Mitrulescu Paiseanu Catalin C. , Faur Cosmin University of Medicine and Pharmacy Victor Babeș Timișoara – 2nd Department of Orthopedics and Traumatology

In the current practice, the orthopaedic practicioner is often placed in the difficult situation of treating hard to diagnose syndromes. The cuboid syndrome is one of them and this article is aimed at guiding any health care professional in making a correct diagnosis, and, once this step is finished, the treatment will be usual easy and straightforward. Any orthopaedist should be aware that any lateral foot and ankle pain may be the result of cuboid syndrome. Once properly diagnosed, the patient responds exceptionally well to conservative treatment by manipulation. Occasionally, if the symptoms have been persistent for more than one week, more than one manipulation may be required. Because the imaging studies aren’t helpful, the diagnosis is made only by physical examination and the history of the patient. KEYWORDS: CUBOID SYNDROME, SUBLUXATION, MANIPULATION

CASE 1 The patient is a 45 years old male who had persistent lateral ankle pain since 30 days ago. He remembered having a mild twisting injury of his left ankle, and since that time, the problem persisted. The mechanism of the injury was forced inversion with plantar flexion. He thought that his pain is a normal one and he delayed his presentation to the doctor. The inspection of his left foot didn’t reveal anything abnormal. His pain was reproduced when walking, especially in the toe off phase. He had tried AINS medication before, but they were of little help. At palpation, the pain was reproduced when pushing down (dorso-plantar) the cuboid zone. Also, pain was reproduced when applying the force in the opposite way from the plantar aspect. The degree of motion in the articulation between the 4-th and 5-th metatarsal and the cuboid was diminished compared to the contralateral foot. The midtarsal adduction test was positive. The test is performed with ankle and subtalar joint stabilized with one hand, while the other puts and adduction force on the forefoot.

other possibilities exists. Later on. The pain was present only when weight-bearing. in activities where the foot abruptly pronates. The x-rays were normal. peroneal cuboid syndrome. It is often a mistreated and misdiagnosed condition 1. with an incidence of 6. The patient was sent to x-ray in order to exclude another possible diagnosis. The incidence is thought to be serious underestimated. This patient had no further x-ray imaging taken. During palpation. when he attempted to walk he felt pain in the lateral aspect of the foot. who presented in our department following a common inversion ankle sprain. CASE 2 The patient is a 22 years old male. Also.Also the midtarsal supination test was positive. The most frequently encountered etiology is a plantar flexion inversion ankle sprain3. that many were further diagnosed at a close follow up with cuboid syndrome. grade 1/2. To perform this test. the examiner grasp with one hand the patient ankle and stabilizes it together with the subtalar joint. He was put in a splint for 3 days and afterwards he continued the immobilization with an elastic bandage. The pain was radiating in the fourth ray. However. The syndrome consists in a minor disruption or subluxation of the calcaneocuboid portion of the midtarsal joint. During the last four days. some warmth and slight edematous feel could be revealed in the dorsal aspect of the cuboid. In a study Newell and Woodle 2 found a 4 % incidence among the athletes. He presented to a new medical visit 8 days later after the initial injury. he exhibited pain on the plantar and dorsal aspect of the cuboid. lateral plantar neuritis. and with the other hand applies a supination motion (inversion. who sustained a plantar and inversion ankle sprain.7 %. Because of the derangement in cuboid position. stating that his original pain didn’t improve during this week. in 2005. the surrounding soft tissues are being irritated. being either an . Jennings and Davies 3 found in a patient series of 107. The midtarsal supination test was positive. plantar flexion and forefoot adduction ). sine the x-rays taken 8 days before didn’t reveal anything abnormal. DISCUSSION The cuboid syndrome has many different names: subluxed cuboid. being mainly restricted to bed for another 4 days.

In the case of a severe subluxation. a plantar subluxation may appear and a lump can be visible on the plantar aspect and a small depression on the dorsum of the cuboid7. The palpation can also discover a warmth and slight edematous feel8. Pain is elicited directly onto the cuboid. where the incidence could be even higher. Fig. .1 Pathomecanics of cuboid syndrome Patients will most commonly present with pain that develops rapidly or occurs gradually overtime as a sequel to an inversion ankle sprain or small microtraumas that overwhelms the ligaments and joint capsule of the lateral column6.this happens in ballet dancers. At inspection. especially during the toe-off phase1. It is thought that the peroneus longus plays an important role in the pathomechanics of this syndrome. either an overuse syndrome . but usually it is present only when walking.1).acute. occasionally swelling. The pain may be located directly over the cuboid or it may radiate into the plantar medial arch or along the fourth metatarsal in a distal manner4.2 and Fig. since the cuboid acts as a fix point and the tendon as a lever5 (Fig. redness and echymosis may be present.3 ).17%4. The pain may even be present when resting. both on the plantar and dorsal aspect(Fig. The pain may also arise from the extensor digitorum brevis muscle.

