CUBOID SYNDROME- CASE REPORTS AND DISCUSSION

Mitrulescu Paiseanu Catalin C. , Faur Cosmin University of Medicine and Pharmacy Victor Babe Timioara 2nd Department of Orthopedics and Traumatology

ABSTRACT
In the current practice, the orthopaedic practicioner is often placed in the difficult situation of treating hard to diagnose syndromes. The cuboid syndrome is one of them and this article is aimed at guiding any health care professional in making a correct diagnosis, and, once this step is finished, the treatment will be usual easy and straightforward. Any orthopaedist should be aware that any lateral foot and ankle pain may be the result of cuboid syndrome. Once properly diagnosed, the patient responds exceptionally well to conservative treatment by manipulation. Occasionally, if the symptoms have been persistent for more than one week, more than one manipulation may be required. Because the imaging studies arent helpful, the diagnosis is made only by physical examination and the history of the patient. KEYWORDS: CUBOID SYNDROME, SUBLUXATION, MANIPULATION

CASE 1 The patient is a 45 years old male who had persistent lateral ankle pain since 30 days ago. He remembered having a mild twisting injury of his left ankle, and since that time, the problem persisted. The mechanism of the injury was forced inversion with plantar flexion. He thought that his pain is a normal one and he delayed his presentation to the doctor. The inspection of his left foot didnt reveal anything abnormal. His pain was reproduced when walking, especially in the toe off phase. He had tried AINS medication before, but they were of little help. At palpation, the pain was reproduced when pushing down (dorso-plantar) the cuboid zone. Also, pain was reproduced when applying the force in the opposite way from the plantar aspect. The degree of motion in the articulation between the 4-th and 5-th metatarsal and the cuboid was diminished compared to the contralateral foot. The midtarsal adduction test was positive. The test is performed with ankle and subtalar joint stabilized with one hand, while the other puts and adduction force on the forefoot.

Also the midtarsal supination test was positive. To perform this test, the examiner grasp with one hand the patient ankle and stabilizes it together with the subtalar joint, and with the other hand applies a supination motion (inversion, plantar flexion and forefoot adduction ). The patient was sent to x-ray in order to exclude another possible diagnosis. The x-rays were normal.

CASE 2 The patient is a 22 years old male, who presented in our department following a common inversion ankle sprain, grade 1/2. He was put in a splint for 3 days and afterwards he continued the immobilization with an elastic bandage, being mainly restricted to bed for another 4 days. During the last four days, when he attempted to walk he felt pain in the lateral aspect of the foot. He presented to a new medical visit 8 days later after the initial injury, stating that his original pain didnt improve during this week. The pain was present only when weight-bearing. During palpation, he exhibited pain on the plantar and dorsal aspect of the cuboid. The pain was radiating in the fourth ray. Also, some warmth and slight edematous feel could be revealed in the dorsal aspect of the cuboid. The midtarsal supination test was positive. This patient had no further x-ray imaging taken, sine the x-rays taken 8 days before didnt reveal anything abnormal.

DISCUSSION The cuboid syndrome has many different names: subluxed cuboid, lateral plantar neuritis, peroneal cuboid syndrome. It is often a mistreated and misdiagnosed condition 1. The syndrome consists in a minor disruption or subluxation of the calcaneocuboid portion of the midtarsal joint. Because of the derangement in cuboid position, the surrounding soft tissues are being irritated. The incidence is thought to be serious underestimated. In a study Newell and Woodle 2 found a 4 % incidence among the athletes. Later on, in 2005, Jennings and Davies 3 found in a patient series of 107, who sustained a plantar and inversion ankle sprain, that many were further diagnosed at a close follow up with cuboid syndrome, with an incidence of 6.7 %. The most frequently encountered etiology is a plantar flexion inversion ankle sprain3. However, other possibilities exists, in activities where the foot abruptly pronates, being either an

acute, either an overuse syndrome - this happens in ballet dancers, where the incidence could be even higher- 17%4. It is thought that the peroneus longus plays an important role in the pathomechanics of this syndrome, since the cuboid acts as a fix point and the tendon as a lever5 (Fig.1).

Fig.1 Pathomecanics of cuboid syndrome Patients will most commonly present with pain that develops rapidly or occurs gradually overtime as a sequel to an inversion ankle sprain or small microtraumas that overwhelms the ligaments and joint capsule of the lateral column6. The pain may be located directly over the cuboid or it may radiate into the plantar medial arch or along the fourth metatarsal in a distal manner4. The pain may even be present when resting, but usually it is present only when walking, especially during the toe-off phase1. At inspection, occasionally swelling, redness and echymosis may be present. In the case of a severe subluxation, a plantar subluxation may appear and a lump can be visible on the plantar aspect and a small depression on the dorsum of the cuboid7. Pain is elicited directly onto the cuboid, both on the plantar and dorsal aspect(Fig.2 and Fig.3 ). The pain may also arise from the extensor digitorum brevis muscle. The palpation can also discover a warmth and slight edematous feel8.

