1. Cuboid Syndrome

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Written By: Chloe Wilson BSc(Hons) Physiotherapy
Reviewed By: FPE Medical Review Board

Cuboid Syndrome is a common cause of lateral foot pain i.e. pain on the outer side of the foot.

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Whilst fairly simple to treat, it is often misdiagnosed so symptoms can last for a long time. It particularly affects athletes such as ballet dancers and runners.

The condition develops when the cuboid bone (one of the small bones in the foot) subluxes i.e. partially dislocates.

This may happen suddenly due to an injury such as an ankle sprain, or develop gradually overtime from repetitive tension through the bone and surrounding structures.

Here, we will look at the common causes of cuboid syndrome, how it presents, diagnosis and the best treatment options.

What Is Cuboid Syndrome?

The cuboid is one of the small bones on the outer side of the midfoot. It attaches to the heel bone (calcaneus) via a number of strong ligaments and a joint capsule forming the calcaneocuboid joint.

Trauma to the foot, be it a sudden injury or gradually repetitive forces may damage the supporting soft tissues causing the cuboid bone to move out of its usual position. It can then act like a block, limiting the movement of the surrounding bones in the foot.

Other terms commonly used are cuboid subluxation, blocked cuboid, dropped cuboid, lateral plantar neuritis and cuboid fault syndrome.

What Causes Cuboid Bone Pain?

There are three main causes of Cuboid Syndrome:

• Injury
  The most common injury that causes cuboid subluxation is an inversion sprain of the ankle. This is when the foot and heel bone are forced inwards while the cuboid is forced outwards.
  This inwards twisting damages the soft tissues which support the bone in place causing it to partially dislocate. In this instance, cuboid pain usually comes on suddenly.
  
• Repetitive Strain
  The peroneus longus muscle runs down the outer side of the lower leg attaching on to the outer side of the foot. Tension placed through this muscle from repetitive activities such as ballet (pointing), jumping and running may cause excessive traction on the cuboid bone causing it to sublux.
  In this case, symptoms come on gradually over time and often fluctuate.

• Altered Foot Biomechanics
  Studies have shown that a majority of people suffering from cuboid subluxation have over-pronated feet i.e. flat feet.

Symptoms of Cuboid Subluxation

Common symptoms of Cuboid Syndrome include:

• Lateral Foot Pain: pain down the outside of the foot which can refer across the foot and to the ankle and toes
  
• Pain Worse With Activity: Pain is usually worse when weight-bearing particularly first thing in the morning, on uneven ground, quickly changing direction, jumping or hopping and symptoms tend to ease with rest
  
• Difficulty Walking: Walking may be difficult and people with cuboid subluxation often walk with a limp in an attempt to keep their weight of the outer foot
  
• Tenderness & Swelling: The bone is usually tender to touch and the area may be slightly red and swollen
  
• Weakness: The foot may also feel weak, especially during the push-off phase of walking, running and jumping

Diagnosing Cuboid Subluxation

Diagnosing a subluxed cuboid can be difficult and cuboid syndrome is often misdiagnosed. Imaging studies such as x-rays, MRIs and CT scans often fail to show cuboid subluxation but they can be useful for ruling out other causes of pain.

There is no conclusive test for Cuboid Syndrome but your doctor will usually assess to see if there is pain and stiffness on palpation of the bone (when they press firmly on the cuboid through the sole of your foot).

They may also move your foot inwards and outwards to see if that elicits pain or get you to try and hop.

Some health professionals may use the midtarsal adduction test or midtarsal supination test to assess for the condition.

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Cuboid Syndrome often goes undiagnosed with ankle sprains. If symptoms continue more than three months following an inversion sprain, cuboid subluxation should be considered.

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How Do You Treat Cuboid Syndrome?

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The best treatment options for Cuboid Syndrome are:

Exercises

Exercises are a vital part of treatment when recovering from cuboid syndrome. Pain-free strengthening and movement exercises should be performed daily to prevent the foot from getting weak and stiff.

Balance exercises should also be introduced once cuboid pain symptoms have settled. If balance work is ignored, you are at increased risk of further foot and ankle injuries such as ankle sprains in the future.

Exercises for cuboid syndrome should be started as soon as possible, gradually progressed as symptoms allow and continued until full function of the foot is restored.

The quicker treatment commences following a cuboid subluxation, the quicker full function will be restored. Chronic (long-term) cases, will take longer to heal.

Manipulation

The most successful treatment for a subluxed cuboid is to have the bone relocated back into its proper position.

A health professional such as a doctor, physical therapist or podiatrist will perform a manipulation, which is a high velocity (quick) small amplitude thrust to the cuboid bone to relocate it. This should only ever be carried out by a trained professional. The symptoms of cuboid syndrome will usually settle immediately if the manipulation is done correctly.

Manipulations for cuboid syndrome are not suitable if you suffer from gout, bone disease, fracture, rheumatoid arthritis or nerve or vascular problems.

Following successful manipulation, other treatments will help to keep the bone in the correct position and to treat any lingering symptoms.

Taping

Taping of the foot and ankle is often used to support and stabilize the bones in the foot with cuboid syndrome. Medical tape is used to support and stabilize the bones in the foot and hold the cuboid in place while the surrounding soft tissues heal. Taping should allow you to walk without pain.

Ice Therapy

Ice therapy can help to reduce pain and inflammation from cuboid syndrome. Place an ice pack or bag of frozen veg wrapped in a tea towel over the outside of the foot for ten minutes at a time.

To find out more visit the Ice Therapy section including how to safely and effectively use ice.

Rest

It is important to rest from aggravating activities while the foot heals from cuboid subluxation. This may require the use of crutches for a short period of time to keep weight off the injured foot.

Orthotics

If over-pronation of your foot (i.e. flat feet) is thought to have been a contributing factor to developing cuboid syndrome, you should be given orthotic insoles to wear in your shoes to correct your foot position to relieve tension on the peroneus longus tendon and support the foot bones and arches.

Cuboid Wedge

You may also be given a small foam wedge to wear in your shoe which helps to support the cuboid bone in the correct position.

Interesting Stats

• 80% of people with cuboid subluxation have over-pronated feet
  
• Cuboid Syndrome accounts for 4% of foot injuries in athletes but 17% of foot injuries in ballet dancers
  
• 6.7% of ankle inversion sprain sufferers also have a subluxed cuboid
  
• The cuboid bone rotates approximately 25 degrees when inverting and everting the foot (turning it inwards and outwards)

What Else Can Help?

There are a number of other causes of pain on the outside of the foot other than Cuboid Syndrome. If this is not sounding like your problem, visit the side foot pain or foot pain diagnosis sections for helping working out what is causing your pain.

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Page Last Updated: 11/08/20
Next Review Due: 11/08/22

*Stats Source:Sports Health Journal

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