Download 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
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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]