CASE REVIEW Joseph J. Piccininni, Report Editor

Cuboid Syndrome in a College BasketballPlayer: A Case Report

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

C UBOID SYNDROME is a condition involv-ing some degree of disruption of thenormal structural congruity of the calca-neo-cuboid (CC) joint.''^ The condition isassociated with several clinical terms for

midfoot pathology, including cuboid fault syndrome,dropped cuboid, subluxed cuboid, and lateral plantarneuritis. The literature suggests that cuboid subluxationis associated with a lateral ankle sprain mechanism,occurring most often with a combination of inversionand plantar flexion.'' The inversion ankle sprain is themost common athletic injury, which accounts for 10-; 5 % of all sport participation time lost to injury.̂

Cuboid subluxations and dislocations are rare.' Themajority of such cases reported in the literature haveinvolved long distance runners and ballet dancers.''"* CCjoint dysfunction following a traumatic episode usuallyresults from a dislocation or subluxation injury, butfoot pain and chronic instability of the lateral columncan result from overuse. The symptoms of cuboidsyndrome are comparable to those of a lateral anklesprain but infrequently present edema or ecchymosis.Table 1 provides a summary of potential clinical find-ings associated with CC joint pathology, which candevelop with or without an acute injury. The athletictrainer can play a vital role in the identification andsuccessful management of this condition.''^

Case ReportAn 18-year-old female freshman NAIA Division

II basketball player (5'ir', 165 lbs) reported acuteleft foot pain after a preseason practice session. Shedescribed the pain as being a dull aching along the

TABLE 1. CLINICAL PRESENTATIONOF CUBOID SUBLUXATION

• No edema or discoloration• Pain that may radiate to heel, mimicking heel spur

pain• May or may not present with palpable defect in

plantar fascia• Point tenderness at calcaneo-cuboid joint and styloid

process of 5th metatarsal• Inability to "work through" the pain during the push-

off phase of the gait cycle• Increased pain with stair climbing• Increased pain with side-to-side movements or

lateral movements

lateral aspect oF the foot. She reported having expe-rienced a traumatic episode three weeks earlier. Theinitial mechanism of injury was foot plantar flexionand inversion while pivoting during a practice drill. Sheexperienced an immediate, transitory sharp shootingpain that was localized over the lateral aspect of thefoot, distal to the lateral malloelus. She continued toplay and did not seek any medical treatment until shecould no longer play through the throbbing pain threeweeks later She had a history of medial longitudinalarch sprains related to pes planus. Her pain was great-est in a weight-bearing position, primarily during thepush-off phase of the gait cycle. No edema, ecchymosis,or deformity was observed. Pain was elicited by palpa-tion over the CC joint and the styloid process of the5th metatarsal, and in response to compression andtuning fork tests. X-rays were negative. A physician

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placed the athlete in a walking boot for imnnobiliza-tion, and NSAlDs for 7 to 10 days were prescribed. Theathlete was instructed to remain in the walking bootand was restricted from all sports activities until bonescan results became available. To maintain cardiovas-cular fitness, the athlete performed aquatic therapyexercises and stationary cycling sessions 5 days perweek. At a two-week foilow-up appointment, the bonescan was reported to be negative and the athlete wascleared to resume all sport activities. Another follow-up appointment was scheduled for one week later.After the two-week period of weight bearing activityrestriction, the treatment program included analgesicmodalities, cardiovascular fitness maintenance, footintrinsic muscle strengthening, ankle strengthening,and gastrocnemius and hamstring flexibility exercises.The athlete was fitted for orthotics and a felt pad (114-inch thick, 1-inch wide, 3 inches long) was placeddirectly beneath the cuboid to provide stabilization(Figure 1 )̂. She was cleared to return to sports partici-pation after the second follow-up appointment and didnot experience any subsequent problems.

AnatomyThe cuboid is located in the midfoot between thecalcaneus, 5th metatarsal, navicular and lateral cunei-form. The CC articular surfaces form a saddle joint thatplays a role in dissipation of force at the mid-foot.*'The CC joint has marked stability, primarily due tothe congruency of its articular surfaces and reinforce-ment from ligaments and tendon attachments."*'̂ '' Itis stabilized on the plantar aspect by the long plantarligament, the plantar CC ligament, and the peroneal

longus tendon. It is stabilized on the dorsal aspect bythe dorsal CC ligament, the dorsal cuoneo-cuboid liga-ment, the dorso-metetarsal ligament, and the dorsalcubideo-navicular ligament, and on its medial aspectby the bifurcated ligament. The dorsal CC ligamentis the key stabilizer on the lateral aspect of the joint.^CC joint function is highly integrated with that of thetalo-navicular and subtalar Joints, which collectivelytransfer forces between the hind foot and the forefootduring walking and running.''^ The CC joint plays animportant role in locking the forefoot for increasedrigidity during the push-off phase of the gait cycle.During the push-off phase, the CC joint is subjected toforces imposed by the body weight and contraction ofthe gastro-soleus complex. Furthermore, the cuboidfunctions as a peroneus longus tendon stabilizer whereit passes beneath the

Cuboid pad placement/

Mechanism of Injury and Clinical FindingsThere is much speculation and disagreement withinthe literature regarding the direct cause of this injury.It is agreed that when a force is applied to the CC joint,it is unable to carry or dissipate the cuboid dislocatesor subluxates toward the plantar surface of the foot.Most speculate that the cause is linked to high energytrauma and/or inversion plantar flexion motion. Exces-sive pronation or pes planus has been linked to thecondition, although Marshall and Hamilton' reportedseeing the condition all in foot types. In addition to footpronation, the pull of the peroneus muscle group onthe cuboid,' tight heel cord structures, and a dynamicoverload particularly following an injury to the lateralstructures (anterior talofibular ligament, peronealtendons) can lead to the disruption of normal weightdistribution through the forefoot thus leading to cuboidsubluxations.''^'°"" Dysfunction of the CC complexleads to instability during push-off of the propulsivephase of the gait cycle.

