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Lateral Foot Pain - Cuboid Syndrome Part 2

Updated: Jul 4


Runners coming out of the racing blocks

In the first part of "Lateral Foot Pain - Cuboid Syndrome," we explored the symptoms, causes, anatomy, and biomechanics of Cuboid Syndrome. We discussed how this condition affects foot function and highlighted the underlying factors contributing to its development. This second part will focus on the detailed examination procedures and effective treatment strategies for managing Cuboid Syndrome. We will provide practical insights into identifying the condition accurately and offer comprehensive therapeutic approaches to alleviate pain and restore optimal foot health.


Article Index:

 

Examination of Cuboid Syndrome

Doctor examining patient

During a physical assessment for Cuboid Syndrome:

  • Patients often experience pain directly over the cuboid bone, intensifying with dorsal pressure on the plantar surface.

  • Symptoms such as bruising, inflammation, and redness may be present in some cases.

  • Ankle flexibility is frequently reduced during both dorsiflexion and plantar flexion.

  • Pain typically occurs during resisted foot or ankle inversion or eversion.

  • An antalgic gait, characterized by avoiding pain, is common. This is especially noticeable during the push-off phase of walking and lateral movements.


Two Specific Tests


Two recommended diagnostic tests for Cuboid Syndrome are the Midtarsal Adduction Test and the Midtarsal Supination Test. Pain during either test may indicate Cuboid Syndrome:


  • Midtarsal Adduction Test: One hand stabilizes the ankle and subtalar joint while the other hand applies an adduction force in the transverse plane.

  • Midtarsal Supination Test: This test assesses the cuboid's involvement through inversion in the frontal plane and plantar flexion in the sagittal plane.


Examination Videos

The following videos demonstrate common procedures for analyzing ankles and feet for potential issues.


Ankle and Foot Examination Video
Click Image to Watch Video

Ankle and Foot Examination

This video uses orthopedic tests to evaluate some of the most common ankle and foot conditions we see in clinical practice. These conditions include Ankle Sprains (inversion sprain), Cuboid Syndrome, Talar Dome Lesions, 5th Metatarsal Fracture, Syndesmosis damage, Achilles Tendon Tendinopathy, Morton's Neuroma, 2nd Metatarsal Stress Fracture, Plantar Fasciitis, and Bunions.


Lower Limb Neuro Examination

The lower limb neurological examination is part of the overall neurological examination process and assesses the motor and sensory neurons that supply the lower limbs. This assessment helps detect any impairment of the nervous system and is used both as a screening and an investigative tool.


Peripheral Vascular Examination - Key Points

A peripheral vascular examination is valuable for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. This video reviews some common procedures we perform in daily clinical practice.


Imaging

Imaging techniques such as X-rays, CT scans, or MRIs typically have limited effectiveness in diagnosing Cuboid Syndrome. However, an X-ray can be valuable for ruling out fractures or other pathological conditions during the diagnostic process.


 


Cuboid Syndrome Treatment

Treatment


The treatment for Cuboid Syndrome depends on the injury's phase and the diagnostic conclusions regarding the affected structures. In the following sections, we discuss:

  • Acute Phase of Cuboid Syndrome

  • Manual Therapy for Cuboid Syndrome

  • Cuboid Whip Manipulation

  • Cuboid Squeeze Technique


Acute Phase of Cuboid Syndrome:

During the acute phase of a Cuboid injury, you may experience increased swelling, pain, and inflammation in the foot. This phase generally lasts for 2-48 hours after the injury. Here are some recommendations for patients during the acute phase of Cuboid Syndrome (note that actual recommendations may vary from case to case):


  • Rest: Avoid weight-bearing activities during this phase. If weight-bearing is intolerable, crutches may be necessary.

  • Ice: For the first 48 to 72 hours, ice the affected area for 15-20 minutes several times daily. Direct ice massage can also be performed for 7-9 minutes, 2-3 times daily.

  • Compression: To help reduce swelling, use a compression sleeve, wrap, or taping. Ensure it is not too tight to maintain proper circulation.

  • Elevation: Keep your legs elevated above the heart to help reduce pain and swelling, especially at nighttime.

  • Foot Mobility Exercises: Perform non-impact, range-of-motion exercises without pushing to the end range (no pain, all gain).

  • Begin Manual Therapy ASAP: In most cases, manipulation and soft tissue therapy can begin immediately. The exact procedures used for treatment will vary with each case of Cuboid Syndrome.



 

Osseous Manipulation Image

Osseous Manipulation

Osseous manipulation is frequently recommended for treating Cuboid Syndrome unless contraindicated by fractures, infections, active inflammatory arthritis, or vascular disease.


