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Help with Patient with cuboid pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bartypb, Dec 11, 2012.

  1. bartypb

    bartypb Active Member

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    Hi Everyone I'm after a little help with a patient that I saw today 55yr old female, moderate height and build, On her feet in warehouse 8hrs/day wears reebok trainers. C/O pain and swelling to the Left foot, happened approx 6/12 ago no initial injury, but she reported that when it was at its worst it "looked like an extra bone sticking out". The area of the pain was dorsal aspect of the cuboid.

    Examination today showed some soft tissue swelling rangeing from calcaneocuboid jt to the 3rd cuneifom dorsally, tender to palpate. Resisted eversion and eversion with dorsiflexion (oblique direction) there was discomfort but no discomfort on resisted dorsiflexion/planterflexion. Slight medial deviation of STJ with everted calc but moderate arch profile with little navicular drop/drift weightbearing stance. I mobilised the cuboid and it didn't really have any restrictions or produce any tenderness.

    GP said the swelling was probably normal but after complaining by the patient he sent for plain films - NAD.

    I was thinking along the lines of cuboid subluxation - but does this happen dorsally and if so how would it be treated? Peroneus tertias injury, or EDL muscle belly injury - but would either of these produce the symptoms described??

    Any ideas would be much appreciated


  2. David Smith

    David Smith Well-Known Member

    Re: Help with Patient

    Try this attached

    Attached Files:

  3. Ian Linane

    Ian Linane Well-Known Member

    A useful, gentle technique can be as follows.

    Set up:
    The patient is seated with their feet flat upon the ground. You are knelt in front and to the side of the patients affected foot.

    Place your thumbs on the dorsal surface of the cuboid and apply a small pressure in an inferior direction.

    Whilst sustaining the thumb pressure ask the patient to slowly and gently lift their heel off the floor whilst simultaneously keeping their forefoot on the ground. Repeat this procedure up to 5 times and re-evaluate (have them walk around and see what change has occurred). If appropriate you can repeat the above placing your thumbs on different aspects of the dorsal surface of the cuboid.

    The effect is that of a sustained pressure by you whilst the patients movement induces a glide of the cuboid , inferiorly, on the surrounding structures.

    Couple of points to note:
    1 There can occasionally be a small discomfort but this is under the patients control and they can adjust this by how high they lift their heel off the ground at any given point in the procedure.

    2 As they raise their heel so the foot undergoes supination and if you are applying a firm pressure (not strong pressure) you will find that your thumbs and hand will follow the foots motion, staying in line with the foot whilst still sustaining the thumb pressure.

    Hope this helps.
  4. bartypb

    bartypb Active Member

    thanks David and Ian, I'm not sure I would be able to sustsain pressure on the dorsal aspect as there is soft tissue swelling and just palpation is painful but I will check when she next comes in

  5. Ian Linane

    Ian Linane Well-Known Member

    Hi Barty
    If there is tenderness then you can place some cushioning on the area that reduces pressure of the tissues onto the cuboid. Do this and use a slight resistance initially as the patient lifts their heel. Alternatively try the thenar eminence of the hand as it is well padded.
  6. Athol Thomson

    Athol Thomson Active Member

    You may need further imaging to rule out a longitudinal split/tear in the peroneus longus tendon. I have picked up a handful of these tears recently and some of the patients complained of pain and had palpable tenderness about the cuboid or just superior to it. Ultrasound or MRI.

    see below:


    All the Best,
  7. Ian Drakard

    Ian Drakard Active Member

    There is a lot going on in that area, the joint articulations, ehb and edb, p tertius crossing over etc where the swelling could be coming from. I'm not sure dorsal pain necessarily relates to dorsal subluxation. Can you describe the cuboid mobilisation you used?

    If the plain films are clear I would try either cuboid mobilisation technique described by Ian or a plantar approach and see what happens- the dorsal cuboid pain should pretty much go and often the surrounding swelling will reduce quite quickly.

    Check the peroneals and ab hal for tenderness before you do this and recheck after.

    Also a bit more patient info would be interesting as there is no initial trauma- supination resistance especially.
  8. Good advice. You may wish to consider bone marrow oedema or osteopenia. Usually post menopausal women and cuboid are commonly affected. Doesn't show on plain film, you need to request an MRI. And it doesn't like being manipulated either.
  9. Barty:

    My guess is this patient has a form of lateral dorsal midfoot interosseous compression syndrome where the lateral forefoot is bearing more ground reaction force than normal and the dorsal joint margins of the cuboid are getting excessive compression forces causing dorsal joint surface microfracture. The forefoot plantarflexion test on the lateral forefoot will be positive if this is the case. However, it may also be a cuboid stress fracture or a cuboid stress reactions which an MRI should be able to determine for you.

    First of all, I would put the patient into a cam walker boot-brace if she is in a lot of pain still with weightbearing activities. Also have her start icing the dorsal cuboid 20 minutes twice a day. Once she is able to walk with less pain she may be taken out of the brace. I would first check her shoes to make sure they are not broken down laterally (i.e. midsole is inverted) since, by itself, lateral midsole compression can easily cause such symptoms in a person who is heavy and on their feet all day long. In addition, a valgus forefoot and rearfoot wedge may help her symptoms but this would be much more effective for the patietn if it is done in conjunction with a custom foot orthosis to support the planatar aspect of the cuboid.

