Cuboid Syndrome

What is a cuboid syndrome ?

Cuboid syndrome is the common cause of lateral foot pain. The pain is on the outer side of the foot. This syndrome particularly affects athletes and belle dancers.

Other names for cuboid syndrome – The other name for cuboid syndrome is cuboid subluxation, blocked cuboid, cuboid fault syndrome, dropped cuboid and lateral plantar neuritis.

How does the cuboid bone function?

In providing stability to outer side of mid foot, Cuboid bone plays an important role. It is one of the small bones on the outer side of mid foot. It is one of the five bones that together make up the mid foot and the other is navicular and three cuneiform bones. It is attached posterior to the calcaneus via a number of strong ligaments along with joint capsule forming the calcaneo cuboid joint while interiorly it forms a joint with fourth and fifth metatarsals. Along with other mid foot bones cuboid bone distributes the weight of the body to help people walk and also stabilises foot. ⁽¹⁾

Symptoms

Cuboid syndrome presents pain down the outside of foot which can refer across the foot and to the toes and ankle.  The pain is usually worse when weight-bearing particularly in the morning, on uneven ground, jumping or hopping, quickly changing direction, and symptoms tend to ease with rest.  Walking is difficult and people with cuboid subluxation often walk with a limp in an attempt to keep their weight of the outer foot.

The bone is usually tender to touch and area may be slightly swollen and red.  The foot may also feel weak, especially during the push-off phase of walking, jumping and running. (2)

The syndrome also represents some typical symptoms like:

• Acute or chronic dull aching pain around outer side of mid foot
• Difficulties in walking
• Pain increases when patient put pressure on foot and start walking
• Some patients may walk on their toes to avoid pressure and weight on cuboid bone
• Pain often diffuses along the lateral foot between the CC joint and the fourth and/or fifth cuboid-metatarsal joints
• Rolling the arches of the foot
• An antalgic gait
• may radiate throughout the foot
• A slight sulcus over the dorsum of the cuboid
• a slight prominence or fullness on the plantar surface may be present with subluxation
• erythema
• edema
• ecchymosis ^{(3), (9)}

The lateral foot ligaments peroneus longus tandon

Risk factors

Risk factors for Cuboid syndrome can be suspected asfollows:

• Ankle sprains
• Physical exercise
• Mid tarsal instability
• Poorly fitting footwear
• Inadequate recovery from physical activity
• Physical training on uneven surfaces
• Obesity

Causes

A sudden injury or gradually repetitive forces to the foot may damage the supporting soft tissues causing the cuboid bone to move out of its actual position. This leads to a block limiting the movement of the surrounding bones on the foot.

There are three main causes for Cuboid syndrome. They are:

Severe trauma/Injury

The most common injury that causes cuboid subluxation is an inversion sprain of ankle.  This happens when the foot and heel bone are forced inwards while cuboid forced outwards.  This damages the soft tissues that support the bone in place causing it to partially dislocate. At this stage, pain usually comes on suddenly.

Repetitive physical activities of foot:  The peroneus longus muscle runs down the outer side of lower leg attaching on to the outer side of foot.  Tension placed through this muscle from repetitive activities such as ballet, running and jumping may cause excessive traction on bone causing to sublux.  In this case, symptoms are seen gradually over time and often fluctuate.

Altered Foot Biomechanics:  A majority of people suffering from the cuboid syndrome have over-pronated feet i.e. flat feet.

A repetitive dancing move (belle dancing) puts pressure on foot and can cause problem. Running bare foot may also lead to altered biometrics of foot and leads to dull aching pain at the middle part of the foot. ^{(7), (8)}

How to diagnose cuboid syndrome ?

Diagnosing a subluxed cuboid syndrome may be difficult and it may be misdiagnosed.  Imaging such as x-rays, MRIs and CT scans often fail to show a cuboid syndrome. But they can be useful for ruling out the other causes of pain.

