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Cuboid syndrome is an easily misdiagnosed source of lateral midfoot pain, and is believed to arise from a subtle disruption of the arthrokinematics or structural congruity of the calcaneocuboid(CC) joint, which in turn irritates the joint capsule, ligaments, and fibularis (peroneus) longus tendon.Cuboid syndrome has been documented in the podiatric, orthopaedic, osteopathic, and physical therapy literature under various terms, including subluxed cuboid, locked cuboid, Dropped cuboid, cuboid fault syndrome, and lateral plantar neuritis.Because of the nature and inconsistent terminology associated with this injury, cuboid syndrome remains a poorly understood condition in both athletic and non-athletic populations,therefore it is a often mistreated and misdiagnosed condition.
Cuboid syndrome represents approximately 4% of all foot injuries.cuboid syndrome is present approximately 7% following plantar-flexion and inversion ankle sprains. It appears that the occurrence of cuboid syndrome in professional ballet dancers may be higher, accounting for up to 17% of reported foot and ankle injuries in this population.
Clinically Relevant Anatomy
The cuboid is a pyramid-shaped, short bone on the lateral aspect of the foot with 6 surfaces. It articulates anteriorly with the fourth and fifth metatarsal bases, medially with the lateral cuneiform and navicular, and posteriorly with the calcaneus.CC joint function is dependent on midtarsal joint mechanics, since the navicular and cuboid bones move essentially in tandem during gait. The mechanics of the CC joint are highly variable. The principal movement at the CC joint is medial/ lateral rotation about an anterior/posterior axis with the calcaneal process acting as a pivot.The cuboid rotates as much as 25° during inversion/eversion about an axis that passes from posteroinferior to anterosuperior at an angle of roughly 52° (range, 43°-72°) with respect to the ground.In addition to inversion/eversion, there is some evidence that posterior-anterior distraction of the CC joint also occurs during the gait cycle.
The CC joint is intrinsically stable due to the congruence of its articular surfaces and reinforcement from ligaments and tendon attachments.The CC joint appears to be maximally congruent radiographically when the calcaneus is placed in a vertical position.The dorsal and plantar cuboideonavicular and cuboideometatarsal ligaments and wedge-shaped fibroadipose labra within the CC joint and cuboid-metatarsal joints contribute to stability.The peroneus longus tendon, which forms a sling around the lateral and plantar aspects of the cuboid before inserting on the plantar aspect of the lateral first metatarsal base and medial cuneiform, also assists with CC joint stabilization. The cuboid is a pulley for the peroneus longus tendon; muscle contraction from midstance through the late propulsive phase exerts an eversion torque on the cuboid. Eversion of the cuboid via the peroneus longus tendon is thought to facilitate load transfer across the forefoot from lateral to medial as stance progresses.
Mechanism of Injury
There are two proposed mechanisms of injury:
- Plantar-flexion and Inversion Injuries: During rapid Plantar flexion and Inversion (i.e. mechanism of lateral ankle sprain) there is a strong reflex contraction of the peroneus longus muscle.During this forceful contraction the cuboid acts as a fulcrum, and the tendon then applies a force on the cuboid causing infero-medial displacement i.e. cuboid subluxation.
- Overuse Syndrome: This is uncommonly described and rarely seen but it is suggested that subluxation of the cuboid occurs secondary to repeated microtrauma secondary to vigourous activities.
- Midtarsal instability
- Excessive body weight
- Ill-fitting or poorly constructed orthoses or shoes
- Exercise (ie, intensity, duration, frequency)
- Training on uneven surfaces
- Sprain of the foot or ankle
- Cuboid syndrome may be more prevalent in individuals with pronated feet due to the increased moment arm of the peroneus longus.
The symptoms of cuboid syndrome resemble those of a ligament sprain. Pain is often diffuse along the lateral foot between the CC joint and the fourth and/or fifth cuboidmetatarsal joints and may radiate throughout the foot. A slight sulcus over the dorsum of the cuboid and/or a slight prominence or fullness on the plantar surface may be present with subluxation along with erythema, edema, and/or ecchymosis. Tenderness may be present along the peroneus longus tendon, the cuboid groove, the dorsolateral and/or plantar cuboid, or the origin of the extensor digitorum brevis muscle. Ankle and/or foot active and passive range of motion may be decreased due to pain. Resisted ankle/foot eversion or inversion may elicit pain. Antalgic gait is common with cuboid syndrome, with pain and/or weakness most pronounced during push-off or with side-to-side movements. Hopping may elicit symptoms,which increase with weight bearing and decrease with rest.
