Treatment of Cuboid Syndrome Secondary

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Treatment of Cuboid Syndrome Secondary
to Lateral Ankle Sprains: A Case Series
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409
REPORT
L
CASE
Study _______________________________________________________________________________________________
Design: Case series.
dropped cuboid, cuboid fault syndrome,
Name
Background: Plantar flexion/inversion ankle sprains are one of the most frequently occurring sports and lateral plantar neuritis.1,5,10,13
injuries. Cuboid
syndrome, which is difficult to diagnose, may result from a plantar flexion/ Cuboid syndrome has been reAddress
_____________________________________________________________________________________________
inversion ankle injury and could become the source of lateral ankle/midfoot pain. The objective of ported as difficult to recognize
Address
this case _____________________________________________________________________________________________
series is to describe the examination, evaluation, and treatment of the cuboid syndrome and is often misdiagnosed or im1,9,13
following a lateral ankle sprain.
According
properlyCode
managed.
City _______________________________State/Province __________________Zip/Postal
_____________________
Case Description: Seven patients were seen in our clinic 1 to 8 weeks following a lateral ankle to several authors, cuboid synsprain with
a chief complaint of lateral ankle/midfoot pain. In these 7 patients, the presence of drome
Phone
_____________________________Fax____________________________Email
_____________________________
may result from a plantar
cuboid syndrome was identified independently by 2 examiners. Treatment consisted of a cuboid flexion/inversion ankle sprain and
manipulation.
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Nobe a source of pain.1,12,13 It is
may
Outcomes: All 7 patients returned to sports activities following 1 to 2 treatments consisting of the
reported that up to 4% of all
‘‘cuboid whip’’ manipulation. No recurrence of symptoms was reported upon immediate return to
competition or during the remainder of the season (mean follow-up, 5.7 months; range, 2 to 8 athletes with foot problems
present with a cuboid syndrome.13
Payment
months). Information
Discussion: Based on those 7 patients, our results suggest that patients who are properly diagnosed It appears that the occurrence of
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with cuboid syndrome and receive the cuboid manipulation can return to competitive activity cuboid syndrome in professional
ballet dancers may be higher, acwithin 1 or 2 visits without injury recurrence. J Orthop Sports Phys Ther 2005;35:409-415.
Credit Card (circle one)
MasterCard
VISA
American Express
counting for up to 17% of reKey Words: foot, manipulation, manual therapy
ported foot and ankle injuries in
Card Number ___________________________________Expiration Date _________________________________________
this population.9
Currently, there are no reported
Signature ______________________________________Date
ateral ankle sprains, which occur from a__________________________________________________
combination of
reliable diagnostic tests or imaging
excessive ankle plantar flexion and inversion, are one of the
techniques that can identify
most common injuries in sports, accounting for up to 38% to
cuboid syndrome.1,7,9,12,13 Conse3
Inversion
anklefax,
sprains
beento:
45% of all injuries. To
order call,
emailhave
or mail
quently, the diagnosis is based on
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estimated to occur
a rate
of 1Street,
per 10Suite
000 100,
persons
per day.VA
1111atNorth
Fairfax
Alexandria,
22314-1436
history, mechanism of injury, clusUp to 40% of patients who have had ankle sprains will have residual
ters of signs and symptoms, differPhone 877-766-3450 • Fax 703-836-2210 • Email: subscriptions@jospt.org
4
symptoms. Because of the multicomponent involvement, the term
ential diagnosis, high index of
sprained ankle syndrome may be more appropriate in these patients with
suspicion, and clinical expertise.
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you
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3
residual symptoms. The cuboid syndrome may be one cause of such
1,9,12,13
residual signs and symptoms.
Cluster of Signs and Symptoms
Cuboid syndrome is a minor disruption or subluxation of the
Following an initial plantar
structural congruity of the calcaneocuboid portion of the midtarsal
joint, which in turn irritates the joint capsule, ligaments, and fibularis flexion/inversion ankle sprain,
(peroneus) longus tendon.1 Cuboid syndrome has been documented in pain may gradually or rapidly dethe podiatric, orthopaedic, osteopathic, and physical therapy literature velop and become chronic in naunder various terms, including subluxed cuboid, locked cuboid, ture. 1,9 Empirically we have
observed that the pain localized
1
over the anterior talofibular and
Physical Therapist/Athletic Trainer, Gundersen Lutheran Sports Medicine, Onalaska, WI.
