Cuboid Syndrome

Cuboid syndrome refers to the disruption of the normal function of the calcaneal-cuboid joint (CC joint). Disruption of the CC joint is often called subluxation. Cuboid syndrome is somewhat obscure and poorly defined in the literature. When conditions are poorly defined in the literature, this means that there is a lack of consensus among doctors as to the etiology (reason for the condition) and the treatment. Cuboid syndrome can also be found in the literature described as a sequella of inversion sprains of the ankle.

Cuboid syndrome can also describe a sprain of the CC joint or any of the supporting structure contiguous to the CC joint. These structures include the calcaneo-cuboid ligaments and peroneus longus tendon.

The onset of cuboid syndrome varies and can be abrupt (most common) or insidious in onset. Pain is typically site specific to the plantar lateral cuboid. Indurated (hard) edema may be found. Bruising is uncommon.

The diagnosis of cuboid syndrome is made based upon the location and onset of pain. Plain x-ray should be used to differentiate cuboid syndrome from fractures. MRI is also helpful to define soft tissue problems that occur in the region of the CC joint (see differential diagnosis below).

Treatment Of Cuboid Syndrome

Cuboid syndrome, when due to subluxation of the calcaneal-cuboid joint, is treated by reducing (realigning) the subluxation of the CC joint and stabilizing the reduction. It is believe by many, but not all practitioners that reduction of the subluxation can be accomplished by manipulating the joint. Manipulation is performed with the patient in a prone (face down) position. The doctor cradles the foot in his/her hands and places both thumbs beneath the CC joint. The CC joint is then manipulated by a forceful movement, moving the leg at the knee and the ankle while applying pressure with the thumbs at the plantar (bottom) aspect of the CC joint. This procedure is called a cuboid whip.

Reduction of the subluxation can be maintained with taping and padding. Padding of the lateral sole is used to maintain the reduction of the CC joint and limit supination (rolling to the outside of the foot).  Lateral sole wedges can be placed in the shoe or applied to the outer sole of the shoe at a shoe repair shop.  Rest, ice, compression and elevation (RICE) is used as a first line treatment of cuboid syndrome. The use of oral NSAID medications is also common. Occasionally, cortisone injections may be helpful in reducing inflammation associated with the subluxation of the CC joint. Patients are instructed to avoid going barefoot or wearing shoes with low heels. Heel lifts worn within the shoe can also be helpful. Once the acute symptoms are resolved, prescription orthotics (arch supports) are helpful in preventing a recurrence of cuboid syndrome.

The response to treatment of cuboid syndrome depends upon the etiology and onset of symptoms. Acute onset of cuboid syndrome, say from an ankle sprain, may respond dramatically to manipulation. If cuboid syndrome is due to chronic, excessive intrinsic load (CT Band Syndrome) treatment such as manipulation may be less effective and take longer to see results.

Cuboid - A bone of the lateral midfoot named after its square shape. The cuboid has historically been used in games as a dice.
Chopart's Joint - Includes the talo-navicular joint and the calcaneal-cuboid joint. Named after the French surgeon Francois Chopart (1743-1795).
CT Band - 'calf to toes' band. Describes a band consisting of the calf, Achilles tendon, ankle and plantar fascia.
Extrinsic load - any load delivered to the foot that is exclusive of intrinsic load. Extrinsic load includes load applied to the lower extremity by proximal muscle transfer or by upper extremity torsion.
Intrinsic load - Load applied to the foot through the CT band.
Subluxation - Motion of a joint that is irregular and not in alignment with the normal range of motion of the joint.
Tarsal bone - the large bones of the rear foot including the calcaneus, talus, navicular and cuboid.
Tarsitis - Chronic inflammation and pain of the tarsal bones.

The calcaneal-cuboid joint (CC joint) is located on the lateral (outside) aspect of the foot. The CC joint can be found immediately below the outside of the ankle and about two fingers distal (towards the toes). The CC joint is a broad, flat joint build to bear load. The joint has very little movement or motion. The CC joint is surrounded by a number of stout ligaments that are intended to limit motion and stabilize the joint. On the plantar aspect (bottom) of the joint are the long plantar ligament and calcaneal-cuboid ligament. The lateral side (outside) of the joint is stabilized by the dorsal calcaneal-cuboid ligament. The dorsal aspect (top) of the cuboid is stabilized by the dorsal cuneo-cuboid ligament, the tarso-metatarsal ligaments, dorsal cuboideo-navicular ligament and miscellaneous inter-tarsal ligaments.

The CC joint is also stabilized by a number of contiguous structures that pass above, below or along the cuboid. The most significant of these is the peroneus longus tendon that wraps along the lateral and plantar aspects of the cuboid. The cuboid is essentially help in a sling by the peroneus longus tendon. Other structures include the peroneus brevis tendon, dorsal and plantar musculature and retinaculum.

Cuboid syndrome occurs at the calcaneal-cuboid joint (CC joint) on the lateral or outside of the foot. The CC joint functions together with the talo-navicular joint (TN joint) and the subtalar joint (STJ) to deliver load to the forefoot. The function of these joints is to deliver load that can be converted into action; walking, running etc. For additional definitions of load in relationship to the normal function of the foot and leg, please refer to our article on CT band syndrome.

Cuboid syndrome occurs when the calcaneal-cuboid joint is unable to carry the load that is applied to it. The calcaneal-cuboid joint is part of what's referred to as the lateral column of the foot. The lateral column is the primary load bearing section of the foot that transfers load from the heel to the forefoot following the heel strike phase of gait. The result is that the calcaneal-cuboid joint subluxes (moves out of its' normal position).

The onset of cuboid syndrome may be due to an acute injury of the lower extremity such as an inversion sprain of the ankle. Occasionally the symptoms of cuboid syndrome occur without an obvious injury. The symptoms of cuboid syndrome are very similar to the symptoms of a sprain. Pain is significant when weight is first applied to the foot. Pain increases with the toe off phase of gait as the weight of the body and load from the calf muscle are delivered to the lateral (outside) column of the foot.

Bone contusion

Calcaneal stress fracture

Compression neuropathy of the sural nerve

Cuboid fracture

Gout

Peroneal tendonitis

Partial peroneal tendon rupture

5th metatarsal avulsion fracture

Os peroneum

Sinus tarsi syndrome

Tarsal coalition

Tarsitis

• Heel Pain

• Forefoot Pain

• Peroneal Tendonitis

• Ankle Pain

• Foot and Ankle Anatomy

This article was written by Jeffrey A. Oster, DPM and last updated 2/5/13.

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2. Leerar, PJ. Differential Diagnosis of Tarsal Coalition versus Cuboid Syndrome In An Adolescent Athlete. J Orthop Sports Phys Ther 2001; 31(12)
3. Marshall P, Hamilton WG. Cuboid Subluxation In Ballet Dancers. Am J Sport Med 1992; 20(2).
4. Mooney M, Maffey-Ward L. Cuboid Plantar And Dorsal Subluxations: Assesment And Treatment. J Ortho Sports Phys Ther 1994; 20(4).