Although there are no defnitive validated diagnostic tests for cuboid syndrome, two clinical maneuvers have been described—the midtarsal adduction test and the midtarsal supination test. During the adduction test, the midtarsal joint is manipulated passively in the transverse plane (about a superior-inferior axis) while the calcaneus is stabilized This maneuver compresses the medial aspect of the CC joint and distracts the lateral side. The supination test is similar by adding inversion (frontal plane) and plantar ﬂexion (sagittal plane). Pain may also be elicited when the cuboid is passively translated dorsally or plantarly. This motion is decreased when the cuboid is “locked.” The diagnostic accuracy of these maneuvers has not been determined.
Multiple sources have recommended manipulation of the cuboid as the initial treatment for cuboid syndrome unless contraindicated (ie, bone disease, inﬂammatory arthritis, gout, neural or vascular compromise, or fracture). Two techniques have been described—the cuboid whip and the cuboid squeeze. For the cuboid whip, the clinician cups the dorsum of the patient’s forefoot, placing thumbs on the planto medial aspect of the cuboid. The patient’s knee is ﬂexed 70° to 90° while the ankle is placed in 0° dorsiﬂexion. With the patient’s leg relaxed, the clinician abruptly “whips” the foot into inversion and plantar ﬂexion while delivering a low-amplitude, high-velocity thrust (via the thumbs) to the cuboid. A “pop” or shift may be heard and/or felt by the clinician and/or patient during the thrust. During the cuboid squeeze, the clinician slowly stretches the ankle into maximal plantar ﬂexion and the foot and toes into maximal ﬂexion. When the clinician feels the dorsal soft tissues relax, the cuboid is “squeezed” (ie, forced dorsal) with the thumbs. The cuboid squeeze may not be appropriate for patients who have a coincident lateral ankle sprain, because the ankle is maximally plantar ﬂexed before the manipulation. Manipulation of the cuboid should be attempted only when edema and ecchymosis have significantly diminished and when the injured ankle capsule and ligaments have healed adequately to tolerate the stress of manipulation. Heel raise tolerance and/or reduced discomfort with passive dorsal-plantar cuboid gliding may be evidence of improvement after manipulation.
Patients who experience partial or incomplete symptom resolution may benefit from additional manipulations. There appears to be an association between the duration of symptoms and the number of manipulations required for complete symptom resolution. Some patients experience mild discomfort after the manipulation and may beneft from cryotherapy, non-thermal ultrasound, pain modulating electrical stimulation, or therapeutic massage. Patients should be advised to avoid vigorous weight bearing activities (eg, running) for several days after manipulation.Following successful manipulation, recurrence may be prevented by employing taping, orthoses, and/or cuboid padding. Various taping techniques have been suggested, with a common goal of supporting the medial longitudinal arch. Padding to support the plantar cuboid is commonly recommended for cuboid syndrome. The dimensions, thickness, and placement of the pad beneath the medial aspect of the cuboid are adjusted to prevent eversion of the cuboid (felt with a thickness of 1/8 or 1/4 in. [3-6 mm]). A lateral wedge under the calcaneus may also help reduce pain with weight bearing.Exercise strategies to mitigate over-pronation (stretching the gastrocs, soleus, peroneus; strengthening intrinsics, tibialis post. etc) as well as foot orthoses may help prevent recurrence of Cuboid syndrome.
- Fracture (rare) or dislocation of the cuboid, calcaneus, or fourth or fifth metatarsals
- Calcaneonavicular coalition
- Peroneal or extensor digitorum brevis tendinopathy
- Plantar fasciitis
- Sinus tarsi syndrome
- Meniscoid of the ankle
- Lisfranc injury
- Compression neuropathy of the sural nerve
- Lateral plantar nerve entrapment
- Anterolateral ankle impingement.3
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