How To Treat Cuboid Syndrome In The Athlete

By Mark A. Caselli, DPM, and Nikiforos Pantelaras, DPM
This rotational force would close pack the cuboid in its articulations and force the bone in an inferomedial direction, tearing interosseous ligaments. Another suggested mechanism is that the inversion stress at the ankle may cause a reflex contraction of the peroneus longus muscle in an attempt to restore balance and medial ground contact. This forceful contracture of the peroneus longus muscle creates a medial rotation of the cuboid. Then the peroneus longus tendon — within the osseous fibrous tunnel on the inferior surface of the cuboid — imparts a dorsal and lateral force on the cuboid, which results in the inferomedial subluxation. Disruption of the intertarsal ligaments may occur from the inversion force or when the cuboid is forcefully rotated. Other Conditions To Consider During Diagnosis There are many clinical conditions one must consider in the differential diagnosis of an athlete who presents with lateral foot pain (see “A Guide To Differential Diagnoses For Lateral Foot Pain” below). If the athlete is an adolescent, one should have a strong index of suspicion for tarsal coalition, a condition that is most similar to cuboid syndrome. Both can present with the same, non-specific symptoms that usually occur after a minor injury such as a mild ankle sprain. However, in the case of tarsal coalition, pain occurs in the subtalar or midtarsal area of the involved foot. It is aggravated by walking, prolonged standing, jumping or participating in athletics. Rest usually relieves the pain. In severe cases, the patient may present with an antalgic gait and have a significant limp. Upon examination, those with a tarsal coalition will usually have a stiff foot with a significant decrease in subtalar joint motion. In these cases, one will often note a loss of the longitudinal arch, hindfoot valgus and forefoot abduction. Forced inversion of the foot will exacerbate the symptoms. Radiographs may or may not be helpful in making a definitive diagnosis. (See “Is Peroneal Spastic Flatfoot Causing Chronic Ankle Pain?” in the June 2002 issue of Podiatry Today.) A Guide To Differential Diagnoses For Lateral Foot Pain Sinus tarsi syndrome Lateral process fracture of the talus Acute tendinitis of the peroneus longus tendon Fracture of the anterior process of the os calcis Malalignment of the lateral ankle and subtalar joints Fractures (including stress fractures) Meniscoid of the ankle Fracture or dislocation of the os peroneum Gout Inflammatory and noninflammatory arthritis Tarsal coalitions (in adolescents) Pertinent Pearls For Treating Cuboid Subluxation Once one has diagnosed cuboid syndrome, reducing the subluxed cuboid is the first step in the treatment process. Clinicians may employ a manipulative technique, which is often defined as a low-amplitude, high-velocity mobilization at the end of joint range, to restore proper joint congruency. However, be aware that there are contraindications to this manipulation technique. The contraindications include neoplastic or bone disease, inflammatory arthritis, gout and neural or vascular abnormalities. While facing the plantar surface of the patient’s foot, place your thumbs on the medial plantar surface of the cuboid with your fingers on the dorsal side. Doing so stabilizes the forefoot. Take care not to place the fingers directly over the cuboid on the dorsal side. Keeping the ankle joint in slight plantarflexion, apply a dorsally directed force to the medial side of the cuboid with a small amplitude, high-velocity thrust (see the photo at left). Often, the athlete experiences complete relief of symptoms with a successful reduction. One can then apply ice to the lateral side of the foot to reduce any inflammatory response and pain if necessary. Afterward, clinicians should use a cuboid pad in conjunction with a low-dye taping to maintain the cuboid reduction and give the arch added support. The cuboid pad is usually made of 1/4 inch felt. It is approximately 1.5 inches wide and 2 to 3 inches long. Ensure that the pad is skived at the edges for better fit and comfort. One can determine the actual length of the pad by measuring the distance from the calcaneocuboid articulation to the cuboid-fifth metatarsal articulation. Place the pad directly under the cuboid bone. It should not extend distally under the styloid process of the fifth metatarsal. Keep in mind that the cuboid pad may at times spontaneously adjust a mildly subluxed cuboid by its upward thrust.

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