Foot Pain: Cuboid Syndrome
Cuboid syndrome is a medical condition caused when the cuboid bone moves out of alignment. It is most often the result of injury or trauma to the joint and/or ligaments surrounding the small tarsal bone. Cuboid syndrome causes discomfort and pain on the outside (lateral side) of the foot. The pain is most often felt around the center of the foot favoring the side where the pinky toe (fifth toe) is located. It has also been reported close to the base of the fourth and fifth toes.
Patients sometimes report difficulty in identifying the exact location of the pain. This can make diagnosing cuboid syndrome a challenge. It can sometimes be misdiagnosed as a stress fracture, even though stress fractures in the cuboid bone are rare.
In this post, I will present you with information about cuboid syndrome, including the causes, symptoms, diagnosis, and treatment options.
Cuboid Syndrome: What is it?
The cuboid bone is one of seven small tarsal bones in the foot. It is found on the lateral (or little toe) side of the foot. Cuboid syndrome results when the cuboid bone moves out of proper alignment causing stress on the surrounding tissue and ligaments. Cuboid syndrome (also called subluxation of the midtarsal joint) occurs when the cuboid bone falls out of alignment with the adjacent bone; the calcaneus bone.
This partial dislocation of the bones in the joint can result from an abrupt injury or excess wear and tear on the joints in the middle of the foot.
Cuboid Syndrome: How Common is it?
Studies show that while cuboid syndrome is not uncommon within the general population, it occurs more frequently among athletes and dancers. A study released in 2011 found that about 4% of those athletes who suffer from foot injuries experienced problems with the cuboid area.
When properly identified and treated in a timely manner, most individuals with cuboid syndrome make a full recovery.
Cuboid Syndrome: What are the Risk Factors?
Individuals who demand a lot of their feet (for example, athletes and dancers) may be at highest risk for developing cuboid syndrome. High impact activities along with repetitive motions can lead to cuboid syndrome.
Additionally, individuals who are significantly overweight may be at higher risk to develop problems with their cuboid as a consequence of the extra stress placed on the structures of the foot.
Cuboid Syndrome: What are Some Common Symptoms?
Typically, cuboid syndrome first presents as discomfort or pain on the lateral (outer) side of the foot. Some sufferers report a sudden onset of pain while for others it develops slowly over time. There are some tell-tale signs that can help you and your physician identify the cause of the pain.
Pain associated with cuboid syndrome typically exhibits the following characteristics:
- pain focused on the lateral (little toe side) of the foot,
- discomfort increases when weight is placed on the foot,
- pain can be either sharp and acute, or dull and aching,
- you will likely have difficulty walking,
- hopping or jumping is very challenging,
- you may experience swelling,
- pain can increase when standing on your toes,
- your foot and/or ankle may suffer from a reduced range of motion,
- the bottom of your foot may become sensitive and
- pain may radiate to the outside of the ankle.
If you are suffering from any of these symptoms, it is time to pay a visit to your doctor.
Cuboid Syndrome: Diagnosing the Problem
While pain is the most common symptom, there are other signs and tools that healthcare providers can use to diagnose cuboid syndrome. The pain that accompanies cuboid syndrome is almost as bad as that associated with a fracture.
Patients with cuboid syndrome will definitely have significant pain, almost as if there is a fracture in the foot. Most sufferers develop an antalgic gait (limp) to compensate for the pain. Not all cases of cuboid syndrome are preceded by a major trauma nor is it always accompanied by swelling and/or bruising. This can lead many people to ignore the pain assuming that it will get better on its own.
Even when an x-ray is taken, the results are generally negative.
The slight rotation inducing cuboid syndrome is difficult to detect. The technician may, however, be able to makeout a small gap at the joint between the calcaneus and cuboid bones on a lateral x-ray. Adding to the difficulty, there are natural variations of the size of the gap throughout the population.
Patients will report tenderness when pressure is placed on the cuboid during a physical examination. Your doctor will rotate and move your foot to get an idea of your range of motion and when the pain is greatest. Your doctor may ask you to push against his or her hand or raise your toes one by one.
Cuboid Syndrome: Causes
Cuboid syndrome may be caused by the following:
One of the most common causes of cuboid syndrome is overuse. For this reason, cuboid syndrome seems to occur most frequently in dancers and athletes. In both groups individuals tend to complete many reps of the same movements, placing repeated physical stress on the structures of the feet. In addition, they are trained to push through the pain, which raises the risk of accidents.
The injury that’s most likely to lead to a case of cuboid syndrome is a sprained ankle. Inversion strains (where the ankle suddenly rolls over the outside of the foot and the toes twists inward) are far more likely to produce the type of injury associated with cuboid syndrome however eversion strains have been known to cause the condition in some cases.