2
Professor, Armstrong Atlantic State University, Department of Physical Therapy, Savannah, GA; Physical calcaneofibular ligaments graduTherapist/Athletic Trainer, Coastal Therapy, Savannah, GA.
ally subsides, while pain in the
Gundersen Lutheran Institutional Review Board approved the protocol for this case series.
Address correspondence to Jason Jennings, 3111 Gundersen Dr, Onalaska, WI 54650. E-mail: calcaneocuboid joint region rejmjennings13@yahoo.com
mains unchanged or worsens. Pain
is specifically located in the region of the
calcaneocuboid joint (plantar or dorsal surface) and
tenderness is often noted with palpation (Figure
1).1,9,13 Edema, redness, and/or ecchymosis may be
present.9,13 Gait is typically antalgic, with the most
pain present during the push-off phase of the gait
cycle.1,9,13 Midtarsal mobility testing1 in supination
and adduction (producing distraction forces) may
reproduce the patient’s symptoms (Figures 2 and 3).
In our experience, pronation and abduction (producing compressive forces) may also occasionally elicit
pain.
Moreover, dorsal-to-plantar and/or plantar-to-dorsal
mobility testing of the cuboid frequently reproduces
the patient’s symptoms.9 A cuboid subluxation should
create hypermobility; however, because pain is the
predominant characteristic, it is very difficult to
perform valid and reliable mobility testing. In our
FIGURE 3. Midtarsal supination test. The arrow demonstrates the
triplane motion applied to the midtarsal area that frequently
replicates symptoms in a patient with a cuboid syndrome.
experience, mobility testing for the purpose of determining hypermobility versus hypomobility does not
provide any additional information to diagnose
cuboid syndrome or to guide our treatment approach. We have noted patterns of both hypermobility and hypomobility in patients.
Resisted inversion has also been described as a
diagnostic procedure to implicate a cuboid syndrome.16 Clinically we have observed that resisted
eversion may also elicit pain. Additional functional
testing, incorporating heel/toe raises or single-leg
hop testing as a performance measure, is also used, if
the patient is able to perform the activity. Frequently,
these activities are difficult or impossible to perform
secondary to pain.9
FIGURE 1. Cuboid palpation. The arrow demonstrates the location
for palpation of symptoms of a patient with a cuboid syndrome.
Stabilize
FIGURE 2. Midtarsal adduction test. The right (proximal) hand
stabilizes the ankle and subtalar joint, while the left (distal) hand
applies the transverse plane adduction force. The arrow demonstrates the direction of the applied force to the cuboid area that
often replicates symptoms in a patient with a cuboid syndrome.
410
Imaging Studies/Differential Diagnosis
The Ottawa Ankle Rules are initially used to rule
out specific fractures.6,15 Radiologic evaluation or
other imaging studies have been reported to have
little value for the diagnosis of cuboid syndrome.1,9,12,13 Therefore, accurate diagnosis is based
primarily on the history provided by the patient and
by the physical findings obtained during the clinical
examination. However, radiographs should be obtained to rule out fractures, tumors, or other pathologies, and to insure an accurate differential diagnosis.
Because the diagnosis of cuboid syndrome may be
difficult, differential diagnosis should include stress
fracture
to
the
cuboid,
Jones
fracture,
calcaneonavicular coalition, fibularis (peroneal)
tendonitis, fibularis tendons subluxation, sinus tarsi
syndrome, extensor digitorum brevis tendonitis,
meniscoid of the ankle, and anterior calcaneal process fracture.1,4,7,9,12,13 Consequently, many of the
special tests commonly used for the ankle and foot
region are also performed to rule out other injuries.
It is beyond the scope of this paper to review these
tests.
J Orthop Sports Phys Ther • Volume 35 • Number 7 • July 2005
TABLE 1. Patient demographics.
