Cuboid syndrome is a common source of lateral foot pain in many athletes. It is believed to arise from a subtle disruption of the arthrokinematics or structural congruity of the calcaneocuboid joint (Durall, 2011). This presumed alteration in arthrokinematics and/or congruence of the calcaneocuboid joint can either develop chronically, or after a traumatic event such as an ankle sprain. In order to fully understand what cuboid syndrome is, let’s define a couple of terms:
Arthrokinematics = Arthrokinematics refers to the specific movement of joint surfaces. The specific movements of joint surfaces can include things such as rolls, spins, and glides. So in other words, it describes whether bones roll on each other, glide on each other, or spin on each other. This is an important biomechanical concept because it explains how to mobilize synovial joints in the human body, as well as why that synovial joint moves the way it does.
Now that we’ve covered what arthrokinematics are, let’s begin to understand the anatomy and mechanics of cuboid syndrome.
Anatomy and Biomechanics of the Cuboid Bone
The cuboid is located in the lateral midfoot, surrounded by the calcaneus posteriorly, the fourth and fifth metatarsals anteriorly, and the navicular and lateral cuneiform medially (Durall, 2011). The calcaneocuboid joint function is dependent on midtarsal joint mechanics, since the navicular and cuboid bones move essentially in tandem during gait. The mechanics of the calcaneocuboid joint are highly variable, but the principal movement at this joint is medial/lateral rotation about an anterior/posterior axis with the calcaneal process acting as a pivot (Durall, 2011). The cuboid is unique for the simple fact that it is the only bone in the foot that articulates with both the tarsometatarsal joint and the midtarsal joint (Patterson, 2006). It is also the only bone linking the lateral column to the transverse plantar arch. Consequently, the cuboid acts as a keystone of the rigid and static lateral column giving inherent stability to the foot (Patterson, 2006).
Right foot plantar view
The calcaneocuboid joint is intrinsically stable due to the congruence of its articular surfaces and reinforcement from ligaments and tendon attachments (Durall, 2011). These reinforcing ligaments include the dorsal and plantar calcaneocuboid, dorsal and plantar cuboideonavicular, dorsal and plantar cuboideometatarsal, and the long plantar ligament (Patterson, 2006).
Ligaments of the lateral foot
Ligaments don’t get all the fun in providing stability for the calcaneocuboid joint. The peroneus longus tendon, which forms a sling around the lateral and plantar aspects of the cuboid before inserting on the plantar aspect of the lateral first metatarsal base and medial cuneiform, also assists with calcaneocuboid joint stabilization (Durall, 2011). The peroneus longus muscle originates on the upper one-third of the fibula, then travels distally down the shaft of the fibula and posteriorly around the lateral malleolus (Patterson, 2006). From here it continues to travel in a plantar lateral direction until the tendon reaches the cuboid. Here the path of the tendon then changes directions and travels anteromedially through the cuboid’s peroneal groove and inserts on the lateral base of first metatarsal and first cuneiform (Patterson, 2006). The cuboid is a pulley for the peroneus longus tendon; muscle contraction from midstance through the late propulsive phase exerts an eversion torque on the cuboid. Eversion of the cuboid via the peroneus longus tendon is thought to facilitate load transfer across the forefoot from lateral to medial as stance progresses (Durall, 2011).
Peroneus longus tendon
Although the normal mechanics of the midtarsal joints are not fully understood, the talonavicular and calcaneocuboid joints are thought to play a vital role in the transition of the foot from a mobile adapter during weight acceptance, to a rigid lever during push-off and in rearfoot-to-forefoot load transfer during propulsion (Durall, 2011). During early stance when the calcaneus is everted, the forefoot tends to flex and extend more; during push-off, the calcaneus is inverted, and the forefoot is more rigid. This phenomenon is attributed to the orientation of the talonavicular and calcaneocuboid joint axes, which become parallel during calcaneal eversion, increasing motion in these joints and in the forefoot in general. Conversely, calcaneal inversion during push-off causes the midtarsal joint axes to diverge, which reduces mobility in the midtarsal joint and the forefoot (Durall, 2011).
Some of these theories about the biomechanics of the midtarsal joints can be applied an ultra-marathoner we are working with who started experiencing lateral foot pain a couple of weeks ago. After a proper differential diagnosis, it became apparent that she was experiencing cuboid syndrome. But the head-scratching question she had was how she got it. Due to what we saw during the diagnosis and throughout her time here at Accelerate, we’ve noticed that she runs with a relaxed arch, even though we are supposed to have a rigid foot during the push-off phase of the gait pattern. Debbie’s tight extensors are causing her dorsal aspect of her foot to be rigid during her early stance, which is what we want. However, they are still taking over during her push-off phase as well. This becomes a problem due to reciprocal inhibition. Reciprocal inhibition describes the process of muscles on one side of a joint relaxing to accommodate contraction on the other side of that joint. Due to this common biomechanical law of the body, her tight and contracted extensors during both the early stance and push-off phases of her gait are causing her flexors to be in a relaxed state at the plantar aspect of her foot, thus not creating a rigid forefoot during push off. That said, running 60-100 miles at time does have influence on the durability of proper mid foot mechanics during running gate and thereafter.
Etiology of Cuboid Syndrome
Although the etiology and pathomechanic mechanism of cuboid syndrome is still unclear, there have been several proposed theories including excessive pronation, overuse, and inversion ankle sprains (Durall, 2011). It is also thought that cuboid syndrome arises from forceful eversion of the cuboid while the calcaneus is inverted, with resultant disruption of calcaneocuboid joint congruity. Loss of congruency between the calcaneus and cuboid may be the source of lateral foot pain. The peroneus longus may also play a role in the development of cuboid syndrome, since this muscle imparts an eversion moment on the cuboid. Impaired peroneus longus function may also affect calcaneocuboid joint stability (Durall, 2011).
