calcaneal fracture-dislocation. Foot Ankle Int. 2021;42(6):706-13. PMID 33478259. doi:10.1177/1071100720980012

5. Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997;46:393-405.

6. Johnson JE, Johnson KA. Dowel arthrodesis for degenerative arthritis of the tarsometatarsal (Lisfranc) joints. Foot Ankle. 1986;6(5):243-53.

7. Mann RA, Beaman DN, Horton GA. Isolated subtalar arthrodesis. Foot Ankle Int. 1998;19(8):511-9.

8. Clain MR, Baxter DE. Simultaneous calcaneocuboid and talonavicular fusion: long-term follow-up study. J Bone Joint Surg Br. 1994;76(1):133-6.

9. O'Malley MJ, Deland JT, Lee KT. Selective hindfoot arthrodesis for the treatment of adult acquired flatfoot deformity: an in vitro study. Foot Ankle Int. 1995;16(7):411-7.

10. DiGiovanni CW, Patel A, Calfee R, et al. Osteonecrosis in the foot. J Am Acad Orthop Surg. 2007;15(4):208-17.

11. Beischer AD, Brodsky JW, Pollo FE, et al. Functional outcome and gait analysis after triple or double arthrodesis. Foot Ankle Int. 1999;20(9):545-53.

12. Thordarson DB. Fusion in posttraumatic foot and ankle reconstruction. J Am Acad Orthop Surg. 2004;12(5):322-33.