Lateral Foot Pain Part 2 - Diagnosis & Treatment
Updated: May 10
In part one of "Lateral Foot Pain - Cuboid Syndrome" we discussed anatomy, biomechanics, symptoms and causes of cuboid syndrome. In part two we focus on the examination, and treatment of Cuboid Syndrome.
EXAMINATION, EVALUATION, AND IMAGING OF THE CUBOID
During physical examination:
The patient may have pain directly over the cuboid bone (especially when pressure is applied dorsally on the plantar surface).
In some cases there may be bruising, redness and swelling.
Range-of-motion in the ankle is often limited during both dorsi and plantar flexion.
It is common for resisted foot or ankle inversion or eversion to cause pain.
An antalgic gait is also common with cuboid syndrome, being most pronounced during the push-off phase of gait, and side-to-side movements. (1)
Two diagnostic tests have been suggested for the evaluation of Cuboid Syndrome. In both tests, pain is an indicator of possible Cuboid Syndrome.
In the Midtarsal Adduction Test, one hand stabilizes the ankle and subtalar joint, while the other hand applies a transverse plane adduction force.
In the Midtarsal Supination Test, inversion in one frontal plane, and plantar flexion in the sagittal plane, is used to test for cuboid involvement.
Diagnostically, X-rays, CT scans, or MRIs are of little value in the diagnosis of Cuboid Syndrome. The only reason an X-ray is of value during diagnosis of this syndrome is to rule out fractures or some type of pathological condition.
TREATMENT OF CUBOID SYNDROME
Treatment of Cuboid Syndrome varies depending on the phase of the injury, and diagnostic conclusions about which structures were affected. 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 of the foot. This phase typically lasts for 2-48 hours after injury.
Here are some of the recommendations we give to patients during the Acute Phase of Cuboid Syndrome. (Please note, the actual recommendations will vary from case-to-case).
Rest: During the acute phase of cuboid syndrome it is best to avoid weight activities. In some cases, when weight bearing is not tolerated crutches many be necessary.
Ice: During the first 48 to 72 hours, I usually recommend patients ice for 15- 20 minutes, several times per day. They can also perform direct ice massage, but that should only be performed for 7-to-9 minutes, 2-3 times per day.
Compression: A compression sleeve, compression wrap or taping can be very useful in helping to reduce swelling. Just make sure that the sleeve/wrap is not too tight, and that it allows for good circulation
Elevate Your legs: Make sure the legs are elevated above the heart to help to reduce both pain and swelling. This is especially effective at night time.
Foot Mobility Exercises: Perform no-impact, range-of-motion exercises, but, do NOT push the end-range of these exercises (no pain, all gain).
Begin Manual Therapy ASAP: Manipulation and soft tissue therapy can begin immediately (in most cases). The exact procedures used for treatment will vary with the each case of Cuboid Syndrome.
Osseous manipulation is often suggested for the treatment of Cuboid Syndrome, unless contraindicated by fractures, infections, active inflammatory arthritis, or vascular disease.
Two common osseous adjusting techniques include the Cuboid Whip and the Cuboid Squeeze.
Cuboid Whip Manipulation
In this procedure the patient lies prone with their knee flexed to 70 to 90 degrees.
The clinician cups the dorsum of the foot with their thumbs on the plantomedial aspect of the cuboid.
Have the patient relax their leg, with the ankle in zero degrees dorsiflexion.
The clinician ’whips” the patients foot into inversion and plantar flexion while delivering a thrust to the cuboid (high velocity, low amplitude).
Cuboid Squeeze Technique
To perform Cuboid Squeeze, the practitioner stretches the ankle into maximal plantarflexion and the foot and toes into maximal flexion.
When the clinician feels the soft tissues relax, the cuboid is “squeezed” in a dorsal direction with the thumbs.
Beside manipulating just the cuboid bone, it become necessary to mobilize multiple restrictions in the ankle and foot. In this video Dr. Abelson demonstrated how this is done. This video is for demonstration purposes only, and should not be considered as a recommendation for treatment.
MSR - 7 Point Ankle & Foot Mobilization: Improving joint mobility is critical if you are going to effectively address the body's full kinetic chain. In fact, we greatly reduce the effectiveness of any myofascial treatment if we don’t also address restrictions in joint mobility. The objective of joint mobilization is to reverse adverse physiological changes by promoting movement between capsular fibers. (Video available for the public June 24/2020)
SOFT TISSUE RESTRICTIONS
In addition to working with the cuboid bone, it essential to address any soft-tissue restrictions within that involve muscles, tendons, ligaments, fascia, and nerve entrapment's. Conservative therapy can very effective in achieving this. The following videos are examples of the type procedures we could use in cases of cuboid syndrome to address soft tissue restrictions.
4 Point Dorsi Flexion Protocol - Motion Specific Release: Dorsiflexion is the movement at the ankle joint where the toes are brought closer to the shin. The muscles of the shins help your foot to clear the ground during the Swing Phase (concentric contraction) of your stride, and absorb much of the impact shock during running. (This video will public June 10/2020)
MSR Calf Muscle + Tom, Dick, and Harry Release: This video is about releasing both your superficial calf muscles (gastrocnemius and soleus) and the deeper muscles Tom, Dick, and Harry (TDH). Tom, Dick, and Harry stands for: T=Tibialis posterior, D=Flexor digitorum longus, an=posterior tibial artery and tibial nerve, and H=Flexor hallucis longus. (This video will public June 16/2020)
Exercise is a critical component of any successful treatment regime. Once the patient has passed the acute stage of Cuboid Syndrome, their exercises need to be focused on three distinct areas: flexibility, strengthening, and balance.
The following videos are examples that we could prescribe to patients suffering from Cuboid Syndrome. The combination of exercise varies based on the specific needs of each patient!
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: Calf stretches for both your calf muscles the gastrocnemius and soleus. Only minor changes in technique can make a huge difference in increasing your calf flexibility.
Foot & Ankle Strengthening Routine - Using a Theraband: This foot and ankle strengthening routine works the flexor, extensors, internal and external foot rotators using a Theraband.
Balance Exercises with the Bosu Ball: Balance Exercises - Here are some great suggestions on how to improve your balance using a Bosu Ball (or wobble board). Balance is essential for both rehabilitation and sports performance.
REFERENCES - PART 2
Cuboid subluxation in ballet dancers. Marshall P, Hamilton WG Am J Sports Med. 1992 Mar-Apr; 20(2):169-75
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.
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.
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.
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 publications which will be available later this year.
Dr. Abelson is the owner of Kinetic Health, a partner in BKAT Motion Specific Release, and a partner in Rowan Tree Books.
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