Many medical professionals struggle to recognize cuboid syndrome because the symptoms mirror those of a stress fracture or ankle sprain. A thorough patient history and physical examination is critical to distinguish this condition from other problems.
Cuboid syndrome typically affects ballet dancers and athletes that place a large amount of strain on their feet during lateral movements. The injury can develop suddenly due to a specific traumatic event or insidiously with repetitive stress over time.
Causes
The cuboid bone, one of seven small tarsal bones in the foot, is susceptible to injury if the foot and ankle are put under stress. Cuboid syndrome is not as common as other foot and ankle injuries, but it can occur. It is most commonly seen in athletes and young children who participate in physical activities that place the feet under a lot of stress or strain.
The most common cause of cuboid syndrome is an ankle sprain that causes the ankle to twist and turn, placing stress on the foot bones and ligaments. This can cause the cuboid bone to evert out of alignment with the calcaneus or heel bone, causing it to be subluxated. This puts pressure on the tendon of peroneus longus and can irritate it, leading to pain and weakness in the foot and ankle.
Other causes of cuboid syndrome are excessive foot pronation (where the feet roll inward) or flat feet, which can also place stress on the calf muscles and cause them to overstretch, pulling the cuboid bone out of alignment. The use of tight shoes can also pull the cuboid bone out of position.
Since the symptoms of cuboid syndrome are similar to other foot and ankle injuries, a thorough physical exam is necessary to make a diagnosis. Treatment modalities may include manipulation of the cuboid bone, low dye taping and physical therapy.
Symptoms
Cuboid syndrome usually causes pain along the outside edge of the foot, near the cuboid bone. The pain may move up into the ankle or towards the toes, and it can become worse while walking. People with untreated cuboid syndrome may adopt a compensatory gait pattern to minimize the pain they feel, which can lead to secondary injuries or conditions in other parts of the foot, ankle, knees, hips, and lower back.
Your doctor can diagnose cuboid syndrome by performing a physical examination of your foot and ankle. During the exam, your doctor will press on areas of your foot and ankle to see where the pain is most intense. Your doctor will also examine your feet while you are standing to determine how your foot and ankle move, and may observe you walking to detect any abnormalities in the way you walk.
If you have cuboid syndrome, your doctor may perform a manipulation to pop the cuboid bone back into place. This procedure is usually done in a doctor’s office or physical therapy clinic. While you lie on your back with your leg straightened, your doctor will forcefully push down on the cuboid area of your foot. This can create a popping sensation, and the cuboid bone will usually spring back into place. Your doctor will repeat this procedure until the cuboid bone no longer feels out of place.
Diagnosis
There are no definitive diagnostic procedures for cuboid syndrome. Your physical therapist will have to base the diagnosis solely on your history and your signs and symptoms. The condition can be difficult to recognize because it does not appear on x-rays and because its symptoms mimic those of a ligament sprain.
The misalignment of the cuboid bone can also be confused with a stress fracture or sprain, particularly since the pain is usually sudden and occurs on the outside of the foot. It is important for your physical therapist to take a detailed medical history and review the type of activities you engage in so they can distinguish between these two conditions.
It is believed that the condition is caused by overuse or injury. This is why it often develops in athletes and dancers who are used to training and performing repetitive high-impact motions over long periods of time. It may also occur as a result of an inversion ankle sprain, which happens when the ankle twists inward.
Other risk factors for developing cuboid syndrome include poor foot biomechanics, including pronation (when the tarsal bones unlock to allow for more movement) and having very mobile feet that can be easily pushed into a position of instability by the peroneus longus tendon. Overweight individuals may also be at higher risk of cuboid syndrome because of the added pressure placed on the feet.
Treatment
The pain associated with cuboid syndrome is very intense and can mimic a stress fracture. It often accompanies an antalgic gait (limping) as the person changes their walk to avoid the painful area on the outside of the foot.
Cuboid syndrome usually results from an injury to the foot and ankle that causes the cuboid bone to move out of place. It is often the result of a twisting injury such as an inversion ankle sprain when the ankle rolls over the cuboid bone. However, it can also occur from repetitive foot motions such as walking or running in high heels or staying in a toe-pointed position (ballet dancer’s position) for long periods of time.
It can be difficult to diagnose this problem because the small gap on the lateral (outside) side of the foot between the cuboid bone and calcaneus is very hard to detect on an x-ray. This is because there are natural variations in what the gap looks like in different people’s feet.
Your physical therapist will perform a physical examination and review your history to diagnose this condition. During the exam, they will press on the cuboid bone and watch your foot and leg move. They will then perform a maneuver called the midtarsal supination test in which they will flex your ankle and push against your foot and cuboid bone to see if the area responds with pain. If the diagnosis is made, your physical therapist will begin treatment right away to help reduce your pain and improve the function of your foot.