Several other factors may increase the likelihood of cuboid syndrome, including midtarsal instability, excessive body weight, ill-fitting or poorly constructed orthoses or shoes, exercise (ie, intensity, duration, frequency), inadequate exercise recovery, training on uneven surfaces, and sprain of the foot or ankle (Durall, 2011). Cuboid syndrome may be more prevalent in individuals with pronated feet due to the increased moment arm of the peroneus longus. In one study, 80% of the patients with cuboid syndrome presented with pronated feet, but it can also occur with supinated feet (Durall, 2011).
Signs and Symptoms of Cuboid Syndrome
The symptoms of cuboid syndrome resemble those of a ligament sprain. Pain is often diffused along the lateral foot between the calcaneocuboid joint and the fourth and/or fifth cuboid metatarsal joints and may radiate throughout the foot (Durall, 2011). Tenderness may also be present along the peroneus longus tendon, the cuboid groove, the dorsolateral and/or plantar cuboid, or the origin of the extensor digitorum brevis muscle. Poor gait is also common with cuboid syndrome, with pain and/or weakness most pronounced during push-off or with side-to-side movements (Durall, 2011).
Diagnosis of Cuboid Syndrome
Although there are no definitive validated diagnostic tests for cuboid syndrome, two clinical maneuvers have been described; the midtarsal adduction test and the midtarsal supination test (Durall, 2011). During the adduction test, the midtarsal joint is manipulated passively in the transverse plane while the calcaneus is stabilized. This maneuver compresses the medial aspect of the CC joint and distracts the lateral side. The supination test is similar by adding inversion and plantar flexion (Durall, 2011).
Treatment of Cuboid Syndrome
1. Manual Therapy Techniques
– There are several manual therapy techniques that can be used to treat cuboid syndrome. One technique that is widely used is called the Cuboid Whip. During this manipulation technique, the clinician cups the dorsum of the patient’s forefoot, placing thumbs on the plantomedial aspect of the cuboid. The patient’s knee is flexed 70° to 90° while the ankle is placed in 0° dorsiflexion. With the patient’s leg relaxed, the clinician abruptly “whips” the foot into inversion and plantarflexion while delivering a low amplitude, high velocity thrust to the cuboid (Durall, 2011). Another manipulation technique that can be used is called the Cuboid Squeeze. During the cuboid squeeze, the clinician slowly stretches the ankle into maximal plantarflexion and the foot and toes into maximal flexion. When the clinician feels the dorsal soft tissues relax, the cuboid is “squeezed” with the thumbs (Durall, 2011).
2. Exercise Prescription
– There are several exercises that can be prescribed to alleviate the symptoms of cuboid syndrome and correct for it. Such exercises are:
Any many other variations of exercises like towel grabs inversion, towel grabs eversion, and single leg strengthening and balancing exercises. The goal of all of these exercises are to strengthen the muscles surrounding the arch of the foot as well as the flexors of the foot, such as the peroneals, flexors, and extensors. Stretching the gastrocnemius, soleus, hamstring, and/or peroneus longus and strengthening the intrinsic and extrinsic foot muscles may also help prevent recurrence of cuboid syndrome (Durall, 2011).
3. Kinesio Taping
– Kinesio taping can also be used as a technique to prevent the symptoms of cuboid syndrome from occurring again, following successful manipulation techniques and exercise prescription. Kinesio tape is different from ordinary tape in that it is able to lift the upper layers of the skin, which creates more space in between the dermis and the muscle. This created space relieves pressure on the lymph channels in the area between the muscle and the dermis, thus allowing for better lymph flow and drainage through an affected area. Not only does does kinesio taping help the lymphatic system, it also helps the neuromuscular system as well. The created space from kinesio tape houses various nerve receptors that send specific information to the brain. When the space between the epidermis and the muscle is compressed during an injury like cuboid syndrome, these nerve receptors are compressed. Kinesio tape allows for created space that relieves pressure from these nerves in order to send proper messages and information to the brain. This increased space also allows for muscles to have greater contractility, which in turn pushes more fluid through the muscle, resulting in better muscular performance. Various kinesio taping techniques have been suggested, with a common goal of supporting the medial longitudinal arch (Durall, 2011).
So, what have we learned? We’ve studied the anatomy and biomechanics of cuboid syndrome, underlining the major theories that contribute to the occurrence of the signs and symptoms. We’ve learned that we need to have flexed and extended forefoot during early stance, and a more rigid forefoot during push-off. In our client case, we’ve learned that we need to work on strengthening intrinsic, extrinsic, foot flexors in order to alleviate her symptoms, but most importantly the proper firing biomechanics of the lower limb. Strengthening these structures will make her arch stronger, and reciprocal inhibition will allow her extensors to relax during the push-off phase so she could instead become more rigid during push off. The A March shown above in the exercise prescription section would be a good exercise to practice due to her having to focus on her rigidity during the push off phase. We’ve gone over the diagnosis and treatment of cuboid syndrome, which include manipulation techniques, exercise prescription, and kinesio taping. Understanding how the structures around the foot allow for proper gait, as well as being able to understand the anatomy and biomechanics of your clients will allow the clinician to become successful in properly diagnosing someone with cuboid syndrome, and any other ailments in the future.
Durall, C. J. (2011). Examination and Treatment of Cuboid Syndrome A Literature Review. Sports Health: A Multidisciplinary Approach, 3(6), 514-519.
Patterson, S. M. (2006). Cuboid syndrome: a review of the literature. Journal of sports science & medicine, 5(4), 597.