CASE REVIEW Joseph J. Piccininni, Report Editor Cuboid Syndrome in a College Basketball Player: A Case Report

Stephanie M. Mazerolle, PhD, ATC • University of Connecticut

UBOID SYNDROME is a condition involv- Table 1. Clinical Presentation ing some degree of disruption of the of Cuboid Subluxation C normal structural congruity of the calca- • No edema or discoloration neo-cuboid (CC) .1-3 The condition is associated with several clinical terms for • Pain that may radiate to heel, mimicking heel spur midfoot pathology, including cuboid fault syndrome, pain dropped cuboid, subluxed cuboid, and lateral plantar • May or may not present with palpable defect in neuritis. The literature suggests that cuboid subluxation plantar fascia is associated with a lateral mechanism, • Point tenderness at calcaneo-cuboid joint and styloid occurring most often with a combination of inversion process of 5th metatarsal and plantar flexion.4 The inversion ankle sprain is the • Inability to “work through” the pain during the push- most common athletic injury, which accounts for 10- off phase of the gait cycle 15% of all sport participation time lost to injury.5 • Increased pain with stair climbing 1 Cuboid subluxations and dislocations are rare. The • Increased pain with side-to-side movements or majority of such cases reported in the literature have lateral movements involved long distance runners and ballet dancers.1,4 CC joint dysfunction following a traumatic episode usually results from a dislocation or subluxation injury, but lateral aspect of the . She reported having expe- foot pain and chronic instability of the lateral column rienced a traumatic episode three weeks earlier. The can result from overuse. The symptoms of cuboid initial mechanism of injury was foot plantar flexion syndrome are comparable to those of a lateral ankle and inversion while pivoting during a practice drill. She sprain but infrequently present edema or ecchymosis. experienced an immediate, transitory sharp shooting Table 1 provides a summary of potential clinical find- pain that was localized over the lateral aspect of the ings associated with CC joint pathology, which can foot, distal to the lateral malloelus. She continued to develop with or without an acute injury. The athletic play and did not seek any medical treatment until she trainer can play a vital role in the identification and could no longer play through the throbbing pain three successful management of this condition.1-6 weeks later. She had a history of medial longitudinal arch related to pes planus. Her pain was great- Case Report est in a weight-bearing position, primarily during the push-off phase of the gait cycle. No edema, ecchymosis, An 18-year-old female freshman NAIA Division or deformity was observed. Pain was elicited by palpa- II basketball player (5'11", 165 lbs) reported acute tion over the CC joint and the styloid process of the left foot pain after a preseason practice session. She 5th metatarsal, and in response to compression and described the pain as being a dull aching along the tuning fork tests. X-rays were negative. A physician

© 2007 Human Kinetics • Att 12(6), pp. 9-11

Athletic Therapy Today november 2007   placed the athlete in a walking boot for immobiliza- longus tendon. It is stabilized on the dorsal aspect by tion, and NSAIDs for 7 to 10 days were prescribed. The the dorsal CC , the dorsal cuoneo-cuboid liga- athlete was instructed to remain in the walking boot ment, the dorso-metetarsal ligament, and the dorsal and was restricted from all sports activities until bone cubideo-navicular ligament, and on its medial aspect scan results became available. To maintain cardiovas- by the bifurcated ligament. The dorsal CC ligament cular fitness, the athlete performed aquatic therapy is the key stabilizer on the lateral aspect of the joint.8 exercises and stationary cycling sessions 5 days per CC joint function is highly integrated with that of the week. At a two-week follow-up appointment, the bone talo-navicular and subtalar , which collectively scan was reported to be negative and the athlete was transfer forces between the hind foot and the forefoot cleared to resume all sport activities. Another follow- during walking and running.1,7 The CC joint plays an up appointment was scheduled for one week later. important role in locking the forefoot for increased After the two-week period of weight bearing activity rigidity during the push-off phase of the gait cycle. restriction, the treatment program included analgesic During the push-off phase, the CC joint is subjected to modalities, cardiovascular fitness maintenance, foot forces imposed by the body weight and contraction of intrinsic muscle strengthening, ankle strengthening, the gastro-soleus complex. Furthermore, the cuboid and gastrocnemius and hamstring flexibility exercises. functions as a tendon stabilizer where The athlete was fitted for and a felt pad (1/4- it passes beneath the foot.1,8 inch thick, 1-inch wide, 3 inches long) was placed directly beneath the cuboid to provide stabilization Mechanism of Injury and Clinical Findings (Figure 17). She was cleared to return to sports partici- pation after the second follow-up appointment and did There is much speculation and disagreement within not experience any subsequent problems. the literature regarding the direct cause of this injury. It is agreed that when a force is applied to the CC joint, Anatomy it is unable to carry or dissipate the cuboid dislocates or subluxates toward the plantar surface of the foot. The cuboid is located in the midfoot between the Most speculate that the cause is linked to high energy calcaneus, 5th metatarsal, navicular and lateral cunei- trauma and/or inversion plantar flexion motion. Exces- form. The CC articular surfaces form a saddle joint that sive pronation or pes planus has been linked to the plays a role in dissipation of force at the mid-foot.8.9 condition, although Marshall and Hamilton1 reported The CC joint has marked stability, primarily due to seeing the condition all in foot types. In addition to foot the congruency of its articular surfaces and reinforce- pronation, the pull of the peroneus muscle group on ment from and tendon attachments.4,8,9 It the cuboid,3 tight heel cord structures, and a dynamic is stabilized on the plantar aspect by the long plantar overload particularly following an injury to the lateral ligament, the plantar CC ligament, and the peroneal structures (anterior talofibular ligament, peroneal tendons) can lead to the disruption of normal weight distribution through the forefoot thus leading to cuboid subluxations.1-7,10-11 Dysfunction of the CC complex leads to instability during push-off of the propulsive phase of the gait cycle. An athlete with CC joint instability will have dif- ficulty with lateral and side-to-side movements,7 complain of the “inability to work through the foot,”2 and avoid forceful push-off during gait.1,7 The athlete may present pain that is located in the midfoot, which may radiate distally along the 4th and 5th metatarsals or on the plantar aspect of the foot toward the medial longitudinal arch and may also present anterior or lateral ankle pain.1 The modest amount of literature Figure 1 Cuboid pad placement.7 pertaining to the topic suggests that cuboid subluxation

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