2 Palpation on the plantar and Fig. Fig. The midtarsal joint can also be tested using the midtarsal adduction test (Fig.4 Midtarsal adduction test Fig. Also compressing the structures involved in this syndrome can reproduce pain. 5 )1.7. 4) and midtarsal supination test(Fig.5 Midtarsal supination test The diagnosis is almost entirely clinical.4. the radiographs being used only to rule out a fracture or other pathology. may be indicative for cuboid syndrome9. by pronation and abduction3. Resisted inversion. CT or MRI is of little help.3.Fig.3 dorsal aspect of the cuboid Special diagnostic tests are being used. The use of x-rays. since the disruption or subluxation is so small that none of this imaging studies can be of help1. . when producing pain along the peroneus longus as it passes underneath the cuboid. with the ad of the patient history.

While placing the ankle gradually in maximal plantar flexion. the treatment should be generally quite simple. the ankle is being plantar flexed and we apply slight suppination to the subtalar joint. stress fracture of the cuboid. The clinician puts the fingers on the dorsal aspect of the foot.6 ). The patient is lying in a prone position. with the knee flexed to approximately 700. After the diagnostic is made. The first manipulation technique was described by Newell and Woodle in 19812. peroneal and extensor digitorum brevis tendonitis. The test is called the’’ cuboid whip ‘’. while the thumbs are positioned on the plantar aspect of the cuboid. such as taping. therapeutic exercises. The pressure is applied through the thumbs (Fig. padding. the knee is being extended. a ‘click’ can be felt or heard by the clinician or the patient as the cuboid is successful put back into its place4. Occasionally.4. gout. the soft tissues relaxes and the cuboid is squeezed with the thumbs. 6 Cuboid ‘whip’ manipulation The contraindication for manipulation of the cuboid consists of inflammatory arthritis.The differential diagnosis is made with a more severe subluxation or luxation of the cuboid. Fig. . the cuboid usually returns to its exact anatomic position and the patient reports a complete cessation of symptoms or at least a mark decrease in pain1. sinus tarsi syndrome. This test was later adapted by Marshall and Hamilton to the ’’cuboid squeze’’ test.7. which is better suited for a syndrome following an overuse injury4. consisting of cuboid manipulation. fracture of the anterior calcaneal process. This technique is suitable for cuboid syndrome that is following a plantar flexion inversion ankle sprain 3. lateral plantar nerve entrapment. The patient’s knee is put into flexion in order to relax the gastrocnemius and to avoid stretching the superficial peroneal nerve. fracture of the cuboid. Jone’s fracture. Beginning with the knee in 70-90 0 of flexion and the ankle in 00 of dorsiflexion. After manipulation. Other helpful therapies may be used. neural or vascular disorders6.

Journal of Orthopedic and Sports Physical Therapy 335(7). J. (1981) Cuboid Syndrome. The two patients from this report responded very well to the ‘cuboid whip ‘ manipulation. during a 2 day period. If the syndrome has been present for one week. (1987) Cuboid syndrome and the significance of midtarsal joint stability. it is recommended that physical therapy to be used. and Morris. In the first case 2 manipulations were needed for complete resolution of symptoms. Journal of the American Podiatry Medical Association 777(12). and also strengthening the intrinsic and extrinsic muscle of the foot7. T. A. CONCLUSION The cuboid syndrome is an easy to treat condition. 409-415. J. 7176. 2. both of the patients were symptom free. Physician and Sports Medicine 9. If the manipulation is successful. S. At 1 week and 1 month follow up. . Newell. and Davies.J. BIBLIOGRAPHY 1. (2005) Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series.J. and Woodle.In the case the manipulation fails.Blakeslee. The doctor must have a high degree of suspicious for this syndrome when in the face of a patient with persistent lateral column ankle pain following an ankle sprain. G. the patient may resume its previous activities. for avoiding recurrences. 2 manipulations may be required2. 638-642. 3 or 4 manipulation may be needed2. 3. and if the symptoms had been present for more than 2 weeks. the incidence of this pathology being probably highly underestimated. it should be abandoned and tried the next day. focusing on stretching the peroneus longus and triceps suralis. enhancing proprioception by neuromuscular control exercises. meaning a great improve or the disappear of pain.G. The second patient had complete resolution of symptoms after the first manipulation. yet the diagnosis may be quite challenging. For the long term.L. Jennings.

Marshall. Davis Company. N. 8. 2nd edition. (1994) Cuboid plantar and dorsal subluxations: assessment and treatment. Journal of the American Podiatry Medical Association 779(8). Caselli. 169-175. Newell. L. (1992) Cuboid subluxation in ballet dancers. 220-226.A. 413-414. A. 9. Subotnick. and Maffey-Ward. (1989) Peroneal cuboid syndrome. W. 7. and Pantelaras. (2002) Evaluation of orthopedic and athletic injuries. . (1981) Cuboid Syndrome. Journal of Orthopedic and Sports Physical Therapy 220(4). M. 5. and Hamilton. S. Philadelphia. 6. American Journal of Sports Medicine 220(2).A. 76-80. and Woodle. (2004) How to treat cuboid syndrome in the athlete. PA.4. M. 7176. Physician and Sports Medicine 9.I. S. C. Starkey. P. F. Podiatry Today 117(10). and Ryan. Mooney.G. J.G.

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