Diagnosing And Treating Cuboid Syndrome In Athletes

What is cuboid syndrome? This condition is not totally uncommon, but we can confuse it with other diagnoses, so obtaining an excellent history and physical is paramount. Since the cuboid is part of the lateral column of the foot, any injury to this portion of the foot could result in a cuboid injury.

The true definition is when the cuboid slips out or subluxes from its resting place behind the fourth and fifth metatarsals. Ruling out other important diagnoses will easily lead the podiatrist to cuboid syndrome.

We can describe cuboid syndrome as a sprain of the ligaments that support the cuboid bone of the lateral column of the foot. The condition is in theory caused by an eversion rotation of the cuboid out of position. Since the cuboid is a part of the midtarsal joint, we can also describe it as a subluxation of the midtarsal joint. Other names for this condition are locked cuboid, dropped cuboid, or peroneal cuboid syndrome.

Key Insights On The Causes Of Cuboid Syndrome

Why does cuboid syndrome occur? Although injury to the cuboid bone and its ligamentous attachments may occur after a lateral ankle or midfoot sprain, cuboid syndrome doesn’t involve ligament damage, so ascertaining a very thorough history will be important to distinguish the difference between a stress/occult fracture or sprain and the syndrome described here. If there is true ligament injury then a midfoot sprain is the correct diagnosis, and other treatment modalities will be necessary. Typically, the culprit is certain movements/vectors of force during gait that occur in dancers or athletes. Most often, there will be no major precipitating trauma event like a twist or fall. However, patients may recall how they had a quick “lateral” like movement or pivoting type movement as the initial precipitating event.

For example, a tennis player or basketball player runs quickly to the net or basket for a shot or backhand shot, and the foot turns internally with a quick lateral-like stopping motion. This quick lateral force can allow the cuboid to sublux out of place as the foot rolls unchecked into supination.

As another example, consider a high school student running around in the hallway, cutting and weaving in and out between other students. With a sudden, quick, pivoting movement, the cuboid subluxes out of place. There is no significant injury, but when questioned the patient recalls running through the hallway. Any quick eccentric pull of the peroneus longus tendon can have a rotational effect on the cuboid, rotating it out of its resting position. Even though a quick movement shift is typically to blame, evaluation for any biomechanical issues in the foot or lower extremity is important and one should correct any biomechanical issues as one part of the overall treatment plan. These may include limb length discrepancy, abnormal pronation or supination issues.

What Are The Signs And Symptoms Of Cuboid Syndrome?

Patients with cuboid syndrome will definitely have significant pain, almost as if there is a fracture, and they may have an antalgic gait. The lack of any major twisting/rotational event and the absence of swelling and/or ecchymosis, which you would suspect with a true fracture or major sprain, will present on the history and physical. The X-rays are generally negative, as the slight rotation of cuboid syndrome is difficult to see, although there may be a small gap at the calcaneocuboid joint on the lateral view. Normal variances do occur within all patient populations, so that finding can be misleading.

The patient will have point tenderness on the cuboid while manipulating the cuboid dorsal and plantar, and with palpation in the notch and ridge area. Occasionally peroneus longus testing will cause some mild discomfort. To test the peroneus longus, the patient pushes the first ray into the examiner’s thumb with a plantarflexion-eversion like movement. Rotation of the midtarsal joint may be tender, but muscle testing elsewhere will traditionally be negative. Sometimes single toe raises can cause pain. Although rare, consider a cuboid stress fracture if symptoms do not resolve within a few days to a week.

Some other possible etiologies that will enhance the potential for this condition can include: tight athletic or work shoes in the midfoot area that squeeze the metatarsals too tightly; shoes that are laterally worn in the heel area, causing a lateral loaded foot; or returning too quickly to “lateral-like” sports after an ankle sprain. This can be common in dancers, especially ballet dancers on pointe. Incorrect technique due to poor alignment while on pointe may predispose the dancer if she is “sickling” as this may lead to undue pressures on the lateral column and cuboid. If the foot is not properly aligned within the box of the pointe shoe, even a slight 4- to 5-degree offset can laterally load the foot with increased pounds onto the lateral column and ankle.

If there is edema, erythema or any ecchymosis, then a true sprain or fracture would be expected, and one should treat this accordingly with appropriate measures. One test I perform is to have the patient stand up and roll a small Super Ball under the foot, directly under the cuboid. This will elicit great pain on the affected side while causing minimal or no pain on the contralateral foot. This test also becomes a treatment for the patient to perform at home daily.   

A Closer Look At Treatment Options

For patients with cuboid syndrome, make sure to treat any underlying biomechanical issues. Make sure the patient is not wearing the shoe gear/heel counter/heel laterally, allowing the foot to supinate continually. Correct any limb length or biomechanical issues. If cuboid syndrome occurs due to repeated lateral ankle or midfoot sprains, treat it with appropriate measures, i.e. strengthening, biomechanical control, bracing, taping and other physical therapy measures.

For straightforward cuboid syndrome, traditional treatments are very simple. Marking the proper location, place a square cuboid pad directly onto the sock liner, insole or orthotic. I use a 1/8-inch adhesive felt pad. Give replacement pieces to the patient to add as the pad flattens out. The patient could also adhere a pad directly on the skin, but this requires more material and time for the patient. The pad is small and patients should place it only under the cuboid bone and not extend it into the metatarsal area. Cuboid mobilizations are also very effective, but success can be influenced by the size of the patient’s foot/examiner’s hand, and/or if the foot is very rigid. Flexible feet are always easier to mobilize.

Perform the cuboid “whip” while patients are prone with knee bent, applying pressure with the thumb to the plantar surface of the cuboid. Then do a quick thrust with a quick plantar- to dorsal-like movement. One can squeeze the cuboid while squeezing the midfoot area with one hand on the dorsum and one hand on the plantar side of the foot, squeezing while the patient’s ankle is in a dorsiflexed position. Sometimes traction of the fourth and fifth metatarsals, by grasping around the second metatarsal together as one unit and pulling distally, can ease the cuboid into place.

Another effective treatment is direct manipulation of the cuboid by mobilizing it with dorsal and plantar motions. The patient and podiatrist may hear or feel a pop as the cuboid eases back into place. One of the best home remedies is to have the patient use the small Super Ball maneuver rolling and pumping the foot downward over the ball at the cuboid location. Being rubber, Super Balls give better traction against the foot, and are slightly softer, unlike golf balls. (I purchase small bags of balls and dispense them to patients as needed.) This is somewhat painful but assures the patient that doing this maneuver once or twice per day for three to five minutes will alleviate the pain fairly quickly.

The addition of the cuboid pad on the orthotic or liner of the shoe, along with the ball rolling daily, will generally resolve the discomfort quickly. Kinesiology tape or other physical therapy treatments can also be helpful for easing pain.  

In Conclusion

Understanding why the cuboid slips out of place will allow the podiatrist to diagnose true cuboid syndrome easily. Easy take-home treatments typically resolve the issues completely to get patients back on track quickly.

Dr. Schoene is a sports medicine specialist and certified athletic trainer who practices at the Gurnee Podiatry and Sports Medicine Association in Chicago. She is a Fellow of the American College of Foot and Ankle Surgeons, the American Academy of Podiatric Sports Medicine, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Schoene has been a podiatric consultant for the DePaul University Blue Demons since 1992.