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I have been referred a pt by one of our Orthopods. She has a 5 yr hx of pain in the cuboid. This originated she believes from an injury, when she kicked the fridge?? Not entirely convinced this is likely to be the mechanism of injury. She has been MR scanned ,which confirmed oedema in the cuboid, but not much else. She has been injected by a Cons radiologist, but without benefit. Finally, she has been passed to me. Biomechanically, not much to find, other than a mild forefoot valgus. She has had physio, which she tells me, included mobilisation, and manipulation of the cuboid, again with no benefit. I was considering trying a simple Frelen insole with a 3 degree lateral heel thro' forefoot wedge, to offload the lateral column. Has anyone any thoughts on this approach, or would you advocate a medial wedge to bring about more stability to the cuboid and improve the pull of P.L? I would be interested in your views.:dizzy:

 

Hi Mel,

I'm sorry I don't have time to go into this a little more in depth but my wife has given me a 10 o clock curphew for switching off the computer!

Here's my quick thoughts

Where is it sore(sounds like an obvious question but don't just rely on the MRI results - the oedema may well be sub clinical)

What other structures are in the area?

How can the aforementioned structures be stress tested? eg per longus and baxters nerve, lateral component of the plantar aponeurosis

If, indeed those structures are injured(and I'm not saying that they are) how could they have their tissue stress reduced.

If there are no other factors and the biggest problem is that the cuboid oedema is not being allowed to settle due to constant overloading then what orthotic modifications can be used to redistribute that load to elsewhere in the foot.

Are there any other treatments that would better redistribute that load eg shoe modifications, aircast boot etc

This is pretty much my thought process for any injury/problem that I see. Simple tissue stress theory.

Hope this helps

Robin

Oh and Welcome to podiatry arena

PS - FF valgus in relation to what?

 

It is hard to give advice when there is not enough information to know what the problem is. (Is the cuboid edema an incidental finding?) However, I can comment on some of your biomechanical theory. A lateral wedge won't have a guranteed result on the load of the lateral column. If there is no further eversion range of motion available, a lateral wedge will increase the load on the lateral column. If there is range of motion, you may not be able to predict what will happen to the load.

"bring about more stability" is a very loose term. There was a theory that was taught that supination of the STJ will "make the foot more stable". This was related to the rigid lever mobile adapter line of thought which is based on flawed logic as well. The idea that supination of the STJ improves peroneus longus pull is flawed as well. Yes, you can see pictures of it in Normal and abnormal function of the foot by Root, Orien and Weed, but those pictures are just artists conceptions without any studies to confirm their premise.

Eric

 

I thought after 5 years it might be time to immobilise it for a month and review.
if no better start all over again.
I doubt you can do something that has not been tried.
Rest is best in these situations.
get the MRI reviewed looking for a subtle stress fracture that may have been missed.
regards from a beautiful day in Sydney
Regards
Paul Conneely
www.musmed.com.au