    You may want to read this thread from over 3 years ago on Lateral Column Pain where I described the diagnosis and treatment of this condition in much greater detail.

    Good luck and hope this helps.:drinks
  10. Lab Guy

    Lab Guy Well-Known Member


    Kevin's post exemplifies why he is not a big fan of foot manipulation. I think he understands manipulation has its place, but he would much rather determine the causitive factors behind the symptoms and objective findings. He can then develop an appropriate treatment plan to provide not only short term relief of symptoms but recurrence of the underlying problem.

  11. bartypb

    bartypb Active Member

    Thanks everyone for the advice, Kevin I did think interossei compression but I couldn't really ellict symptoms on dorsal/planterlexion movement forefoot to rearfoot (is this what you mean by forefoot test?) Footwear didn't show anything unusual and she has been wearing the same footwear for approx 5 months. I do do mobilisations when I feel they may help, but I wasn't overly keen in this instance as it is a little weird in the presentation of the swelling and history of when the problem was acute? Also I would expect a trigger point on the planter aspect of the cuboid on the calcaneal/cuboid or cuboid/intermediate cuneiform ligaments if cuboid is subluxed?

    Ian why would I want to check Ab Hallucis have you found this to become symptomatic after mobilisation, I haven't myself?

    I work in a community NHS podiatry clinic and do not have access to MRI, I have sent for U/S just to see if anything comes back but will probably refer to orthopaedics (for MRI) if symptoms don't improve. I really want to try and solve/ understand what is happening here myself as it is something I haven't seen before so its a great learning opportunity.


  12. Barty:

    Anytime you see localized dorsal swelling in the foot, you must consider stress fracture. Put her in a cam walker brace. I described the forefoot plantarflexion test in this thread. http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=4558

    Here is some extra reading on Dorsal Midfoot Interosseous Compression Syndrome (DMICS).

    Forefoot plantarflexion test: While stabilizing the rearfoot at the ankle joint, plantarflex the lateral forefoot on the rearfoot to detect inflammation in the dorsal 4th-5th metatarsal-cuboid joint ligaments and/or their insertion points on these bones. This test is nonpainful in the normal foot (a negative test). This test is painful in the foot with dorsal midfoot ligament/capsular inflammation (a positive test).
  13. Ian Linane

    Ian Linane Well-Known Member

    "Kevin's post exemplifies why he is not a big fan of foot manipulation. I think he understands manipulation has its place, but he would much rather determine the causitive factors behind the symptoms and objective findings. He can then develop an appropriate treatment plan to provide not only short term relief of symptoms but recurrence of the underlying problem."

    I'm slightly confused Steve, and it might be my misreading of your above comment in which case my apologies, but it almost implies that others who utilise mobilisation (not manipulation in my case) do not "determine causitive factors" or arrive at "objective findings" before applying a modality that, in my experience and contrary to what you said, sometimes resolves the problem long term without any other form of intervention being required. At other times it serves only to be part of a number of modalities required to resolve the problem. It is also important to recognise that mobilisation also refers to the tissues surrounding an area and would be part of the mobilisation rehab.

    Where the causitive factors indicate that mobilisation is to be only one of the intervention tools needed for a patient then that is simply what it is. Using it on its own in this instance would indeed only get short term results.

    For me, the role of the orthosis at timesis the same, simply yet another tool with a place.

    It is determining, where possible, what the underlying causitive elements are that means at times means I will only mobilise and get long term results, at other times it means I go down a multi-tool route. I'm sure there are other practitioners who operate similarly.
  14. Lab Guy

    Lab Guy Well-Known Member

    Ian, I should have worded my post better and can see the misunderstanding. I mainly meant that Kevin has little interest in manipulation (not his cup of tea) from his past posts I have read on Podiatry Arena. I should not even speak for Kevin who I have the highest respect for and I apologize.

    I also believe that there are many practitioners that use manipulation without truly identifying the underlying etiology, especially in the USA where biomechanics is not taken seriously as in the UK and here on the Arena. I have much respect for you, Ian and the many other posters that participate on here.

  15. Ian Linane

    Ian Linane Well-Known Member

    Hi Steve

    Thanks for clarifying this and I was not offended in any way, I just didn't want to misunderstand you.

    I think you raise a valid point however because mobs can be a highly effective and significant tool in our work to rehab the low limb. If there is a joint and it is meant to move but doesn't I have to do two things. Firstly, try to work out why and, secondly, restore appropriate function to the joint. This can often achieve a lot in terms of reducing stress to tissues in their function.

    Unfortunately a bit like orthotics have been wrongly put across in the past, they are considered at times to be a one off fix without giving consideration to the fact that much injury in the low limb needs not only resolution of symptoms, where possible, but rehabilitation into as full performance as possible.

    Where abouts are you based Steve? Seems like the USA.
  16. Lab Guy

    Lab Guy Well-Known Member


    You are correct, I am from the USA. I live in Florida which is very nice this time of year.

    Keep up the good work doing mobs, I am sure your patients love it.


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