Fig.2 Palpation on the plantar and

Fig.3 dorsal aspect of the cuboid

Special diagnostic tests are being used. Resisted inversion, when producing pain along the peroneus longus as it passes underneath the cuboid, may be indicative for cuboid syndrome9. The midtarsal joint can also be tested using the midtarsal adduction test (Fig. 4) and midtarsal supination test(Fig. 5 )1,3. Also compressing the structures involved in this syndrome can reproduce pain, by pronation and abduction3.

Fig.4 Midtarsal adduction test

Fig.5 Midtarsal supination test

The diagnosis is almost entirely clinical, with the ad of the patient history, the radiographs being used only to rule out a fracture or other pathology. The use of x-rays, CT or MRI is of little help, since the disruption or subluxation is so small that none of this imaging studies can be of help1,4,7.

The differential diagnosis is made with a more severe subluxation or luxation of the cuboid, fracture of the cuboid, fracture of the anterior calcaneal process, Jones fracture, peroneal and extensor digitorum brevis tendonitis, sinus tarsi syndrome, lateral plantar nerve entrapment, stress fracture of the cuboid. After the diagnostic is made, the treatment should be generally quite simple, consisting of cuboid manipulation. Other helpful therapies may be used, such as taping, padding, therapeutic exercises. After manipulation, the cuboid usually returns to its exact anatomic position and the patient reports a complete cessation of symptoms or at least a mark decrease in pain1,4,7. The first manipulation technique was described by Newell and Woodle in 19812. The test is called the cuboid whip . The patient is lying in a prone position, with the knee flexed to approximately 700. The patients knee is put into flexion in order to relax the gastrocnemius and to avoid stretching the superficial peroneal nerve. The clinician puts the fingers on the dorsal aspect of the foot, while the thumbs are positioned on the plantar aspect of the cuboid. Beginning with the knee in 70-90 0 of flexion and the ankle in 00 of dorsiflexion, the knee is being extended, the ankle is being plantar flexed and we apply slight suppination to the subtalar joint. The pressure is applied through the thumbs (Fig.6 ). This technique is suitable for cuboid syndrome that is following a plantar flexion inversion ankle sprain 3. This test was later adapted by Marshall and Hamilton to the cuboid squeze test, which is better suited for a syndrome following an overuse injury4. While placing the ankle gradually in maximal plantar flexion, the soft tissues relaxes and the cuboid is squeezed with the thumbs. Occasionally, a click can be felt or heard by the clinician or the patient as the cuboid is successful put back into its place4.

Fig. 6 Cuboid whip manipulation The contraindication for manipulation of the cuboid consists of inflammatory arthritis, gout, neural or vascular disorders6.

In the case the manipulation fails, it should be abandoned and tried the next day. If the syndrome has been present for one week, 2 manipulations may be required2, and if the symptoms had been present for more than 2 weeks, 3 or 4 manipulation may be needed2. If the manipulation is successful, meaning a great improve or the disappear of pain, the patient may resume its previous activities. For the long term, for avoiding recurrences, it is recommended that physical therapy to be used, focusing on stretching the peroneus longus and triceps suralis, enhancing proprioception by neuromuscular control exercises, and also strengthening the intrinsic and extrinsic muscle of the foot7.

The two patients from this report responded very well to the cuboid whip manipulation. In the first case 2 manipulations were needed for complete resolution of symptoms, during a 2 day period. The second patient had complete resolution of symptoms after the first manipulation. At 1 week and 1 month follow up, both of the patients were symptom free.

CONCLUSION

The cuboid syndrome is an easy to treat condition, yet the diagnosis may be quite challenging. The doctor must have a high degree of suspicious for this syndrome when in the face of a patient with persistent lateral column ankle pain following an ankle sprain, the incidence of this pathology being probably highly underestimated.

BIBLIOGRAPHY 1.Blakeslee, T.J. and Morris, J.L. (1987) Cuboid syndrome and the significance of midtarsal joint stability. Journal of the American Podiatry Medical Association 777(12), 638-642. 2. Newell, S.G. and Woodle, A. (1981) Cuboid Syndrome. Physician and Sports Medicine 9, 7176. 3. Jennings, J. and Davies, G.J. (2005) Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. Journal of Orthopedic and Sports Physical Therapy 335(7), 409-415.

4. Marshall, P. and Hamilton, W.G. (1992) Cuboid subluxation in ballet dancers. American

Journal of Sports Medicine 220(2), 169-175. 5. Newell, S.G. and Woodle, A. (1981) Cuboid Syndrome. Physician and Sports Medicine 9, 7176. 6. Caselli, M.A. and Pantelaras, N. (2004) How to treat cuboid syndrome in the athlete. Podiatry Today 117(10), 76-80. 7. Mooney, M. and Maffey-Ward, L. (1994) Cuboid plantar and dorsal subluxations: assessment and treatment. Journal of Orthopedic and Sports Physical Therapy 220(4), 220-226. 8. Starkey, C. and Ryan, J. (2002) Evaluation of orthopedic and athletic injuries. 2nd edition. F.A. Davis Company, Philadelphia, PA. 9. Subotnick, S.I. (1989) Peroneal cuboid syndrome. Journal of the American Podiatry Medical Association 779(8), 413-414.