Article reviewed by Evan Peterson PT, DPT
Background
Foot pain is a common injury experienced across the population in both the athletic and non-athletic population alike. There are many different causes for foot pain, but one in particular is often misdiagnosed or missed. Cuboid syndrome is one cause of lateral foot pain which is thought to arise from a change in the arthrokinematics of the calcaneocuboid joint. The author of this article states this condition may be brought on insidiously or after a traumatic event.
The Cuboid and It’s Mechanics
The cuboid is surrounded by a variety of other foot bones on the lateral side of the foot. Its borders are the navicular, the calcaneus, the 4th and 5th metatarsals, and the lateral cuneiform. The cuboid is part of the midtarsal portion of the foot and moves in tandem with the navicular. Though it has a variety of motions, the calcaneocuboid joint typically rotates medially or laterally (inversion or eversion). Due to the congruence of articular surfaces, the cuboid is relatively stable but it also has the support of ligaments as well as a fibroadipose labra between the calcaneocuboid joint and cuboid-metatarsal joints. Another stabilizing feature is the peroneus longus tendon wrapping underneath the cuboid. The cuboid acts as a pulley system for the peroneal tendon to allow for efficient eversion during the late stance phase of gait to propel the body forward. The mid tarsal joint plays a large role in allowing the foot to be both a mobile adaptor and a rigid lever for push off. When the foot transitions its weight from lateral to medial, it creates the windlass effect giving the foot enough energy to push off effectively.
What Causes Cuboid Syndrome?
Although a distinct reason for the cause of cuboid syndrome is uncertain at this time, several pathologies have been suggested as culprits. Causes proposed are excessive pronation, overuse, and inversion ankle sprains. The actual mechanical movement of the cuboid is isolated eversion while the calcaneus is in an inverted state. The unwanted cuboid eversion may be caused by improper peroneus longus muscle firing causing an eversion moment on the cuboid. In turn, causing incongruence between the calcaneus and the cuboid resulting in pain.
There are a multitude of factors that could predispose someone to cuboid syndrome such as ill-fitting shoes, midtarsal instability, and being overweight. A study showed 80% of patients with excess pronation had cuboid syndrome due to the increased moment arm of the peroneus longus. Because the calcaneocuboid joint has a labrum, it may become impinged and restrict motion.
The prevalence of cuboid syndrome is not fully understood but it appears to be most common in ballet dancers with foot/ankle injuries or those with plantarflexion/inversion sprains.
What to Look For
Pain is often broadly felt along the lateral aspect of the foot. There may also be bruising, redness, and in some cases a prominence may be felt along the plantar surface of the foot. Patient may be tender to palpate along the peroneals, the cuboid groove, or the extensor digitorum brevis muscle. The patient may also have pain with resisted eversion as well as painful or decreased push off during gait. Although there is no gold standard for cuboid syndrome testing, the author suggests two procedures to rule in the possibility of cuboid syndrome. Either the midtarsal adduction test or the midtarsal supination test. The adduction test stabilizes the calcaneus while the mid tarsal joint is distracted medially and compressed laterally. The supination test adds compression into inversion and plantarflexion. Pain may also be elicited with dorsal or plantar cuboid movement with surrounding joints stable. The therapist must rule out fracture or dislocation of the cuboid, calcaneus, 4th and 5th metatarsals, plantar fasciitis, sinus tarsi syndrome, and several others.
Treatment of Cuboid Syndrome
It is recommended to perform manipulations upon initial presentation of cuboid syndrome. The two techniques most commonly used are the cuboid whip and the cuboid squeeze. The cuboid whip is performed with the patient in prone and the patient’s foot resting in neutral. The therapist then will “whip” the foot into plantarflexion and inversion while thrusting thumbs into cuboid. The cuboid squeeze is performed when the therapist stretches foot into maximal plantarflexion and maximal toe flexion. The therapist will then push the cuboid dorsal. Manipulation should only be performed when bruising subsides or the patient has no other contraindications for manipulation. Following manipulation, if successful, the therapist can implement taping techniques, lateral wedge, and foot intrinsic strengthening.
Physical Therapy First
If you are someone who recently had an ankle sprain or have been experiencing lateral foot pain, reach out to Physical Therapy First where you will be examined by a physical therapist trained in the techniques to pick up on and address cuboid syndrome.
Reference:
Durall, C. J. (2011). Examination and treatment of Cuboid syndrome. Sports Health: A Multidisciplinary Approach, 3(6), 514–519. https://doi.org/10.1177/1941738111405965