Start/Renew Form Journal of Orthopaedic & Sports Physical Therapy Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Supplemental Video Available at www.jospt.org Please start my one-year subscription to the JOSPT. Please renew my one-year subscription to the JOSPT. Treatment of Cuboid Syndrome Secondary to Lateral Ankle Sprains: A Case Series Individual subscriptions are available to home addresses only. All subscriptions are payable in advance, and all rates include normal shipping charges. Subscriptions extend for 12 months, starting at the month they are entered or renewed (for example, September 2002-August 2003). Single issues are generally available at $20 per copy in the United States and $25 per copy when mailed internationally. USA International $215.00 Institutional Jason Jennings, DPT, SCS, ATC, MTC, CSCS 1 $265.00 $135.00 $185.00 Individual George J. Davies, PT, DPT, MEd, SCS, ATC,LAT, CSCS, FAPTA 1,2 Student $75.00 $125.00 Agency Discount $9.00 Subscription Total: $________________ Shipping/Billing Information Journal of Orthopaedic & Sports Physical Therapy 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. Would you like to receive JOSPT email updates and renewal notices? Yes 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 Check enclosed (made payable to the JOSPT). 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 3 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: [email protected] 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. Thank you for subscribing! 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 [email protected] 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 Med Assoc. 1987;77:638-642. 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 REFERENCES CASE We thank Sheldon Wagner, MS, ATC, CSCS and Joseph La Mere, MS, ATC, PES at Gundersen Lutheran Sports Medicine for having identified and referred potential patients. Thanks to David BazettJones, ATC, CSCS, and Nikki Konzem for their assistance in preparation of this manuscript. 3. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg. 1998;37:280-285. 4. Freeman MA. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg Br. 1965;47:669-677. 5. Jones LH. Foot treatment without hand trauma. J Am Osteopath Assoc. 1973;72:481-489. 6. Leddy JJ, Smolinski RJ, Lawrence J, Snyder JL, Priore RL. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center. With a modification to increase specificity for identifying malleolar fractures. Am J Sports Med. 1998;26:158-165. 7. Leerar PJ. Differential diagnosis of tarsal coalition versus cuboid syndrome in an adolescent athlete. J Orthop Sports Phys Ther. 2001;31:702-707. 8. Maigne JY, Vautravers P. Mechanism of action of spinal manipulative therapy. Joint Bone Spine. 2003;70:336341. 9. Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. Am J Sports Med. 1992;20:169-175. 10. McDonough MW, Ganley JV. Dislocation of the cuboid. J Am Podiatry Assoc. 1973;63:317-318. 11. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150:971-979. 12. Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: assessment and treatment. J Orthop Sports Phys Ther. 1994;20:220-226. 13. Newell SG, Woodle A. Cuboid syndrome. Phys Sports Med. 1981;9:71-76. 14. Salo D, Eget D, Lavery RF, Garner L, Bernstein S, Tandon K. Can patients accurately read a visual analog pain scale? Am J Emerg Med. 2003;21:515-519. 15. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269:1127-1132. 16. Subotnick SI. Peroneal cuboid syndrome. J Am Podiatr Med Assoc. 1989;79:413-414. 17. Turner JA, Deyo RA, Loeser JD, Von Korff M, Fordyce WE. The importance of placebo effects in pain treatment and research. JAMA. 1994;271:1609-1614. 18. Vernon HT, Dhami MS, Howley TP, Annett R. Spinal manipulation and beta-endorphin: a controlled study of the effect of a spinal manipulation on plasma betaendorphin levels in normal males. J Manipulative Physiol Ther. 1986;9:115-123.
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