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Subluxated cuboid

Discussion in 'Biomechanics, Sports and Foot orthoses' started by yehuda, Apr 4, 2006.

  1. yehuda

    yehuda Active Member

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    Subluxated cubiod --
    1) How do you treat it
    2) how do you prevent it


    (go on craig say trigger points :D )
  2. Craig Payne

    Craig Payne Moderator

    Cuboid syndrome / subluxation

    From my notebook:
  3. yehuda

    yehuda Active Member

    Differential diagnosis – myofascial trigger point; sinus tarsi syndrome; stress fracture; peroneal tendonitis; irritation of os peroneum; ankle meniscoid lesion/impingement.

    I knew it

    :D :D
  4. Ian Linane

    Ian Linane Well-Known Member

    As a sufferer of a chronic one it is facinating to see how it affects AJC movement in gait and the knee!!

  5. Mark Egan

    Mark Egan Active Member


    What is AJC?

    The 2 patients I have seen with subluxed cubiod we were able to mobilise/manipulate the cubiod into an improved position and apply strapping to hold it initially as well as apply semicompressed felt cubiod padding to their shoes. It seemed to work.

    Yehuda - you also asked "how to prevent it" could that be add cubiod pads/notches to all orthotics? a very simplistic method. Or is their a mechanical pattern that makes someone more prone to suffer from this?

  6. admin

    admin Administrator Staff Member

    AJC = ankle joint complex
  7. Ian Linane

    Ian Linane Well-Known Member

    Hi Mark

    For me the weightbearing affects include:

    restricted dorsiflexion especially when moving towards early heel lift and beyond, limiting of resupination of heel
    increased stress upon the medial knee

    All these are most noticeable when getting up first thing in the morning.

    Wearing my orthotics makes the affects minimal but when not wearing them there is a vulnerable feel to the foot and knee on one side.

    Had Manip's and Mobs which have had a short term benefit but does not last.

  8. Mark Egan

    Mark Egan Active Member


    What caused your problems initially? I assume you have worked on the peroneals i.e.. heat packs and massage and neural stretches. You mention problems first thing in the am have you tried a night splint?

  9. yehuda

    yehuda Active Member

    Neural stretches :confused:
  10. Mark Egan

    Mark Egan Active Member

    I have used them for those with peroneal issues it was shown to me by some physios.

    patient is reclined in bed with a beach towel (as it is longer and easier to hold onto) place the towel around the foot mainly at the forefoot with the knee flexed pull the foot into a supinated position. Then bring the leg up and gradually extend the knee depending on how tight the muscles are will dictate the at what point you need to get to get the stretch in the peroneals by doing a straight leg raise at the same time you are doing a neural stretch. I advised patients not to hold it for more than 8 seconds as you can flare the nerve up. I have them repeat this 2-3 daily for 2 weeks and then review things. It appears to help in most cases.
  11. Freeman

    Freeman Active Member

    I find that cuboid subluxation occur with patients who have tight peroneous longus and gastroc soleous. So I encourage them to stretch them gently at first, making sure that they are stretching what they are supposed to, and not a bad imitation. Technique is very important. Excessive pressure or loading on the first ray increassed the peroneous longus tension, and if the foot is pronating on a plantarflexing first met head it (cuboid) can sublux. I often see them after a bad inversion sprain that has not been properly rehabed.

    I will try to put the foot in a position where the lesser met heads are taking their share of the load, expecially early in stance...I tend to use a first met cut out, increased cuboid support (a poron addition can be more comfrtable than a rigid one if the cuboid is not yet in place), heel raises on those with tight calves, and a full medial long arch support. IN a cavus foot I will put in a long plantar groove. People will tell you that if they wear Birks or similar sandals with cuboid support that when it is "out" the sandals are almost intolerable until it is back in place. I sometimes do a whip cuboid maneuver which works best when pre-stretching the calves and peroneals has already occurred. Keep them stretching but with the hopes that when it pops back, it does it by itself. The more whips you do, the more risk I believe there is to joint integrity. Loose bed sheets may be a help for those who sleep with their feet in plantar flexion with all kinds of bed sheets, dog, etc on their feet.
  12. Mark Egan

    Mark Egan Active Member

    do you use heating at the calc/cubiod joint prior to wips?

