Cuboid Syndrome is a common cause of lateral foot pain. Unfortunately, this syndrome is not well-recognized by the majority of medical practitioners. Cuboid Syndrome also goes by several other names: subluxated cuboid, dropped cuboid, cuboid fault syndrome, and lateral plantar neuritis.

Approximately 7% of the population experience Cuboid Syndrome after an ankle sprain. Within the dance community (especially ballet dancers), this syndrome is much more prevalent, rising up to about 17%. (1,2)

Cuboid Syndrome is defined as a “minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint”. In non-confusing laymen’s terms, it means the cuboid bone of the foot has moved from its normal position within the joint, and is now stuck or restricted from its normal range-of-motion.

ANATOMY & BIO-MECHANICS OF THE CUBOID BONE

It is important to understand something of the anatomy and biomechanics of the foot in order to effectively resolve this syndrome. The cuboid bone is one of the seven tarsal bones of the foot. The tarsal bones are comprised of the cuboid, medial, intermediate, and lateral cuneiform, navicular in the midfoot, and the talus and calcaneus (heel bone) in the hindfoot. See the following image:

The cuboid bone articulates anteriorly with the fourth and fifth metatarsals to form the tarsometatarsal joint. The cuboid also articulates posteriorly with the heel bone (calcaneus) to form the calcaneocuboid or CC joint. On the inside (medially), the cuboid articulates with two bones, the lateral cuneiform and the navicular. It is important to keep in mind that the cuboid and the navicular move in tandem during gait. (3)

The proper movement of the CC joint is very important if you want to maintain normal gait patterns.

• The primary movements of the CC joint are for medial and lateral rotation. During these motions the heel bone (calcaneus) acts as a pivot with an anterior-posterior axis of rotation.

• With normal foot motion (inversion and eversion), the cuboid bone can rotate as much as 25 degrees. (4)

• The CC joint is very stable due to the perfect encasing of it’s articular surfaces, and because it is well reinforced by both tendon and ligamentous attachments.

THE PERONEUS LONGUS MUSCLE

The peroneus longus muscle performs an important role in maintaining foot stability. Anatomically, the peroneus longus:

• Originates on the lateral lower leg (upper one-third of the fibula).

• It then runs down around the outside of the ankle (lateral malleolus) then through the cuboid grove.

• Finally, it inserts into the base of the first metatarsal and cuneiform.

• Along its path, the peroneus longus muscle forms a sling around the lateral and medial aspect of the cuboid, to create even more stability for the foot. Specifically, the tendons of the peroneus longus and tibialis anterior form a sling under the middle part of the foot. Together, this sling supports the medial arch of the foot. (7)

BIOMECHANICS OF THE PERONEUS LONGUS MUSCLES

• The peroneus longus muscle is involved in foot eversion, ankle plantar flexion, support of the transverse arches of the foot, and in stabilizing the lesser tarsals. (6)

• The peroneus longus muscle helps to stabilize the big toe when the subtalar joint is pronated. (6)

CLINICAL TIP: The peroneus longus shows a different activation pattern when there is ankle instability. This is often due to restrictions that have formed in the muscle. These restrictions, if not removed, could make a runner more susceptible to future injuries. (7)

THE AMAZING CUBOID PULLEY SYSTEM

So, how do these components all work together? It is all part of the amazing Cuboid Pulley System.

If you view the bottom of the cuboid bone, you can see a groove along which the tendon of the peroneus longus muscle runs. This anatomical feature creates a very effective pulley system.

The Cuboid Pulley System works to increase the mechanical advantage for the peroneus longus muscle. During the mid-stance to the late propulsion phase of gait, the contraction of the peroneus longus muscle causes an eversion torque on the cuboid bone, which distributes forces allowing for propulsion. Research has postulated that this force distribution facilitates load transfer across the forefoot from the lateral aspect of the foot to the medial aspect. (5)

WHAT CAUSES CUBOID SYNDROME?

The causes of Cuboid Syndrome are varied. Runners and dancers (especially ballet dancers) are more susceptible to this injury because of the high levels of repetitive impact in their sports. As we mentioned, Cuboid Syndrome is often associated with ankle inversion sprains, which are one of most common injuries for runners and dancers.

We often see certain common factors when reviewing the patient’s history or during examination of patients who may be suffering from Cuboid Syndrome. Some of key factors causing this problem include:

• Training on uneven surfaces.

• Previous history of repeated ankle sprains.

• Excessive foot pronation.

• Lack of good foot support.

• Using the wrong type of orthotic support.

SYMPTOMS OF CUBOID SYNDROME

The symptoms of Cuboid Syndrome are often very similar to those of an ankle inversion sprain. This can lead to the practitioner overlooking, or misdiagnosing this syndrome. The type of pain caused by Cuboid Syndrome may or (may not) be a very good indication of this condition. Since pain can be intermittent or persistent, it can also develop suddenly, or slowly over a period of time. Some of the most common symptoms of Cuboid Syndrome include:

• Pain that is more noticeable during the toe-off portion of the gait cycle, or upon impact. (2)

• Lateral foot pain between the CC joint and the fourth and fifth cuboid metatarsal joints.

• Tenderness along the entire lateral aspect of the foot, along the peroneus longus tendon, or above or below the cuboid.

In part two of Lateral Foot Pain - Cuboid Syndrome, we will go the over the examination processes, followed by the treatment and rehabilitation of Cuboid Syndrome.

We will discuss how to address this injury during the acute stage, then provide recommendations for treatment therapy and exercise rehabilitation.

Lateral Foot Pain Part 1 - Cuboid Syndrome

Lateral Foot Pain Part 2 - Diagnosis & Treatment

REFERENCES PART - 1

1. Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. The american journal of sports medicine. 1992 Mar;20(2):169-75.

2. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. Journal of orthopaedic & sports physical therapy. 2005 Jul;35(7):409-15.

3. Hardy RH. Observations on the structure and properties of the plantar calcaneo-navicular ligament in man. Journal of anatomy. 1951 Apr;85(Pt 2):135.

4. Greiner TM, Ball KA. The calcaneocuboid joint moves with three degrees of freedom. Journal of foot and ankle research. 2008 Sep;1(1):O39.

5. Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off.Bojsen-Møller F J Anat. 1979 Aug; 129(Pt 1):165-76.

6. Forman WM, Green MA: The role of intrinsic musculature in the formation of inferior calcaneal exostoses. Clin Podiatr Med Surg. 1990;7:217-223.

7. Michaud, Thomas C.. Human Locomotion: The Conservative Management of Gait-Related Disorders (p.123). Newton Biomechanics.

DR. BRIAN ABELSON DC.

Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.

Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.

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