Patient
Age (y)
Gender
Mechanism of Injury
1
24
Male
2
25
Male
3
19
Female
4
36
Female
5
20
Male
6
16
Male
7
15
Male
Plantar flexion/inversion
ankle sprain
Plantar flexion/inversion
ankle sprain
Plantar flexion/inversion
ankle sprain
Plantar flexion/inversion
ankle sprain
Plantar flexion/inversion
ankle sprain
Plantar flexion/inversion
ankle sprain
Plantar flexion/inversion
ankle sprain
Treatment Options
From July 2002 to December 2003, all patients
presenting at the clinic with lateral ankle sprains, and
patients referred from our sports medicine team with
recalcitrant pain secondary to a lateral ankle sprain,
were examined to identify the presence of a cuboid
syndrome. Out of 104 patients, 7 cuboid syndromes
were identified. Other lateral-ankle pathologies included anterior talofibular ligament sprain,
calcaneofibular ligament sprain, anterior inferior
tibiofibular
ligament
sprain
(syndesmotic),
calcaneocuboid tarsal coalition, fibularis (peroneal)
tendon strain, subluxing fibularis tendons, talar dome
osteochondritis dissecans, Jones fracture, and Salter I
fracture of the distal fibula. All subjects’ rights were
protected, and a Health Insurance Portability and
Accountability Act (HIPPA) waiver form was submitted to forgo informed consent for this retrospective
study. Gundersen Lutheran Sports Medicine Institutional Review Board approved this study.
J Orthop Sports Phys Ther • Volume 35 • Number 7 • July 2005
Collegiate basketball
Collegiate volleyball
Recreational runner
Collegiate soccer
High school football
High school football
The patients’ ages ranged from 15 to 36 years
(mean, 21.1 years) and they were either competitive
or recreational athletes (Table 1). They all reported
their mechanism of injury as a plantar flexion/
inversion ankle sprain. The patients’ chief complaint
when they presented to the clinic was lateral
midfoot/ankle pain. All patients with lateral ankle
sprains were examined independently by 1 of the
authors to implicate or rule out a cuboid syndrome.
Because of the awareness of our sports medicine
team of the cuboid syndrome, the majority (5/7) of
the patients were referred from various high schools,
colleges, and a professional arena football team,
secondary to being nonresponsive to traditional ankle
rehabilitation methods. However, no patients had
previous treatments for a cuboid syndrome prior to
their initial visit at our clinic.
If the patient presented with the clusters of signs
and symptoms consistent with cuboid syndrome, the
other author independently examined the patient in
a blinded manner, using criteria the senior author
(G.J.D.) had previously established for this condition.
This co-evaluation procedure for the cuboid syndrome is typical in our clinic because of the difficulty
of its diagnosis. Inclusion into this study required the
agreement of cuboid syndrome as the diagnosis by
both authors. There were no patients that the examiners disagreed on regarding the diagnosis of cuboid
syndrome. No other patients received cuboid manipulations except for those included in this series.
Exclusion criteria were patients with lateral midfoot/
ankle pain who were not diagnosed with cuboid
syndrome.
Examination
A visual analog pain scale (VAS) was used to assess
each patient’s subjective pain (pretreatment and posttreatment) at rest, with palpation, midtarsal mobility
testing, gait, and single-leg hop (patient jumping
vertically on involved extremity), if pain permitted
411
REPORT
CASE DESCRIPTIONS
Arena football
CASE
Because of the limited literature, which consists
primarily of descriptive information or case reports
(with minimal information regarding demographics,
number of subjects, and follow-up data), the treatment of cuboid syndrome is controversial.1,7,9,12,13
Although frequently misdiagnosed, once the symptoms are recognized, diagnosis can be made and
dramatic immediate results may occur with treatment.1,9,12,13 Some authors have described manipulation techniques as the treatment of choice for the
cuboid syndrome.1,9,12,13 The authors of this paper
are in agreement with this approach. Other techniques that have been utilized in the treatment of
cuboid syndrome include the use of low-dye taping,
orthotics, cuboid pad, stretching, and modalities.1,9,12,13 The purpose of this article is to describe
the examination and treatment of suspected cuboid
syndrome following lateral ankle sprains in 7 patients.
Sport
TABLE 2. Examination findings using a visual analog scale.*
Pretreatment
Patient
Symptom
Duration
Rest
Cuboid
Palpation
Midtarsal
Mobility
1†
2¶
3
4¶
5
6¶
7
1d
2 wk
4 wk
8 wk
3 wk
1 wk
2 wk
5
2
1
2
2
4
4
7
4
2
4
5
6
5
8
5
5
5
6
6
5
Immediately Posttreatment
Number
of
Single-Leg ManipulaRest
Gait
Hop
tions储
8
8§
8
5
5
8§
6
N/A‡
N/A‡
N/A‡
7
7
N/A‡
7
1
1
2
2
1
1
1
0
0
0
0
0
0
0
Cuboid
Palpation
Midtarsal
Mobility
Gait
Single-Leg
Hop
1
0
0
0
1
0
0
1
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
* All visual analog scale values range from 0 to 10 (0, no pain; 10, worst pain imaginable).