In a 2006 report, the authors found that as many as 40 out of 100 people who suffered from an inversion ankle sprain can also develop cuboid syndrome.
Pronated or Flat Feet:
Cuboid syndrome can be brought on my misalignments in the feet, for example pronated and flat feet. The feet of individuals with pronated feet, roll inward as they walk placing excess pressure on the arch. Pronated feet can be a precursor to fallen arches or flat feet. When the peroneus longus (calf muscles) are overstretched (as is the case in these conditions), they can pull the cuboid bone out of alignment.
Other Risk Factors:
The following activities are also linked to the development of cuboid syndrome:
- frequently participating in sports with rapid, side-to-side movements, such as basketball, tennis and racquetball,
- going up stairs,
- wearing shoes that don’t fit well, or shoes without appropriate support,
- running on uneven surfaces and
- failing to let your feet recover after strenuous activity.
Cuboid syndrome can lead to pain along the lateral side (outside) of the foot.
Understanding the Causes of Cuboid Syndrome
The cause and diagnosis of cuboid syndrome can be difficult. This is partially due to the fact that in most cases there is no preceding traumatic event like a fall or twist. Usually, cuboid syndrome occurs after repetitive stressful motions, similar to those that an athlete or dancer may execute when training. This is why a detailed personal history is essential in helping your physician understand the condition. Some individuals will recall a step or roll on the lateral side of the foot right before the pain started.
A lateral ankle or midfoot sprain can result in an injury to the cuboid bone and/or the attached ligaments. As the medical conditions are very different in their underlying physiology, treatment will also be different. Again, a thorough patient history will be used to differentiate between cuboid syndrome and a stress fracture or sprain. Stress fracture and sprains require different treatment modalities.
If there is no trauma immediately preceding a sharp onset of pain, misalignment of the cuboid bone is a likely culprit. Upon questioning from a medical professional, the patient may recall a quick stop or turn on the outside of the foot in the hours or days prior to the onset of pain.
Treating Cuboid Syndrome
The first steps in treating cuboid syndrome is rest. Avoid placing weight or stress on the affected foot and significantly reduce or eliminate the activity or activities that may have lead to the onset of the condition.
At home you can employ the RICE treatment.
If your pain doesn’t go away on its own or gets worse, you should seek medical advice. Trained professionals can manipulate the foot to solve cuboid syndrome. These techniques include:
The cuboid whip
- The patient will lie on his or her back, bending the knee of the injured foot.
- The therapist will hold the injured foot while the patient straightens his or her knee quickly with the foot flexed.
- From the bottom of the foot, the therapist will forcefully push on the cuboid bone, popping it back into place.
In some cases, people can hear the cuboid springing back into place.
The cuboid squeeze
This method is more commonly used if pain is worse on the dorsum (top) of the foot.
- The patient will lie on his or her back with leg relaxed, hanging off the table.
- Holding onto the foot, the therapist will flex it, pushing the cuboid bone down from the dorsum of the foot.
Cuboid bone manipulation is most effective if done during the first 24 hours after the injury. If the pain has been present for a prolonged period of time, several manipulations may be needed to properly realign the bone. According to studies published in the late 1990’s, cuboid manipulations are successful in 90% of cases.
Medical professionals do not recommend manipulation for individuals suffering from other conditions of the foot. For example:
- bone disease,
- broken bone,
- conditions affecting circulation or
- nerve problems.
There are other treatments that can be effective in treating cuboid syndrome if manipulations are not fully successful or cannot be employed due to another medical condition.
- Deep-tissue massaging of calf muscles may provide relief.
- Orthotics can be used to encourage proper alignment.
- Over-the-counter NSAIDs (Nonsteroidal anti-inflammatory drugs) can be taken to reduce swelling and pain.
- Pads or braces can be used to support the affected joints.
- The foot can be wrapped in tape or bandages to help stabilize movement.
As a last resort, surgery may be recommended for this condition. This is only when other treatment options have not brought relief.
What Should I Expect for Treatment?
Below, I will dig into the tools and techniques practitioners have at their disposal to treat cuboid syndrome. You should expect one or more of the following treatment modalities to be employed on your condition. A variety of factors, including the severity of the syndrome and the underlying cause will determine what type of treatment will be most effective in your case.
If your cuboid syndrome is the result of some underlying biomechanical condition, your physician will want to first address that. He or she will insure that you are not wearing ill-fitting shoes. Using improper shoes can cause the foot to repeatedly supinate (roll to the outside turning the bottom of the foot towards the opposite foot). Your healthcare provider will take a medical history and check for any irregularities in limb length. He or she may observe you while you walk. Any biomechanical issues should be addressed first.