There is no conclusive test for Cuboid Syndrome. But it is usually assessed to see if there is any pain and stiffness on palpation of the bone.   The foot may also be moved inwards and outwards to see if it elicits pain or get the patient to try to hop.  Some health professionals may use the mid tarsal adduction test to assess for the condition.  ⁽⁶⁾

The Cuboid Syndrome often goes undiagnosed with ankle sprains.  Cuboid syndrome should be considered if symptoms continue more than three months following an inversion sprain.

Treatment

Following successful treatments will help to keep the bone in the correct position and treat any lingering symptoms. There are various treatment options for cuboid syndrome:

1. Manipulation

The most successful treatment for a subluxed cuboid is to have bone relocated at the back into its proper position.  Respective health professional such as a doctor, physical therapist or podiatrist will perform a manipulation, which is a high velocity small amplitude thrust to the bone to relocate.  This should be carried out by a trained professional. The symptoms will usually settle immediately.  Manipulations are not suitable if you suffer from  bone disease,gout, fracture, nerve or rheumatoid arthritis or vascular problems.

Cuboid whip manipulation cuboid squeeze technique

2. Ice therapy

Ice therapy can help to reduce the inflammation and pain from cuboid syndrome. Place an ice pack or bag of frozen veg wrapped in a tea towel over the foot for ten minutes at a time.

3. Cuboid Wedge/padding

The patient may be given a small foam wedge to wear in shoe which also helps to support the bone in the correct position. It also helps to prevent recurrence of subluxation in future.

4. Compression bandage

To minimize movement of foot Comprehension bandage can be used. By this elevation of affected leg and rest is necessary for speedy recovery. ⁽⁴⁾

5. Taping

Taping of an ankle and the foot is often used to support and stabilize the bones in foot and hold the cuboid in place while healing the surrounding soft tissues.  Taping should allow the patient to walk without pain.

6. Rest

It is very important to rest from aggravating activities during the foot heal.  The use of crutches for a short period of time is required to keep weight off the injured foot.

7. Orthotics

A flat foot is a contributing factor to develop cuboid syndrome. Orthotic insoles should be given to wear in your shoes to correct your foot position to relieve tension on the peroneus longus tendon and support the foot bones and arches.  It also helps for proper alignment of foot bones.

8. Exercises

Movement exercises and strengthening exercises should be performed daily to prevent the foot from getting stiff and weak. If once symptoms have settled balance exercises should also be introduced.  If balance work is ignored, you are at increased risk of further ankle and foot injuries such as ankle sprains in the future. ⁽⁵⁾

Exercises should be started as soon as possible and continued until full function of the foot is restored.  Chronic cases will take longer to heal.

Prognosis

Orthoses may reduce an excessive pronation and may also prevent recurrence of cuboid syndrome. Stretching the gastrocnemius, hamstring, soleus, peroneus longus and strengthening the extrinsic and intrinsic foot muscles help prevent recurrence of cuboid syndrome. Pain usually reduces after complete rest. It may respond favorably to manipulation.

References:

1. Baravarian B. Diagnostic dilemmas: a guide to understanding and treating lateral column pain. Podiatry Today. 2005;18(3):100-105
2. Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of midtarsal joint stability. J Am Podiatr Med Assoc. 1987;77(12):638-642
3. Bojsen-Moller F. Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979;129:165-176
4. Caselli MA, Pantelaras N. How to treat cuboid syndrome in an athlete. Podiatry Today. 2004;17(10):76-80
5. Dorn-Lange NV, Nauck T, Lohrer H, Arentz S, Konerding MA. Morphology of the dorsal and lateral calcaneocuboid ligaments. Foot Ankle Int. 2008;29(9):942-949
6. Hardy RH. Observations on the structure and properties of the plantar calcaneo-navicular ligament in man. J Anat. 1951;85(2):135-139
7. Houtz SJ, Walsh FP. Electromyographic analysis of the function of the muscles acting on the ankle during weight-bearing with special reference to the triceps surae. J Bone Joint Surg Am. 1959;41:1469-1481
8. Khan K, Brown J, Vass N, et al. Overuse injuries in classical ballet. Sports Med. 1995;19(5):341-357
9. Kolker D, Marti CB, Gautier E. Pericuboid fracture-dislocation with cuboid subluxation. Foot Ankle Int. 2002;23(2):163-167