Cuboid Syndrome
Cuboid Syndrome HELENE SIMPSON SPORT INJURIES UCT SPORTS CENTRE Definition of Cuboid Syndrome Disruption of the structural congruity of the calcaneo-cuboid joint complex Complication after lateral sprain: Relatively uncommon (less than 3%) Often misdiagnosed Lack of valid and reliable diagnostic tests Andermahr’s classification based on MRI findings: Cuboid syndrome = Type 1 injury of calcaneo-cuboid ligaments Diagnosis of Cuboid Syndrome Based history and mechanism of the injury Cluster of signs and symptoms Systematic differential diagnosis ruling out other conditions Physiotherapists = first line practitioners should be able to identify as conservative treatment is successful and effective in returning athletes to sport. Anatomy Cuboid is the keystone of the lateral column of the foot: concave cuboid rests on the convex navicular and lateral cuneiform. Cuboid is the only mid-tarsal that articulates with the navicular, linking the lateral column with the medial longitudinal arch of the foot. Multiple ligaments re-inforces the stability. Peroneus longus slings laterally and inferiorly into a fibro-osseus tunnel in the plantar aspect of the cuboid. Anatomy Mid-tarsal joint complex Peroneus longus Functional anatomy The peroneus contracts eccentrically into midstance to late push-off to control the position of the cuboid and the lateral border of the foot. It acts as a global stabiliser, controlling pronation of the mid-tarsal joint complex. The cuboid increases the mechanical advantage of this pulley system. The calcaneo-cuboid joint is relatively locked in supination (late push off) to create a rigid midfoot for propulsion. Eccentric control of Peroneii on pronation Aetiology of cuboid syndrome The degree and the direction of the force of the peroneus with sudden inversion of the midfoot, while relatively unlocked – causes a medial and inferior glide of the cuboid. The cuboid thus subluxes medially and inferiorly/ plantar direction. Simultaneous disruption/ tearing of the inter- osseous ligaments occur. Presentation (Objective signs) Persistent and localized pain over the cuboid following an inversion sprain Pain with toe push off walking Inability to perform plyometric activities Pain radiating along the medial arch and or the length of the MT4. Palpable prominence on the plantar lateral aspect of the foot. Limited and painful dorsi-flexion, inversion and eversion localised to the CC joint. Painful dorsal glides of the cuboid. Objective findings Dorsal glides Prominence plantar aspect Physiotherapy management Rule out other diagnosis with clinical reasoning and objective examination. “Cuboid squeeze” manipulation as described by Marshall and Hamilton in 1992 has good clinical outcome: this technique offers better control and direction of the manipulation than the “cuboid whip” as described by Morris and Blakeslee in 1987. “Cuboid whip” Suggestions: Based on the arthrokinematics of the CC joint: hold the midfoot in more supination – unlocked state will facilitate ease of glide and thus successful manipulation. MVM’s (Mulligan) are specifically recommended for derangements of joints as in these cases. Cuboid squeeze Marshall and Hamilton Helene Simpson MVM’s Other recommended treatments: Taping of the CC joint to stabilise the midfoot Rehabilitation regime inclusive of retraining of intrinsic of the foot to ensure a stable midfoot in closed chain activity, Re-education of the Tibialis Posterior as a local and global stabiliser of the foot to minimise excessive pronation (counteract the peroneus longus activity) General neuromuscular rehabilitation of the kinetic chain Taping technique Re-education of Intrinsics of the foot Re-education Tibialis posterior Rehabilitation of kinetic chain Star test Aeroplane More recommended treatments: Cortisone injections for pain and low intensity ultrasound Careful selection of shoe wear to minimise excessive pronation Surgery to be considered as a last resort and only in case of fractures and recurring subluxations. Neurodynamics: peripheral neurogenic pain – superficial peroneal nerve. Conclusion Cuboid syndrome should be recognised. Successful treatment are based on a sound knowledge of the arthrokinematics of the mid-tarsal joint complex. Modification of the “cuboid squeeze” (midfoot supination) is recommended to optimize the relative “unlocked status of the midfoot” Comprehensive rehabilitation is recommended to prevent recurrence and possible dynamic instability. Finally…… Thank you. Questions? [email protected]
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