  13. Labrum of Calcaneo-cuboid joint


    There are those of us who believe that a "subluxed cuboid" might actually be a figment of clinician's imaginations, since a "subluxed cuboid" has never been shown to be present on plain film radiograph, CT or MRI scan, to my knowledge. In fact, the symptoms generally described as being due to a "subluxed cuboid" are more likely due to impingement in a virtually unknown structure within the human foot, the labrum of the calcaneo-cuboid joint.

  14. davidh

    davidh Podiatry Arena Veteran

    This certainly makes sense to me.
    Anatomically, it's difficult for me to see how the cuboid could sublux.

    Does anyone else find the symptoms associated with "subluxed cuboid" in patients with chronic plantar fasciitis?

  15. Craig Payne

    Craig Payne Moderator

    Perhaps it is unfortunate that, as the manipulation for this works so well, it has become called 'Cuboid subluxation' when perhaps the more appropriate term should be 'Cuboid syndrome'.

  16. Atlas

    Atlas Well-Known Member

    Brukner and Khan in 'Clinical sports medicine' describe this pretty well. Invariably, we are dealing with a cuboid that is stiff to palpation (plantar-to-dorsal); when compared to the contra-lateral foot.

    This is one of the few conditions that one can improve considerably within one session of manual therapy.
  17. One Foot In The Grave

    One Foot In The Grave Active Member

    Maybe it's "subluxed" in the same way as the bones that Chiropractors see are "subluxed".

    I know that rest, not wearing my sandals, massage and "mobilisation" with a hand-held massage unit (couldn't get my hands into a good position to mobilise my own foot adequately) reduced and improved my cuboid syndrome.
  18. Freeman

    Freeman Active Member

    Cuboid syndrome works for me....I have had a few people who have had a pain similar to PF. I had it myself 3 years ago. As soon as I did the stretches on calves and peroneals, the "snap" took away the pressure on my lateral foot and the heel pain went away...instantly.

    Yes Warming the foot and calves seems to help. (Soory I did not answer right away...was in Winnipeg for a week
  19. Admin2

    Admin2 Administrator Staff Member

    Just picked up this from a physio forum:
    Link to thread at Physiobase
  20. Atlas

    Atlas Well-Known Member

    A perfect example of over-complicating a simple problem. Most of that is nonsense IMO. As I said, Brukner and Khan spell it out well and simply.
  21. Footsies

    Footsies Active Member

    Does anyone else find the symptoms associated with "subluxed cuboid" in patients with chronic plantar fasciitis?

    that sounds a little like baxter's?!
  22. Craig Payne

    Craig Payne Moderator

    Maybe both caused by the same thing (ie one of the windlass dysfunctions)
  23. Freeman

    Freeman Active Member

    I would agree with Craig...
    here is an "aside" story.

    3 years ago Nova Scotia was hit with a class 3 hurricane (Juan) and my fair city of Halifax took it square on the chin (110 mile per hour winds) THe day before the surf was quite spectacular. At a local beach many were body surfing...my kids and I went out to watch. I went in to catch a few waves. One wave tumbled me topsy turvey and I did not know know which end was up. I was quite literally tossed/slammed onto the sand much like a ragdoll. I got out thinking that was quite enough: one could get killed!. The next morning after the city was very much trashed, my right foot had symptoms of plantar fasciitis which I have never had in that foot before. I also noted that associated with the pain on midstance and heel off there was a very specific reducation/limitation in subtalar motion. The pain increased very quickly so I literally sat down on the sidewalk and mobed my right subtalr joint. Bingo! It snapped and there was an instant flooding of relief in my foot whereby the heel pain disappeared with the snap. I have not had it since.




