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Lateral Foot Pain - Cuboid Syndrome Part 1


Trail Runners

Cuboid Syndrome is a common cause of pain on the outer side of the foot. Unfortunately, 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.


Approximately 7% of people experience Cuboid Syndrome after an ankle sprain. This condition is even more prevalent in the dance community, particularly among ballet dancers, with its occurrence rising to about 17%.


Cuboid Syndrome can be described as a "minor disruption or subluxation of the structural congruity of the calcaneocuboid portion of the midtarsal joint." In simpler terms, 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


 

Lateral Foot Image

Symptoms of Cuboid Syndrome


Cuboid Syndrome symptoms often resemble those of an ankle inversion sprain, which can lead to misdiagnosis or the condition being overlooked. The pain associated with Cuboid Syndrome can be intermittent or persistent and may develop suddenly or gradually. Common symptoms include:


  • Pain that becomes more noticeable during the toe-off phase of walking or upon impact.

  • Lateral foot pain between the calcaneocuboid 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 vary. Runners and dancers, particularly ballet dancers, are more susceptible to this injury due to the repetitive impact of their activities. As previously mentioned, Cuboid Syndrome is often associated with ankle inversion sprains, which are among the most common injuries for runners and dancers.

Ballet Dancer

Certain factors frequently emerge when examining the medical history or assessing patients with Cuboid Syndrome. Some of the primary contributing factors include:


  • 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 requires a fundamental understanding of the foot's anatomy and biomechanics. The cuboid bone is one of the seven tarsal bones that form the foot's structure. These tarsal bones include the cuboid, medial, intermediate, and lateral cuneiform bones in the midfoot, as well as the navicular bone, talus, and calcaneus (heel bone) that make up the hindfoot.

Osseous Anatomy Image

The cuboid bone connects to the fourth and fifth metatarsals at the front, forming the tarsometatarsal joint. At the rear, it joins with the heel bone, the calcaneus, to create the calcaneocuboid (CC) joint. Medially, the cuboid interacts with the lateral cuneiform and navicular bones, and it is important to note that the cuboid and navicular synchronize their movements while walking.


Proper functioning of the CC joint is crucial for maintaining normal walking patterns. The key movements of the CC joint include medial and lateral rotations, with the calcaneus serving as a pivotal point and an axis of rotation running from front to back. The cuboid bone can rotate up to 25 degrees during standard foot movements, such as inversion and eversion. The CC joint maintains remarkable stability due to its well-aligned articular surfaces and strong support from tendon and ligament attachments.


Peroneus Longus Muscle Image

Peroneus Longus Muscle

The peroneus longus muscle is essential for foot stability. It originates in the lateral lower leg (upper one-third of the fibula), runs down around the lateral malleolus, passes through the cuboid groove, and inserts into the base of the first metatarsal and cuneiform.


Along its path, the peroneus longus forms a sling around the lateral and medial aspects of the cuboid, enhancing foot stability. The tendons of the peroneus longus and tibialis anterior support the medial arch by creating a sling beneath the middle part of the foot.


Biomechanics of the Peroneus Longus Muscle:


  • Participates in foot eversion and ankle plantar flexion

  • Supports the foot's transverse arches

  • Stabilizes the lesser tarsals and the big toe during pronation of the subtalar joint


Clinical Tip: The peroneus longus activates differently in cases of ankle instability, often due to muscle restrictions. If not addressed, these restrictions can increase the risk of future injuries for runners.


 
Cuboid Pulley System Image

The Remarkable Cuboid Pulley System


How do all these components work together? They form the incredible Cuboid Pulley System.


At the bottom of the cuboid bone, there's a groove where the tendon of the peroneus longus muscle runs, creating an efficient pulley system.


This system enhances the mechanical advantage of the peroneus longus muscle. During the mid-stance to late propulsion phase of walking, the contraction of the peroneus longus generates an eversion torque on the cuboid bone. This torque distributes forces, facilitating propulsion. Research suggests this force distribution helps transfer the load across the forefoot from the lateral to the medial aspect of the foot.



 

Conclusion


Cuboid Syndrome, often mistaken for an ankle inversion sprain, is characterized by specific foot pain patterns, especially noticeable during certain phases of walking. Its prevalence among runners and dancers highlights the importance of understanding the foot's anatomy and biomechanics. The intricate Cuboid Pulley System, driven by the peroneus longus muscle, is crucial for foot stability and force distribution during movement. Recognizing the nuances of this system, including the pivotal role of the CC joint and the synchronization of the cuboid and navicular bones, helps us effectively address and prevent potential disruptions.


In the upcoming second part of "Lateral Foot Pain - Cuboid Syndrome," we will explore examination procedures, treatment, and rehabilitation in greater detail. Stay tuned for insights on managing this injury during its acute stage, along with comprehensive therapy and exercise rehabilitation suggestions. This knowledge is essential for maintaining optimal foot health and function.




 

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. Davenport KL, Keskula DR. (2014). Managing cuboid syndrome in athletes. Current sports medicine reports, 13(6), 365-9.

  3. Neumann, D. A. (2017). Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation (3rd ed.). Elsevier.

  4. Subotnick SI. (1991). Cuboid syndrome. The American journal of sports medicine, 19(2), 192-4.

  5. Durall, C. J. (2011). Examination and treatment of cuboid syndrome: a literature review. Sports Health, 3(6), 514-519. doi: 10.1177/1941738111417565

  6. Adams, E., Madden, C., & Moley, P. (2015). Cuboid Syndrome. Current Sports Medicine Reports, 14(6), 465-469. doi: 10.1249/JSR.0000000000000214

  7. 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.

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

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

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


 

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DR. BRIAN ABELSON, DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.




 


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