Repeated ankle sprains
If your cuboid syndrome is caused by repeated sprains of the ankle or midfoot, there are steps your doctor can recommend to limit their recurrence. He or she might suggest the following:
- biomechanical control,
- taping or
- other physical therapy measures.
In cases that don’t seem to have an underlying biomechanical cause, treatments are fairly straightforward. After locating the cuboid, your physician will place a small felt pad under the bone. In many cases the pad is about 1/8 inch thick. It can be stuck to the sock, shoe or even the foot (but this will require more padding and can take longer). Talk to your doctor about which placement is best for you. When using the pad, make sure that it is placed under the cuboid bone only. If it extends it into the metatarsal area it will not be effective.
Your doctor may also suggest manipulatingーor mobilizatingーthe cuboid. Cuboil manipulations can be extremely effective. Some factors can impact the success of cuboid mobilization. These include:
- size of the patient’s foot,
- size of the provider’s hand and
- the rigidity of the foot.
It is easier to manipulate flexible feet.
How long does Recovery Take?
Each situation is unique and the recovery time will depend on the individual case. The length of time recovery will take can vary between a few days to several months. This depends on many factors including:
- the duration of the injury (Did it just start or has it been happening for a while?)
- the cause (Did it develop over time or was it caused by an acute injury?)
- and if acute, is there another accompanying injury? (for example a sprained ankle)
If the damage is isolated to the cuboid bone, most patients will start to feel relief in less than a week. On the other hand, if the individual’s case of cuboid syndrome is accompanied by other injuries (such as a sprain), the healing process can take much longer.
Your doctor may recommend physical therapy. Depending on the particulars of your condition, strengthening and stretching the structures of the foot, may be essential in promoting a complete recovery.
Physical therapy to treat cuboid syndrome can include:
- exercises designed to strengthen the foot,
- stretching activities that focus on the foot and calf muscles and/or
- low-impact maneuvers tailored to improve balance
Physical therapy will not only help you heal but it can also help prevent further injury.
There are certain conditions in which a physician or physical therapist may prescribe an ankle or foot brace. Braces can restrict movement of the ankle and foot to prevent a recurrence of the injury. They can also provide needed support and stability for the foot and ankle while they becomes stronger.
Diagnosing Cuboid Syndrome
Apart from being essential to almost all of our day-to-day activities, the foot is a very complex structure. This miracle of the human body is both durable and flexible. It is strong enough to support the full weight of our bodies and yet versatile enough to perform complex movements all while maintaining balance in a way that modern technologies have yet to replicate.
How is all this possible? The foot utilizes over 100 muscles, ligaments, and tendons to simultaneously adjust 28 bones along their 30 joints. Due to the complicated nature of the structure and the general nature of cuboid syndrome pain, this injury can be very difficult to diagnose.
Even state-of-the-art imaging techniques, such as MRIs (magnetic resonance imaging) and X-rays do not always locate the signs of cuboid syndrome. This can sometimes lead to false negatives and incorrect diagnoses.
The symptoms of cuboid syndrome can also mirror other common foot problems. For example, stress fractures and heel spurs can present in the same way. Some sufferers of cuboid syndrome have a difficult time accurately identifying the exact location of their pain, adding to the confusion.
To further complicate things, other medical conditions can also develop at the same time as cuboid syndrome. For example, stress fractures and ankle sprains may accompany misalignment of the cuboid bone. Very often the fracture or sprain is treated while the cuboid is ignored. As the cuboid bone itself does not bear weight, stress fractures of the cuboid are very uncommon.
When making a diagnosis and determining a successful course of treatment, your physician will perform an extensive physical exam and review of the patient’s medical history.
Outlook for Cuboid Syndrome
The outlook for a full recovery of an individual suffering from cuboid syndrome is generally quite encouraging. After finishing treatment, most patients are able to return to all normal activities, with only a very small risk of reinjury.
The cuboid is one of seven small tarsal bones in the foot. Conditions of the cuboid can be medically described in several ways. However, the take-away is that cuboid syndrome is a somewhat common misalignment of the cuboid bone that results in pain. It is most common in dancers and other athletes.
The condition can occur in conjunction with and can be easily confused with other diagnoses. This makes gathering correct information, including a thorough personal history and physical, is of the utmost importance.
When correctly diagnosed, the outlook for full recovery is excellent and can be realized in a few short days, although some cases can take up to several months.
If you have any questions or concerns about cuboid syndrome or other conditions of the foot, leave a message below or call our office.