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BME/Osteopenia in Cuboid

Discussion in 'General Issues and Discussion Forum' started by Mark Russell, May 13, 2010.

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    66 y/o female with lateral mid foot pain for 2 months. No trauma or infection or previous injury/symptoms. Acute pain over cuboid and on passive inversion/supination of foot. X-ray normal. MRI shows the whole of the cuboid giving an abnormal signal cosistent with regional bone marrow [o]edema/osteopenia - with the adjacent bones on the mid and rear foot giving a normal signal.

    Patient presently immobilised in a aircast walker. Two questions:

    1. Any drug/meds that will specifically treat the osteopenia/reduce pain?
    2. What is most effective way to offload the cuboid - during normal walking and playing golf!


    Mark Russell

    Attached Files:

  2. Question 1 notsure, but would a high dose of NSIDS help ?

    Question 2 anyway that you can reduce the pull of the peronius Longus. It could be that the tendon of the PL is irratating the Cuboid when the muscle fires and when the cuboid is used as a fulcrum.

    so you can look at the 1st ray and Cuboid area in your device. You would want to build a device with a lateral skive, ie pronated the STJ and a cuboid notch
    ( make this from a soft material, as not to irratate the cuboid and PL through increased pressure from the device) and then look at the 1 ray is it plantarflexed/dorsiflexed what the Range of motion and Quality of Motion, then build the forefoot extensions according to what you find.

    I would guess a differiential diagnosis of Peroneal Longus subluxation from the peroneal grove on the cuboid and or cuboid subluxation from the info. These things can occur during gait but be within normal limits when xrayed or MRI due to the patient not moving.

    ice will help as well 2-3 times 25 mins every day and you may look at some manipulations of the cuboid.

    Hope that helps.
  3. Cheers Mike - it's definately osteopenia not PL subluxation. I've only seen a handful of these cases and never involving the cuboid. What we don't know is whether the affected bone is more likely to develop other pathology - like stress fractures or localised necrosis - when the bone is in its acute phase i.e. the first 8 weeks. Usually it settles down within 6 months and the bone returns to normal, but I am a little concerned in that the affected bone is in the midfoot and subject to more compressive stresses. I would be interested to hear if anyone else has seen secondary degeneration of acute/sub-acute osteopenic bone and whether reducing mechanical stress on affected bone is indicated.
  4. Hi Mark, Sorry got a carried away with DD and all, but the device I mentioned with lateral skive should take some pressure from the cuboid, with a soft cuboid notch to reduce impact and compression forces.

    Sorry again. I´ll be quite now.:drinks
  5. RobinP

    RobinP Well-Known Member

    Don't know about secondary degeneration sorry Mark but it sounds like you require considerable axial offloading given the proximity of the cuboid to the line of action of the axial load.

    It might be overkill, but a proximal offloading device such as a patella tendon bearing conventional ankle foot orthosis might reduce the axial load for the acute phase.


    Just a suggestion


    EDIT - Definately overkill - just read the bit about wanting to play golf
    Last edited: May 13, 2010
  6. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    I can recall 2 cases in recent years where patients have presented with cuboid pain, which has been investigated by MRI and striking bone marrow oedema throughout the bone has been discovered. Both had otherwise normal bone density, but certainly a propensity towards a cavo-varus foot type.

    Due to the high sensitivity of MRI, the radiological appearance of the bone marrow oedema is alarming. However, I think this is just a case of getting use to the beauty of MRI in diagnosis. IMHO, the oedema is likely to be bone bruising, and a precursor to developing cuboid stress fracture.

    I have treated these people with either weight-bearing CAM walkers, or complete non weight bearing on crutches. Usually followed with an appropriate orthosis long term, however you wish to approach it, to offload stress form the cuboid.

    Hope this helps,


    PS - for confidentiality you should rename the image files!
  7. Robin, Lucky, Mike - thanks for your input - much appreciated. I guess the problem is that osteopenia is a relatively "new" condition insofar as the ability to diagnosis is concerned - thanks to MRI. What is uncertain and controversial seems to the the significance of the condition - either as a precurser to stress fractures or osteoporosis - or whether the oedema occurs solely as a direct result of other aetiological factors. Either way, I guess off-loading the affected bone is a good idea! Thanks again.


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