†
Patient did not have anterior talofibular or calcaneofibular ligaments pain upon evaluation.
‡
Patient was unable to perform secondary to pain.
§
Patient was ambulating with crutches.
储
Number of manipulations equals number of visits (patients requiring a second manipulation returned the following day for their second
treatment).
¶
Negative radiographs.
(Table 2). Several studies have documented the
reliability of the VAS.2,14 In all patients, pain was
present at rest in the area of the cuboid. All patients
in this series had pain elicited with palpation of the
dorsal surface of the cuboid. Midtarsal mobility testing (supination and adduction) reproduced the patients’ symptoms. Gait evaluation created significant
discomfort ranging from 5/10 to 8/10 on the VAS (a
0-to-10 scale, with 0 representing no pain and 10
representing the worst pain imaginable). Two patients
came into the clinic using crutches. Functional testing included a single-leg hop test, which 4 of the 7
patients were unable to perform because of pain
limitations. The other 3 patients all had substantial
symptom reproduction while performing this testing.
Three patients received radiographs that did not
reveal bony abnormalities. The other patients all had
negative findings using the Ottawa Ankle Rules6,15;
therefore, radiographs were not considered indicated.
Intervention
In our experience, an effective treatment approach
for a cuboid syndrome consists of a specific manipulation technique (the ‘‘cuboid whip’’), as described by
Newell and Woodle.13 However, we have modified this
technique by having the patient lie prone as opposed
to having the patient stand. All of the manipulations
were performed by the senior author (G.J.D.). The
cuboid manipulation is performed by placing the
fingers in an interlocking position over the dorsum of
the foot. The thumbs are placed on the plantar
surface of the cuboid. The knee is then flexed to
approximately 70°, with the ankle dorsiflexed to
approximately 0°. The actual manipulation is performed by extending the knee, plantar flexing the
ankle, with slight supination of the subtalar joint. The
thumbs apply a thrust force to the cuboid with
412
stabilization of the foot from the interlocking fingers
(Figure 4). The goal is to re-establish proper alignment of the calcaneocuboid joint by moving the
medial aspect of the cuboid dorsally and laterally
simultaneously with respect to the calcaneous.1,13
Oftentimes there is an audible snap/pop heard by
the patient and/or clinician.1,9 However, in our
experience this is not necessary for successful outcomes.
Immediately following manipulation, gentle massage was performed to the area for approximately 1
minute to reduce any pain from the manipulation.
Careful reassessment was then performed, which
included the patient’s subjective pain response via the
VAS. Pain was usually markedly decreased or totally
resolved immediately following manipulation (Table
2).
OUTCOMES
All the patients had a substantial resolution of their
symptoms following cuboid manipulation (Table 2).
To achieve complete resolution of their symptoms, 2
patients returned the following day for a second
manipulation. Both of these patients had a longer
duration of symptoms. All of the patients were able to
return to their activities of daily living and athletic
competition immediately (within 24 hours). In 2 of
the cases, the patients presented to the clinic ambulating with crutches secondary to pain and following
treatment returned to athletic competition that same
day. Patients were advised to contact or return to the
clinic if their symptoms returned. Six of the 7
patients were monitored for recurrence of symptoms
by the athletic trainer of their respective professional,
collegiate, or high school teams. The other recreational athlete follow-up was completed via phone
conversation. No recurrence of symptoms was reported upon immediate return to their competitive
J Orthop Sports Phys Ther • Volume 35 • Number 7 • July 2005
A
B
FIGURE 4. The cuboid manipulation is performed with the patient
in the prone position, starting with the knee flexed to 70° and the
ankle near neutral (A). The knee is then passively extended as the
ankle is plantar flexed with slight supination of the subtalar joint (B).
A thrust force is applied using both thumbs on the plantar aspect of
the cuboid (C).
in-season sport/activity or remainder of the season
(average follow-up duration, 5.7 months; range, 2 to
8 months).
DISCUSSION
Newell and Woodle13 suggest that 4% of all athletes
with foot problems present with a cuboid syndrome.