An athlete with CC joint instability will have dif-ficulty with lateral and side-to-side movements,'complain of the "inability to work through the foot,"^and avoid forceful push-off during gait.'^ The athletemay present pain that is located in the midfoot, whichmay radiate distally along the 4th and 5th metatarsaisor on the plantar aspect of the foot toward the mediallongitudinal arch and may also present anterior orlateral ankle pain.' The modest amount of literaturepertaining to the topic suggests that cuboid subluxation

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does not present edema or ecchymosis.'^ Diagnosisis generally made on the basis of history and physicalfindings.

Conservative Treatment OptionsInitial treatment may include manual reduction ofthedisplaced cuboid by an individual trained in extremitymanipulation. Prior to reduction, deep effleurage mas-sage of the peroneal muscle group and gastro-soleuscomplex may facilitate relaxation. Repositioning of thearticular surfaces of the CC joint is performed with thepatient in a prone position. The clinician manually cupsthe patient's foot and applies pressure to the plantarsurface of the foot with the thumbs. While forcefullythrusting the foot Into plantar flexion, the clinician'sthumbs push the cuboid dorsally.^ Maintenance ofnormal CC joint alignment may be facilitated by pad-ding beneath the cuboid or custom-fitted orthotics.Marshall and Hamilton' suggest the application of a1 /8" felt pad to the plantar surface of the cuboid witha modified longitudinal arch taping technique. NSAIDadministration, or cortisone injection in some cases,reduces inflammation associated with the condi-tion.'^" The athlete should avoid vigorous weight bear-ing activities that place stress on the lateral column forat least two to three days following CC joint reduction. ''̂Upon return to normal functional activity, a plantarcuboid pad that is secured by tape may reduce therisk of further injury^'' T^pe strips that span the CCjoint may be incorporated with a lateral ankle tapingprocedure to provide additional support. In addition togastro-soleus and hamstring stretching exercises, heeilifts (less than 112" thick) can be placed in the patientsshoes to reduce the load placed on the lateral columnby the gastro-soleus complex.''^ Patients should beinstructed to wear low-heeled shoes and avoid goingbarefoot during activities of daily living.

SummaryThe athlete was able to return to her normal level ofcompetition without any subsequent complications.Protective taping was performed for the remainder ofher season. Consistent with published observationsreported by other clinicians, the athlete demonstrated

excessive pronation and gastro-soleus inflexibility,'"'-'°'" she reported symptoms similar to those associatedwith a lateral ankle sprain,'-^ and her injury was notdiagnosed until symptoms had persisted for severalweeks. Cuboid syndrome is often unrecognized andmisdiagnosed, due to a mechanism of injury that issimilar to the lateral ankle sprain,- nonspecific clinicalfindings,''" and lack of a universally accepted etiol-ogy.''̂ Knowledge of the anatomical structure andbiomechanicai function of the CC joint must be com-bined with the acquisition of a thorough injury historyto recognize the existence of cuboid syndrome" Thecondition usually responds favorably to conservativetreatment and protective taping, with surgical interven-tion only necessary for chronically recurrent sublux-ations ofthe CCjoint.'^l

References1 Marshall P. Hamilton WG. Cuboid subluxation in ballet dancers. AmJ

Sport Med. 1992;20(2),2. Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of

midtarsai joint stability. J Am Podiair Med Assoc. 1987;77( 12).3, Newell, SG. Woodie A. Cuboid syndrome- Physic Sports Med,

I98];9(4):71-76.4. Smith JS. Flemister AS, Complete cuboid dislocation in a professional

baseball player. AmJ Sports Med. 2006;34(l);2-3,5. Trojian TM. McKeag DB. Ankie sprains: expedient assessment and

management. Physic Sportsmedicine.f 998;26(10); 1905-1915,6, Leerar PJ. Differentia! diagnosis of tarsal coalition versus cuboid

syndrome in an adolescent athlete, J Orthop Sports Phys Ther.200];31{t2).

7, Allen R, Subluxated cuboid bone. Instep Dance Magazine. 2002:Nov,

8, Anderson MK. Hal! SJ. Marln M. Foundations of Athletic TYaining:Prevention. Assessment, and Management. Philadelphia, Pa: LippincottWilliams & Wilkins; 2005.

9. Prentice WE, Amheim's Principles of Athletic TYaining. 11 th ed. St Louis,Mo: Mosby Year Book; 2003,

10, Mooney M, Maffey-Ward L, Cuboid plantar and dorsal subluxations:assessment and treatment, J Ortho Sports Phys Ther. 1994;20(4).

11, Stone DA. Kamenski R. Shaw J, Nachazel KMJ. Conti SF, Fu PH. SportsInjuries. Mechanics. Prevention. Treatment. 2nd ed, Philadelphia, Pa:Lippincott Williams and Wilkln: 2001.

12, Baravarian B, Diagnostic dilemmas: a guide to understanding andcreating lateral ccAumn p^in. Podiatry Today. 2005:18(3): 100-105.

13, Caselli MA. Pantelaras N, How to treat cuboid syndrome in an athlete.Podiatry Tbday. 2004:17(10):76-80.

Stephanie M. MazeroUe is the Director of Entry-Level Athletic TrainingEducation program at the University of ConnecEicut in Storrs. She hasprevious clinical experience at the collegiate and high school levels.E-mail: stephanJe.mazerolle@uconn,edu.

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