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Management Strategies for Cuboid Syndrome

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Management Strategies for Cuboid Syndrome CASE REVIEW Joe J. Piccininni, EdD, CAT(C) Management Strategies for Cuboid Syndrome Jennifer L. Roney, MS, ATC • University of Utah; Melissa L. Yamashiro, ATC • Orthopedic Specialty Group; and Charlie A. Hicks-Little, PhD, ATC • University of Utah Cuboid syndrome refers to a subluxation and Woodle3 reported that nearly all cases of the cuboid or calcaneo-cuboid joint dys- of cuboid syndrome were associated with function.1,2 Cuboid syndrome only accounts pes planus. Pronation of the subtalar joint for 4% of sports-related foot injuries, but provides the peroneal longus muscle with a represents 17% of foot injuries among ballet greater mechanical advantage.5 The intrinsic dancers.2,3 The purpose of this report is to foot muscles, predominantly the flexors, are present an effective management strategy believed to play an important role in stabiliz- for cuboid syndrome. ing the transverse tarsal joint during gait.4 The stability of the Current conservative management of Key PointsPoints articulation between the cuboid syndrome includes manual therapy, Cuboid syndrome is rarely found in ath- cuboid and the distal taping, padding, and use of an orthosis.5-10 letes, other than ballet dancers. portion of the calca- Newell and Woodle3 described a cuboid neus is maintained by manipulation technique that was later Current management options include a number of ligaments referred to as the “black snake heel whip.”1 manual techniques, taping, padding, and and a joint capsule. The patient stands with the affected leg in orthotics. The peroneus longus a knee-flexed, non-weight-bearing position. tendon runs through The clinician grasps the forefoot, placing the The “four mini-stirrup” taping can help the peroneal groove on thumbs on the plantar aspect of the cuboid manage cuboid syndrome. the plantar aspect of the and wrapping the fingers around to the dorsal cuboid.1,4 The line of aspect of the midfoot. The clinician applies pull on the peroneal longus produces medial a quick plantar flexion force to the ankle and inferior rotation of the cuboid around as the thumbs push the cuboid in a dorsal the oblique axis of the transverse tarsal joint, direction.3 This technique was modified by which is an important aspect of foot function Jennings and Davies,8 who placed the patient during gait.1,4,5 At heel-strike, the subtalar joint in a prone position on a plinth with the knee is supinated and body weight is concentrated of the affected leg flexed to approximately 90 on the lateral aspect of the heel. During the degrees. The clinician extends the patient’s transition from heel-strike to midstance, the knee while plantar-flexing the affected foot. 8 subtalar joint pronates and the body weight A self-mobilization technique was described is shifted to the medial aspect of the foot. The by Marshall.9 cuboid is most susceptible to displacement Mobilization techniques are widely advo- when tension within the peroneus longus cated for treatment of cuboid subluxation, tendon exerts more force than the passive but other conservative measures have also stabilizers of the calcaneo-cuboid joint.5-7 Any been suggested.5-10 There is no widely recog- joint that primarily relies on passive stabiliz- nized procedure for cuboid taping. Marshall9 ers is predisposed to hypermobility.4 Newell described a J-strapping technique that has © 2010 Human Kinetics - ATT 15(5), pp. 10-13 10 SEPTEMBER 2010 AThlETic ThERAPy TodAy been found to be very beneficial. Other researchers She exhibited reduced plantar-flexion and dorsiflexion, have suggested using a “low-dye” taping technique to due to pain and muscle tightness. support the joints of the midfoot that form the medial 10 3 longitudinal arch. Newell and Woodle suggested Differential Diagnosis the use of a cuboid pad, or wedge, to add stability to the lateral column of foot joints. This pad is typically Possible conditions included extensor digitorum brevis constructed from one-fourth inch closed-cell foam or or peroneus brevis tendinopathy, fifth metatarsal felt and incorporated with a taping technique.3 Some ligament injury, sinus tarsai syndrome, stress fracture, clinicians advocate long-term utilization of an orthosis malalignment of the talocrural and subtalar joints, to keep the foot in a neutral position, thereby decreas- meniscoid lesion of the ankle, Jones fracture, subluxat- ing the amount of tension generated by the peroneus ing peroneal tendons, lateral plantar nerve entrapment, longus tendon.1,3,10 and Lisfranc sprain. Other conservative treatment options mentioned in the literature include massage, cryotherapy, and Treatment therapeutic exercise.5-10 Although outcome studies have not been conducted to document the effective- Palpation revealed grinding and hypermobility of the ness of any of these management strategies, they may left cubo-metatarsal joint of the first athlete. The team decrease pain and inflammation within the calcaneo- physician recommended cross-training for several days cuboid joint. Lacking a widely-recognized standard for to allow pain to subside, tape application to immobilize conservative management, clinicians may be forced to the cuboid during activity, and a wedge-shaped orthotic take a “trial and error” approach to treatment. Assum- to increase foot pronation. A J-strapping technique ing that laxity develops in the passive stabilizers of was utilized on the first day, but it was not successful. the calcaneo-cuboid joint in dancers and runners, it is Low-dye taping with a cuboid wedge was then used. logical to hypothesize that taping of the mid-foot and The athlete reported increased pain after one day with strengthening of the intrinsic foot muscles and extrin- the wedge, so its use was discontinued. Her foot was sic lower leg muscles may help to prevent recurrent then taped for activity utilizing a “four mini-stirrup” subluxations of the cuboid. method (Figure 1). The taping procedure utilized one strip of moleskin as a stirrup that was pulled later- Case Presentations ally from the medial malleolus. Then three strips of Leukotape© (BSN Medical, Hamburg, Germany) were Athlete 1 used to secure the subtalar joint and transverse tarsal joint. Along with taping, the athlete participated in a This case series reports the evaluation and manage- daily ankle strengthening program (Table 1), followed ment of two female distance runners with differing by cold whirlpool submersion for pain control. Periodic presentations of cuboid subluxation. During the 2007 petrissage was administered to relieve tightness in the spring track season, a 22-year-old female collegiate gastrocnemius, soleus, and peroneal muscles. cross country and 1500-meter runner (mass = 52.27 For the second athlete, palpation revealed point kg, height = 162.6 cm) presented lateral ankle pain tenderness over the calcaneal fat pad, medial longi- at the base of her fifth metatarsal and extending to the tudinal arch, and along the peroneal tendons of the lateral aspect of the distal one-third of the lower leg. foot. Pain was elicited by resisted eversion, and the Her pain was exacerbated by walking, after running amplitude of subtalar motion was less than that of on uneven surfaces, and with extreme ankle inversion. the uninvolved extremity. The fourth metatarsal head was depressed and the cuboid was subluxated. The Athlete 2 team physician used the “cuboid whip” mobiliza- During the 2008 summer training camp, a 21-year- tion method (Figure 2) to reduce the cuboid. Taping old female cross country runner (mass = 59.09 kg, was recommended for weight-bearing activities until height = 160 cm) presented pain in the Achilles custom orthotics could be fabricated. Low-dye taping tendon approximately 5 cm superior to its insertion, was initially utilized with poor results, and the foot the inferior aspect of the lateral malleolus, and along was subsequently taped using the “four mini-stirrup” the middle one-third of the plantar surface of the foot. method. The athlete received custom orthotics two AThlETic ThERAPy TodAy SEPTEMBER 2010 11 .
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