J Orthop Sports Phys Ther • Volume 35 • Number 7 • July 2005
Subjective findings
• Mechanism of injury (plantar flexion/inversion)
• Pain location (lateral midfoot/ankle)
Objective findings
• Pain on palpation of the cuboid
• Positive midtarsal mobility testing (symptom reproduction)
• Positive dorsal/plantar and/or plantar/dorsal mobility testing
(pain)
• Antalgic gait (most prominent during push-off phase)
• Manual muscle tests—resisted inversion/eversion (pain and
possible weakness)
• Functional testing (heel/toe raises or single leg hop testing)
Differential diagnoses
• Radiological/imaging studies to rule out other pathologies
413
REPORT
TABLE 3. Cluster of signs and symptoms suggested for the diagnosis of cuboid syndrome.
CASE
C
The incidence of the cuboid syndrome related to a
specific population of professional ballet dancers was
17%.9 In this case series, 104 patients who sustained a
plantar flexion/inversion lateral ankle sprain were
evaluated and 7 patients with cuboid syndromes were
identified. This represents an incidence rate of 6.7%.
We believe this percentage may be inflated because
the authors of this paper are considered specialists in
the examination and treatment of the cuboid syndrome and have patients referred to them specifically
to examine and treat this comorbidity secondary to
lateral ankle sprains.
Midtarsal instability has been suggested as a causative factor of cuboid syndrome.13 Newell and
Woodle13 claim that 80% of their patients with
cuboid syndrome presented with pronated feet. With
the foot in the pronated position and the midtarsal
joint in a less stable position, the fibularis longus has
a greater mechanical advantage. It is thought that the
fibularis longus is able to sublux the unstable cuboid.
Others have been in partial agreement with this
theory.1 Marshall and Hamilton9 in their case series
found that the cuboid syndrome might occur with all
foot types.
Blakeslee and Morris1 have stated that the cuboid
syndrome occurs commonly as a result of abnormal
inversion force acting primarily on the rearfoot when
the forefoot is loaded during weight bearing. We
agree that this occurs with a plantar flexion/inversion
ankle sprain. Due to the cuboid’s osseous and ligamentous stability, the authors believe this is its main
mechanism for disruption in traumatic cases.
In contrast, Marshall and Hamilton9 have reported
a high incidence of ‘‘overuse syndrome’’ in professional ballet dancers, leading to the cuboid syndrome. They also reported a higher incidence in
females as compared to males. They state that cuboid
subluxation may occur secondary to the dorsal ligamentous laxity associated with hypermobility of the
joints of the midfoot that is so frequently seen in
dancers. Marshall and Hamilton9 also stated that the
cuboid syndrome may occur secondary to a lateral
ankle sprain, but may be more difficult to recognize
and/or treat. Although we have not seen a cuboid
syndrome secondary to overuse syndrome, this rationale seems logical in their reported population.
Because of the difficulty of accurate diagnosis of
cuboid syndrome, our clinical experiences have focused on the clusters of signs and symptoms utilizing
history (mechanism of injury and location of pain),
VAS, palpation, mobility testing (midtarsal and
cuboid), gait analysis, manual muscle testing, and
functional testing (Table 3). Over time our clinic has
developed these specific criteria to assist in the
clinical decision-making process. Others1,9,12,13 have
advocated palpation and mobility testing as their
primary criteria for clinical diagnosis of a cuboid
syndrome. However, there are no studies demonstrating whether these are valid or reliable methods. In
addition, imaging studies in the diagnosis of the
cuboid syndrome have been reported to have little
value.1,9,13 Three of our patients had radiographs and
no positive clinical findings were observed. The 4
other patients were excluded from needing radiographs via the Ottawa Ankle Rules.6,15
Manipulation has been described as the treatment
of choice in patients with cuboid syndrome.1,9,12,13 It
is thought that the manipulation realigns the
calcaneocuboid joint to its normal position.9,13 However, this theory has not been confirmed. In all
likelihood the manipulation may alter the stresses on
the surrounding innervated bony and soft tissue
structures.8 Furthermore, manipulation used in other
areas has demonstrated an analgesic response probably due to the gate theory of pain11 and resulting
elevated plasma beta endorphin levels.18 There are
also numerous articles documenting the placebo
effects of various treatment interventions.8,17 As with
all treatments, a placebo effect may occur with the
cuboid manipulation. The feeling of the cuboid
returning to its normal position, the perceived audible ‘‘crack’’ or ‘‘pop,’’ and manual contact may all
contribute to a placebo effect.
