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Lateral Foot Pain Part 2 - Diagnosis & Treatment

Updated: Dec 5, 2023



In the first part of "Lateral Foot Pain - Cuboid Syndrome," we delved into symptoms, causes, anatomy, biomechanics, and causes of Cuboid Syndrome. In this second part, we concentrate on examining and treating Cuboid Syndrome.


Article Index:


Examination & Diagnosis

Treatment

Exercise

Conclusion & References

 

Examination

During a physical assessment:

  • Patients might feel pain directly over the cuboid bone, which intensifies when pressure is exerted dorsally on the plantar surface.

  • Symptoms like bruising, inflammation, and redness might be observable in certain scenarios.

  • The patient's ankle flexibility is often reduced during both dorsiflexion and plantar flexion.

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

  • A pain-avoiding gait, or antalgic gait, is a common characteristic of Cuboid Syndrome, most noticeable during the push-off phase of walking and lateral movements.


Two Specific Test


Two suggested diagnostic tests for Cuboid Syndrome are the Midtarsal Adduction Test and the Midtarsal Supination Test. In both tests, the presence of pain could suggest Cuboid Syndrome:

  • In the Midtarsal Adduction Test, one hand stabilizes the ankle and subtalar joint, while the other hand imposes a transverse plane adduction force.

  • In the Midtarsal Supination Test, the cuboid's involvement is tested 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.


Effective Ankle and Foot Examination

This video uses orthopaedic 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 is used to assess the motor and sensory neurons which supply the lower limbs. This assessment helps to detect any impairment of the nervous system. It 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. In this video, we review some common procedures we perform in daily clinical practice.


Imaging techniques like X-rays, CT scans, or MRIs generally have limited effectiveness in diagnosing Cuboid Syndrome. However, an X-ray can be useful to eliminate the possibility of fractures or certain pathological conditions during the diagnosis process.


 


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 (please note that actual recommendations may vary from case to case):

  • Rest: It's best to avoid weight-bearing activities during the acute phase of Cuboid Syndrome. In some cases, crutches may be necessary if weight-bearing is not tolerated.

  • Ice: For the first 48 to 72 hours, it's recommended that patients ice for 15-20 minutes several times per day. Direct ice massage can also be performed for 7-9 minutes, 2-3 times daily.

  • Compression: A compression sleeve, wrap, or taping can help reduce swelling. Ensure the sleeve or wrap isn't too tight, allowing proper circulation.

  • Elevate Your Legs: Keep your legs above the heart to help reduce pain and swelling, especially at nighttime.

  • Foot Mobility Exercises: Perform non-impact, range-of-motion exercises without pushing 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

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


The Cuboid Whip and the Cuboid Squeeze are two common bone adjustment techniques for Cuboid Syndrome.


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 thrust to the cuboid (high velocity, low amplitude).

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" in a dorsal direction with the thumbs.


Not Just the Cuboid Bone


Besides adjusting the cuboid bone alone, it might be required to loosen various constraints in the ankle and foot. 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 address the body's full kinetic chain effectively. We greatly reduce the effectiveness of any myofascial treatment if we don’t also address restrictions in joint mobility. Joint mobilization aims to reverse adverse physiological changes by promoting movement between capsular fibers.



 

Soft Tissue Treatment

Besides focusing on the cuboid bone, addressing any soft tissue restrictions involving muscles, tendons, ligaments, fascia, and nerve entrapments is crucial. Conservative therapy can be quite effective in accomplishing this. The following demonstration videos showcase the types of procedures that could be used in cases of Cuboid Syndrome to address soft tissue restrictions.


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, when 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 the healing process.

  • 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, and 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, suggesting that 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: While the patient has improved, the body might still have vulnerabilities. Regular check-ins allow the practitioner to catch and address any minor issues before they become significant problems.


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



 

Exercise


Physical activity plays a crucial role in any effective therapy plan. As a patient progresses past the acute phase of Cuboid Syndrome, their exercises should focus on three key areas: flexibility, muscle strengthening, and balance.


The subsequent demonstration videos showcase examples of exercises that may be recommended for patients afflicted with Cuboid Syndrome. The mix of exercises will be tailored to suit the unique requirements 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

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 works the flexor, extensors, and internal and external foot rotators using a Theraband.







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.


 


Conclusion


In conclusion, our comprehensive exploration of Cuboid Syndrome has delved into its anatomy, biomechanics, symptoms, causes, examination, and treatment approaches. By understanding the complexities of this condition, medical professionals and the general public can better recognize and address the challenges it presents. Early intervention, proper diagnosis, and a well-rounded treatment plan that includes manual therapy, soft tissue work, and targeted exercises can significantly improve outcomes for those suffering from this often under-recognized cause of lateral foot pain. With increased awareness and appropriate management, individuals can regain their mobility and return to their daily activities without the hindrance of Cuboid Syndrome.


 

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.

 


Revolutionize Your Practice with Motion Specific Release (MSR)!


MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.


Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!


 

REFERENCES - PART 2

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  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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