Cuboid Whip and Cuboid Squeeze Techniques


Cuboid Whip Manipulation

  • In this procedure, the patient lies face down, flexing their knee between 70 and 90 degrees. The clinician cups the top of the foot with thumbs on the cuboid bone's inner side. The patient relaxes their leg, keeping the ankle in a neutral position. The clinician then "whips" the patient's foot into inversion and plantar flexion while delivering a high-velocity, low-amplitude thrust to the cuboid.


Cuboid Squeeze Technique

  • To perform the Cuboid Squeeze, the practitioner stretches the ankle into maximum plantar flexion and the foot and toes into maximum flexion. When the clinician feels the soft tissues relax, the cuboid is "squeezed" dorsally with the thumbs.


Not Just the Cuboid Bone

In addition to adjusting the cuboid bone alone, loosening various constraints in the ankle and foot might be required. In the following demonstration video, Dr. Abelson illustrates the process. Please remember that this video is purely for demonstration purposes and should not be interpreted as a therapeutic recommendation.


MSR - 7 Point Ankle & Foot Mobilization

Improving joint mobility is critical if you effectively address the body's full kinetic chain. Any myofascial treatment greatly reduces its effectiveness if we don’t also address restrictions in joint mobility. Joint mobilization reverses adverse physiological changes by promoting movement between capsular fibres.



 

Soft Tissue Treatment

In addition to focusing on the cuboid bone, addressing any soft tissue restrictions involving muscles, tendons, ligaments, fascia, and nerve entrapments is crucial. Conservative therapy can be highly effective for this purpose. The following demonstration videos highlight procedures that can address soft tissue restrictions in cases of Cuboid Syndrome.


4 Point Dorsi Flexion Protocol - Motion Specific Release (MSR)

Dorsiflexion is the movement at the ankle joint where the toes are brought closer to the shin. The shins' muscles help your foot clear the ground during the Swing Phase (concentric contraction) of your stride and absorb much of the impact shock during running.





MSR Calf Muscle + Tom, Dick, and Harry Release

In the video, Dr. Abelson, the developer of MSR, demonstrates how to effectively release both the superficial calf muscles (gastrocnemius and soleus) and the deeper muscles Tom, Dick, and Harry (TDH). Tom, Dick, and Harry stand for T=Tibialis posterior, D=Flexor digitorum longus, an=posterior tibial artery and tibial nerve, and H=Flexor hallucis longus.


 

Treatment Frequency Recommendations


The treatment strategy is crafted to adapt to the patient's evolving response to manual therapy for cuboid syndrome. Continuous communication between the patient and therapist is essential to adjust treatment. Notably, techniques focusing on cuboid repositioning, combined with exercises, have been highly effective in managing cuboid syndrome, leading most patients to substantial relief and recovery. Adherence to treatments and at-home exercises is key for optimal results.


Initial Treatment Phase:


  • Objective: Reduce acute inflammation and pain, improve local blood flow, and initiate healing.

  • Frequency: 2-3 times a week.


Response Assessment:


  • After two weeks of initial treatment.

Positive Response:

  • Frequency: Reduce sessions to once a week and review weekly.

Persistent Symptoms:

  • Frequency: Maintain sessions at 2-3 times a week, review each week.


Cessation of Treatment:


  • Complete resolution of symptoms: If the patient has no pain, discomfort, or any functional limitations related to Cuboid Syndrome, these results are consistent over several sessions.

  • Lack of progress: If after an extended period (e.g., 6-8 weeks), the patient sees no improvement or even worsening of symptoms despite different treatment strategies.


When to Make an Appropriate Referral:


  • Diagnostic ambiguity: If the therapist is uncertain about the diagnosis or feels there's an underlying condition not within their scope.

  • Complex presentations: If the patient presents with symptoms suggesting a more complex condition, like a systemic disease or neurologic issues.

  • Persistent symptoms: If symptoms do not improve despite consistent treatment, suggest another specialty's intervention is required.


Transition to Maintenance Care:


  • Objective: To ensure the gains from therapy are maintained and to prevent the recurrence of symptoms.

  • Criteria: A consistent reduction in symptoms, restoration of foot biomechanics, and the patient's ability to engage in regular activities without pain.

  • Frequency: Once every 2-4 weeks, then gradually lengthening the interval between sessions as long as the patient remains symptom-free.

  • Logic: The body might still have vulnerabilities while the patient has improved. Regular check-ins allow the practitioner to catch and address minor issues before they become significant problems.


