Cuboid Syndrome is a widespread source of pain on the foot's outer side. Regrettably, many medical professionals are not well-acquainted with this condition. It is also known by various names, such as subluxated cuboid, dropped cuboid, cuboid fault syndrome, and lateral plantar neuritis. (2)
Roughly 7% of people experience Cuboid Syndrome after an ankle sprain. This condition is even more common in the dance community, particularly among ballet dancers, with its prevalence rising to about 17%. (1,2)
Cuboid Syndrome can be described as a "minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint." Simply put, it means that the cuboid bone in the foot has shifted from its normal position within the joint and is now restricted or stuck, preventing it from moving as it typically would.
Article Index
Introduction
Anatomy & Biomechanics
Conclusion & References
Symptoms of Cuboid Syndrome
Cuboid Syndrome symptoms often resemble those of an ankle inversion sprain, which can lead to misdiagnosis or overlooking the condition. The pain caused by Cuboid Syndrome may or may not be a clear indication of the issue, as it can be intermittent or persistent and can develop suddenly or gradually over time. Some of the most common symptoms of Cuboid Syndrome include:
Pain that becomes more noticeable during the toe-off phase of the walking 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 side of the foot, along the peroneus longus tendon, or above or below the cuboid.
What Causes Cuboid Syndrome?
The causes of Cuboid Syndrome differ. Runners and dancers (particularly ballet dancers) are more prone to this injury due to the repetitive impact of their activities. As previously mentioned, Cuboid Syndrome is often linked to ankle inversion sprains, which are among the most frequent injuries for runners and dancers (1,5).
Certain common factors often emerge when examining the medical history or assessing patients with Cuboid Syndrome. Some of the primary factors contributing to this issue include (1,5):
Training on uneven surfaces.
A history of repeated ankle sprains.
Excessive foot pronation.
Insufficient foot support.
Utilizing inappropriate orthotic support.
Anatomy and Biomechanics
Successfully managing Cuboid Syndrome necessitates a fundamental knowledge of the anatomy and biomechanics of the foot. The cuboid bone is one of the seven tarsal bones constituting the foot's structure. This group of tarsal bones consists of the cuboid, medial, intermediate, and lateral cuneiform bones found in the midfoot, along with the navicular bone and the talus and calcaneus (heel bone) that form the hindfoot. (3)
The cuboid bone connects the fourth and fifth metatarsals at the front, establishing the tarsometatarsal joint. At the rear, it joins with the heel bone, the calcaneus, to form the calcaneocuboid, or CC joint. Medially, or on the inner side, the cuboid interacts with the lateral cuneiform and navicular bones. It's important to note that the cuboid and navicular synchronize their movements while walking. (3,4)
The proper functioning of the CC joint is instrumental in preserving normal walking patterns. The key movements of the CC joint include both medial and lateral rotations. During these movements, the calcaneus, or heel bone, is a pivotal point with an axis of rotation from front to back. The cuboid bone has the ability to rotate up to 25 degrees during standard foot movements, such as inversion and eversion (5). The CC joint boasts remarkable stability thanks to its well-aligned articular surfaces and the strong support it receives from tendon and ligament attachments.
Peroneus Longus Muscle
The peroneus longus muscle plays a crucial role in maintaining foot stability. Anatomically, the peroneus longus originates in the lateral lower leg (upper one-third of the fibula), runs down around the outside of the ankle (lateral malleolus), passes through the cuboid groove, and finally 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 aspects of the cuboid, providing additional foot stability. Specifically, the tendons of the peroneus longus and tibialis anterior create a sling beneath the middle part of the foot, supporting the medial arch (7).
Biomechanics of the Peroneus Longus Muscles:
The peroneus longus muscle participates in foot eversion, ankle plantar flexion, support of the foot's transverse arches, and stabilization of the lesser tarsals (6).
It also helps stabilize the big toe when pronating the subtalar joint (6).
Clinical Tip: The peroneus longus exhibits a different activation pattern in cases of ankle instability, often due to restrictions in the muscle. If these restrictions are not addressed, a runner may become more prone to future injuries (7).
The Remarkable Cuboid Pulley System
So, how do all these components work together? They are part of the incredible Cuboid Pulley System.
When examining the bottom of the cuboid bone, you can observe a groove through which the tendon of the peroneus longus muscle runs. This anatomical feature forms an efficient pulley system.
The Cuboid Pulley System enhances the mechanical advantage of the peroneus longus muscle. During the mid-stance to the late propulsion phase of walking, the contraction of the peroneus longus muscle generates an eversion torque on the cuboid bone. This torque distributes forces, allowing for propulsion. Research suggests that this force distribution aids in transferring the load across the forefoot from the foot's lateral aspect to its medial aspect (5,8).
Conclusion
Cuboid Syndrome, often mistaken for an ankle inversion sprain, is a condition characterized by specific foot pain patterns, especially noticeable during certain phases of walking. Its prevalence among runners and dancers underscores the importance of understanding the underlying anatomy and biomechanics of the foot. The intricate Cuboid Pulley System, powered by the peroneus longus muscle, is central to foot stability and force distribution during movement. Recognizing the nuances of this system, from the pivotal role of the CC joint to the synchronization of the cuboid and navicular bones, equips us to address and prevent potential disruptions effectively. In the upcoming second part of "Lateral Foot Pain - Cuboid Syndrome," we will delve deeper into examination procedures, treatment, and rehabilitation.
Stay tuned for insights on managing this injury during its acute stage, as well as comprehensive therapy and exercise rehabilitation suggestions. This knowledge is pivotal for those seeking to maintain optimal foot health and function.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References Part 1
Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. The american journal of sports medicine. 1992 Mar;20(2):169-75.
Davenport KL, Keskula DR. (2014). Managing cuboid syndrome in athletes. Current sports medicine reports, 13(6), 365-9.
Neumann, D. A. (2017). Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation (3rd ed.). Elsevier.
Subotnick SI. (1991). Cuboid syndrome. The American journal of sports medicine, 19(2), 192-4.
Durall, C. J. (2011). Examination and treatment of cuboid syndrome: a literature review. Sports Health, 3(6), 514-519. doi: 10.1177/1941738111417565
Adams, E., Madden, C., & Moley, P. (2015). Cuboid Syndrome. Current Sports Medicine Reports, 14(6), 465-469. doi: 10.1249/JSR.0000000000000214
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.
Greiner TM, Ball KA. The calcaneocuboid joint moves with three degrees of freedom. Journal of foot and ankle research. 2008 Sep;1(1):O39.
Forman WM, Green MA: The role of intrinsic musculature in the formation of inferior calcaneal exostoses. Clin Podiatr Med Surg. 1990;7:217-223.
Michaud, Thomas C.. Human Locomotion: The Conservative Management of Gait-Related Disorders (p.123). Newton Biomechanics.
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