Good answers re the topic of Wikipedia reference-linkcuboid syndrome. I have treated this for 2 decades so have some thoughts. I intended to submit a letter to the editor after the article cited earlier in JOSPT in 2005, but never did. There are essentially 2 basic types of cuboid syndrome and I do not believe that this has been adequately addressed in the literature. For convenience I am going to name one type a Type I and the other Type II.
Type I. Can be symptomatic or asymptomatic. It responds beautifully to a manipulation of the cuboid and the cuboid alone. If painful, the pain resolves very quickly and the treatment is repeated 1 or 2 times. Client and clinician are both happy. Recovery is quick. Basically the cuboid fixation is the key lesion in the foot and ankle complex and restoring mobility directly to the cuboid makes for significant improvement. Sometimes there is a pattern that appears to involve several other structures in the foot and ankle, yet the manipulation performed only at the cuboid is almost magical. Retesting the other motion fixations reveals that they are also remarkably improved and they do not require treatment. I affectionately refer to the cuboid as 1/2 of a keystone - and I do this metaphorically. It is very helpful to have a foot and ankle model that includes the whole foot and a short portion of the distal tibia and fibula, of course talus and calcaneus included. Take apart the joint leaving the forefoot, the cuneoforms, the navicular and the cuboid as one and the talus and calcaneus are seperate as is the distal tibia and fibula. It is so helpful to learning. You can put the pieces together and observe how the bones interact. It should be easy to perceive how the cuboid is "out there by itself" being most lateral and it is easy to see how it could be elevated and remain stuck in an inversion injury.
The cuboid can be palpated and compared to the unaffected side. Typically it is more prominent on the painful side and inferior glide spring testing and "pronatory" spring testing reveal fixation. I do not believe that onecan accurately perform a superior glide spring test due to thickness of the thickness of the soft tissue on the plantar surface of the foot. The typical manipulation appears to enhance the lesion - yet gap the joint and I believe that it recoils back to normal position. I prefer to mobilize it with progressive inferior glide and medial rotation mobilization.
Now a description of what I conveniently refer to as Type II. This can be symptomatic or asymptomatic, with all grades in between from acute to chronic. The difference is that a supinatory pattern of the foot and ankle complex has set in and efforts to mobilize only the cuboid will fail miserable, will not provide that quick fix. Instead, you have to treat all major articulations and this is where we get into some controversy. (Actually the direction in which I describe it re position and mobilization is contrary to most if not all of the literature-so here is more controversy). I find restrictions and restore mobility in the following directions:
posterior glide of the talus - the method also mobilized the calcaneus anteriorly at the same time
+ or - posterior glide of distal tibia
internal rotation of the talus
posterior glide of the distal malleolus
+ - ant or post glide of fibular head
superior glide of the fibula (not described in the literature, but indeed a seperate accessory motion - great research project)
inferior glide and medial rotation of the navicular and then incorporating the cunieoforms
inferior glide and medial rotation to the cuboid
At this point one will typically note that the calcaneus still has restricted eversion and abduction and the secret to restoring valgus (ultimately to restore normal pronation) is actually to mobilize the above sequence and then the calcaneus 30x into abduction and the valgus is then restored automatically without directly performing a valgus/eversion force. the abduction is the key - of course, after the above sequence. I think that I might be one of the first to namethe abduction - I just stumbled on it many years ago - but spank me if I am wrong.
Sometimesbefore the final mob to the calcaneus I will evaluate and treat if needed, medial glide to the talus working through the distal fibula and just below it as well.
After all of the above I go into a weight-bearing context and adress those motions that I can - if I find them to be restricted in weight bearing such as distal tibia rotation, calcaneal valgus, etc. I teach the client to internally rotate from hip down to distal tibia and gentley repeatedly self-mobilize into pronation 30-100 reps.
There are other flavors in which there is enough laxity in the ligaments that the above is not effective, fortunatley these are in the minority and I am not referrring to this sub-population is this commentary.
there is a great need for more research on the above topic and I think that our profession does not typically look at structures as patterns of motion dysfunction the cuboid syndrome a perfect example in which only 1 mobilization is described. After restoring normal motion, stability, strength, blance, endurance, proprioception, etc it is very appropriate to look up the kinetic chain and find out where the body has adapted or compensated for this pattern and treat what you find. Typically I end up treating the pelvis/SI and upper cervical spine, though if the pattern iis not chronic; the compensation may reflexively resolvewith no direct effort on my part.
enough!
Jerry Hesch, MHS, PT
[email protected]