The recommendations are based on a combination of best practices, logical deduction, and an understanding of Cuboid Syndrome's typical clinical course. They serve as guidelines and can be adjusted based on individual presentations and the practitioner's clinical judgment.


 

Exercises for Cuboid Syndrome


Physical activity is essential in any effective therapy plan. As patients progress beyond the acute phase of Cuboid Syndrome, their exercises should focus on three key areas: flexibility, muscle strengthening, and balance.


The following demonstration videos highlight a variety of exercises that may be recommended for patients with Cuboid Syndrome. These exercises are tailored to meet each patient's unique needs, ensuring a personalized and effective approach to recovery.

Peroneal Muscle - Stretching & Myofascial Release

The peroneal muscles are a key link in foot stability. This video shows you several ways to stretch and release myofascial restrictions.








Stretching Your Calf Muscles

This video shows calf stretches for both your calf muscles, the gastrocnemius and soleus. Minor changes in technique can make a huge difference in increasing your calf flexibility.








Foot & Ankle Strengthening Routine

This foot and ankle strengthening routine uses a Theraband to work the flexors, extensors, and internal and external foot rotators.









Improve Your Balance - Exercises for Beginners

Balance exercises are a fundamental aspect of training that should not be ignored in rehabilitation or Sports Performance training. Improve your balance with these simple exercises. Using our progression techniques, you can ensure that you perform these exercises safely without increased risk of injury.



 


Treating Cuboid Syndrome

Conclusion


In the first part of "Lateral Foot Pain—Cuboid Syndrome," we examined the symptoms, causes, anatomy, and biomechanics of Cuboid Syndrome. This second part focused on detailed examination procedures and effective treatment strategies. We provided practical insights into accurately identifying the condition and offered therapeutic approaches to alleviate pain and restore foot health.


Managing Cuboid Syndrome requires a combination of osseous manipulation, soft tissue therapy, and targeted exercises for flexibility, strength, and balance. Initial treatments include rest, ice, compression, and elevation, followed by manual therapy and tailored exercises.


Regular treatment plan assessment and adjustment ensure progress and address persistent symptoms. By following these recommendations, practitioners and patients can work together to maintain optimal foot health and prevent future issues related to Cuboid Syndrome.


 

REFERENCES - PART 2

  1. Cuboid subluxation in ballet dancers. Marshall P, Hamilton WG Am J Sports Med. 1992 Mar-Apr; 20(2):169-75

  2. The talonavicular and calcaneocuboid joints: anatomy, biomechanics, and clinical management of the transverse tarsal joint. Sammarco VJ Foot Ankle Clin. 2004 Mar; 9(1):127-45.

  3. Rademaker J, Sadka Rosenberg Z, Delfaut EM, et al. Tear of the peroneus longus tendon: MR imaging features in nine patients. Radiology 2000;214:700-704.

  4. Chopart's joint load during gait. In vitro study of 10 cadaver specimen in a dynamic model. Suckel A, Muller O, Langenstein P, Herberts T, Reize P, Wulker N Gait Posture. 2008 Feb; 27(2):216-22.

  5. Durall CJ. Examination and treatment of cuboid syndrome: a literature review. Sports Health. 2011;3(6):514-9. doi: 10.1177/1941738111417565

  6. Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. J Orthop Sports Phys Ther. 2005;35(7):409-15. doi: 10.2519/jospt.2005.35.7.409

  7. Mooney M, Maffey-Ward L, Ganley EJ. Cuboid plantar and dorsal subluxations: assessment and treatment. J Orthop Sports Phys Ther. 1999;29(9):546-52. doi: 10.2519/jospt.1999.29.9.546

  8. Adams E, Madden C. Cuboid subluxation: a case report and review of the literature. J Am Podiatr Med Assoc. 2009;99(4):348-54. doi: 10.7547/0980348

  9. Kaeser M, Wyss C, Bashir S, Brunner R. Subluxation of the cuboid bone: a case report. J Foot Ankle Surg. 2014;53(4):467-71. doi: 10.1053/j.jfas.2013.09.012

  10. Price C. The role of the cuboid in the foot: a review of the literature. Foot Ankle Surg. 2019;25(5):609-13. doi: 10.1016/j.fas.2018.10.010

  11. Newell SG, Woodle A. Cuboid syndrome. Phys Ther. 1981;61(1):42-4. PMID: 7450760

  12. Cohen I. Cuboid syndrome. J Am Podiatr Med Assoc. 1983;73(11):577-82. doi: 10.7547/87507315-73-11-577


 
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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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