Marshall and Hamilton9 described a variation to
the cuboid whip manipulation called the ‘‘cuboid
squeeze.’’ For the cuboid squeeze, the clinician
gradually stretches the foot and ankle into maximal
plantar flexion. When the examiner feels the dorsal
soft tissues relax, the cuboid is reduced with a final
squeeze with the thumbs. Their experience suggests
that the cuboid squeeze is far more effective than the
cuboid whip secondary to better control and intensity
of force. They also suggest that the dorsal soft tissues
may absorb less stress. However, they state that this
technique should not be used for reduction in
patients with the cuboid syndrome secondary to
ankle sprains.
414
Two patients required 2 manipulations for resolution of their symptoms. It has been suggested9,13 that
cuboid syndrome of longer duration requires a
greater number of treatments for resolution of symptoms. A cuboid syndrome present for only 1 week
would usually respond to 1 to 2 manipulations, while
presence for 1 month would require 3 to 4 manipulations.13 Our results suggest similar results, with patients with short duration of symptoms responding to
1 manipulation. But our patients with symptoms over
a month only required 2 manipulations for complete
resolution of their symptoms and return to functional
activities.
Other treatments, such as low-dye taping, orthotics,
cuboid pad, stretching, self-mobilization, and modalities, may assist in the treatment and prevention of
recurrence of cuboid syndrome.1,9,13 In our experience with an isolated cuboid syndrome, we have not
found a need for other treatments except for the use
of ice in pain management following the manipulation and return to sports. However, in 2 of our cases,
where the patients returned to athletics on the same
day as the intervention after previously being on
crutches, we had their respective athletic trainers tape
the affected foot for preventative maintenance for 1
week following the manipulation. In this case series,
we have not had a recurrence of the injury for a
follow-up period varying between 2 and 8 months.
Many patients may have a clinical presentation
similar to cuboid syndrome with only subtle variations, but may have a different underlying pathology.
These patients, not surprisingly, typically will not
respond to treatment with the use of the cuboid
manipulation. If there is little or no response to
conservative treatment, a re-evaluation must be considered to rule out other pathology.
Limitations
Limitations of this report are inherent to its case
series design. Without a comparison group, we cannot determine if similar improvements would have
occurred had these patients received a different
treatment approach or no treatment at all. In addition to the manipulation, all patients received 1
minute of massage and 2 patients were taped, which
may have contributed to successful outcomes. As with
all treatments, the placebo effect may have influenced results. Furthermore, because of the lack of
agreed-upon diagnostic criteria for cuboid syndrome,
we are unable to categorically confirm the diagnosis
and the effect of the manipulation technique. Additional research is needed to determine epidemiological incidence, standardization of examination,
classification, and interventions of the cuboid syndrome. Moreover, prospective randomized controlled
clinical trials should be performed to document the
efficacy of outcomes. However, because of the apparJ Orthop Sports Phys Ther • Volume 35 • Number 7 • July 2005
ent low prevalence of this condition, it may be more
appropriate to have single-subject or sequential clinical trial designs.
CONCLUSION
The sports medicine team needs to be aware of the
cuboid syndrome as a possible source of lateral
foot/ankle pain following a plantar flexion/inversion
ankle sprain. In this case series, 7 patients were
identified to have a cuboid syndrome, based on their
mechanism of injury (plantar flexion/inversion ankle
sprain), with associated lateral midfoot pain. The
patients presented with pain at rest, had tenderness
with palpation over the dorsal surface of the cuboid
and symptom reproduction with midtarsal mobility
testing (supination and adduction). In addition, gait
evaluation and functional hop testing created substantial symptoms. All 7 patients responded to a
cuboid manipulation procedure with complete and
long-term resolution of symptoms after 1 or 2 visits.
ACKNOWLEDGMENTS
1. Blakeslee TJ, Morris JL. Cuboid syndrome and the
significance of midtarsal joint stability. J Am Podiatr
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2. Crossley KM, Bennell KL, Cowan SM, Green S. Analysis
of outcome measures for persons with patellofemoral
pain: which are reliable and valid? Arch Phys Med
Rehabil. 2004;85:815-822.
J Orthop Sports Phys Ther • Volume 35 • Number 7 • July 2005
415
REPORT
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CASE
We thank Sheldon Wagner, MS, ATC, CSCS and
Joseph La Mere, MS, ATC, PES at Gundersen
Lutheran Sports Medicine for having identified and
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assistance in preparation of this manuscript.
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