(Also known as subluxed cuboid, cuboid fault syndrome, dropped cuboid, locked cuboid)
What is cuboid syndrome?
Cuboid syndrome is a condition characterized by subluxation (partial dislocation) of the cuboid bone in the foot (figure 1).
The foot comprises of many small bones, one of which is the cuboid (figure 1). The cuboid bone is situated at the outer aspect of the mid-foot and is connected to adjacent bones via strong connective tissue forming joints. These joints provide outer foot stability and allow movement to take place.
During weight bearing activity, certain movements of the foot and ankle and contraction of certain muscles of the lower leg and foot (e.g. peroneus longus), stress is placed on the cuboid bone and surrounding soft tissue. If these forces are excessive and beyond what the bone and surrounding soft tissue can withstand, tearing of the supportive connective tissue may occur. This may allow the cuboid bone to sublux or partially move out of its normal alignment relative to the adjacent foot bones. When this occurs, the condition is known as cuboid syndrome.
Causes of cuboid syndrome
Cuboid syndrome may develop due to excessive traction on the cuboid due to repetitive contraction of the peroneus longus muscle (figure 2). This may occur in association with Peroneus Longus Tendinopathy. Cuboid syndrome may also develop following a Sprained Ankle whereby the foot and ankle are turned inward excessively (inversion), therefore causing damage to the connective tissue holding the cuboid bone in position. Most patients who develop this condition have excessively pronated feet (flat feet) although the condition may also be seen in those with lateral ankle instability. Cuboid syndrome is particularly common in ballet dancers and runners.
Signs and symptoms of cuboid syndrome
Patients with cuboid syndrome usually experience outer (lateral) foot pain that increases with weight bearing forces through the outer foot and may cause weakness during the push off phase of walking. Pain will often increase with twisting or unguarded movements or with running (particularly on hard surfaces and in unsupportive shoes). Pain may radiate into the sole of the foot, the front of the ankle or into the toes. In more severe cases, the patient may limp or walk with an abnormal gait (e.g. walk on their toes) in attempt to reduce stress on the cuboid bone. Pain may also increase on firm palpation of the cuboid bone. Rest from weight-bearing activity usually eases symptoms, unless significant inflammation is involved. Pain upon initial weight-bearing in the morning is also common.
Diagnosis of cuboid syndrome
A thorough subjective and objective examination from a physiotherapist or doctor is important to assist with diagnosis of cuboid syndrome. Investigations such as an X-ray, MRI, CT scan, bone scan or ultrasound may be required in some cases to confirm diagnosis and rule out other injuries.
Treatment for cuboid syndrome
Most patients with cuboid syndrome heal with appropriate physiotherapy. Treatment usually comprises of manipulation of the cuboid bone to reverse the subluxation. This is often followed by protective padding and taping to maintain the position of the cuboid.
It is also important for patients to rest sufficiently from any activity that increases their pain until they are symptom free (crutches, protective taping or bracing may be required).
Rest from aggravating activities ensures the body can begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Treatment in the first 48 – 72 hours of injury is vital to reduce bleeding, swelling and inflammation. This should involve following the R.I.C.E regime which comprises of rest from aggravating activities (crutches are often required), regular icing, the use of a compression bandage and elevation of the affected limb. Anti-inflammatory medication may also be useful in this initial phase of injury and can hasten the healing process by reducing the pain and swelling associated with inflammation.
Patients with this condition should perform pain-free range of movement, strengthening and balance exercises early in the rehabilitation process to prevent stiffness and weakness from developing and to ensure the foot and ankle are functioning correctly. These exercises should generally be implemented as soon as pain allows and should be guided by the treating physiotherapist. A gradual return to activity should occur once the patient is pain-free, provided symptoms do not increase.
In some cases orthotics may be required as part of treatment and symptom prevention. Appropriate footwear is also important.
Prognosis of cuboid syndrome
Following appropriate manipulation from an experienced therapist, many patients with this condition may be symptom free. A gradual return to activity or sport can occur once symptoms settle. Patients with more severe injuries involving damage to other structures will usually require a longer period of rehabilitation to gain optimum function.
Physiotherapy for cuboid syndrome
Physiotherapy for patients with cuboid syndrome can hasten the healing process, ensure an optimal outcome and reduce the likelihood of symptom recurrence. Treatment may comprise:
- joint mobilization or manipulation
- cuboid padding
- protective taping
- soft tissue massage
- electrotherapy (e.g. ultrasound)
- anti-inflammatory advice
- the use of crutches
- the use of a brace
- the use of heel wedges
- ice or heat treatment
- exercises to improve flexibility, strength and balance
- footwear advice
- activity modification advice
- a graduated return to activity program
Other intervention for cuboid syndrome
Despite appropriate physiotherapy management, a small percentage of patients with this condition do not improve adequately and require other intervention. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigation such as an X-ray, CT scan, bone scan, ultrasound or MRI, pharmaceutical intervention, corticosteroid injection or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. A review with a podiatrist for the prescription of orthotics may also be indicated.
Exercises for cuboid syndrome
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Foot and Ankle Up and Down
Move your foot and ankle up and down as far as possible and comfortable without pain (figure 3). Repeat 10 times provided there is no increase in symptoms.
Figure 3 – Foot and Ankle Up and Down
Foot and Ankle In and Out
Move your foot and ankle in and out as far as possible and comfortable without pain (figure 4). Repeat 10 times provided there is no increase in symptoms.
Figure 4 – Foot and Ankle In and Out
Physiotherapy products for cuboid syndrome
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with condition include:
- Appropriate Footwear
- Heel Wedges
- Sports Tape (for protective taping)
- Ankle Braces
- Ice and Heat Packs
- Theraband (for strengthening exercises)
- Duradiscs and Wobble Boards (for rehabilitation)
To purchase physiotherapy products for cuboid syndrome click on one of the above links or visit the PhysioAdvisor Shop.
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