    There are those of us who believe that a "subluxed cuboid" might actually be a figment of clinician's imaginations, since a "subluxed cuboid" has never been shown to be present on plain film radiograph, CT or MRI scan, to my knowledge. In fact, the symptoms generally described as being due to a "subluxed cuboid" are more likely due to impingement in a virtually unknown structure within the human foot, the labrum of the calcaneo-cuboid joint."

    Kevin, I have seen many plantarflexed cuboids in my time on lateral weight bearing X-rays so this could be the jamming mechanism you describe. I firmly believe cuboid's sublux. I have managed this treatment with manipulation of the CC jt, and if the pain contains, a nice simple Feehry extension under the cuboid and a long extrinsic Denton extension under the 5th ray works great.
  25. Andrew:

    Please provide us with a photo of the radiograph of one of the many plantarflexed cuboids that you have seen in your time so that we may all be educated as to what this looks like on a lateral weightbearing radiograph. It would also be nice if you could provide us with a "post-manipulation" radiograph for comparison so that we all can see the difference in the orientation of the cuboid between pre and post manipulation.



    I see that you are sceptical, i have no access to X-ray a patient after a manipulation so i cannot provide evidence of post-manipulation cuboid position. My X-rays are mainly taken to try and discern biomechanical abnormalities of the foot. A manipulated cuboid may be in a "corrected" position during a non-weight bearing manipulation, but surely as soon as the patient weight bears the cuboids function will change, thus it's going to be a different position (simple mechanical loading of the lateral column). So, what can I prove if i take an X-ray after a manipulation, NOTHING!!! The cuboid has changed place, I may be able to prove the cuboid isn't as subluxed as it was, so in theory manipulation may work, but what factor caused the cuboid to sublux in the 1st place?

    As in any diagnostic situation you have to find out what causes the CCjt to dysfunction, as you stated :-

    "In fact, the symptoms generally described as being due to a "subluxed cuboid" are more likely due to impingement in a virtually unknown structure within the human foot, the labrum of the calcaneo-cuboid joint."

    These impingements are listed elsewhere in this thread. My general rule of thumb is that if a object of some description has been dropped on the foot then the CCJT may become displaced in a plantarflexed position, and lets say a patient steps onto an object then the CCjt may become displaced in a dorsiflexed position. Treatment is dependent upon each individuals case and a variety of the treatments proposed in this thread may be used.
  27. Andrew:

    Yes I am skeptical. However, since you made the statement earlier, "I have seen many plantarflexed cuboids in my time on lateral weight bearing X-rays so this could be the jamming mechanism you describe. I firmly believe cuboid's sublux.", then I thought I would provide you the opportunity to show us what radiographic findings you use to determine that a cuboid is "plantarflexed". I am simply asking you how what objective criteria you use when assessing a lateral radiograph that a cuboid is "plantarflexed". If you can't provide this criteria or can't provide evidence of some change pre and post manipulation in cuboid joint position, then how do you know the cuboid is plantarflexed abnormally?

    Here is what I said earlier in this thread:

    Do you disagree with the above statement?
  28. StuCurrie

    StuCurrie Active Member

    2 cents from a Chiropractor:

    It has been interesting to read the terminology debate as it is something I deal with quite a bit, both with colleagues and patients. The term subluxation is used by some chiropractors to describe changes in the spine and other joints. For those who use the term subluxation (latin root luxa or displace) it does not connote an actual change in position of the joint. It is a sub dislocation if you will. For me, the term subluxation is really clinically irrelevent, for how can you treat a sub problem?

    I tend to look at things from a motion perspective. Is the cuboid moving as it should, or as the other one is? If it is not, then I manipulate it to induce motion, not to put it back in place. I like the term cuboid syndrome, but when I describe it to patients it's just plain stuck. From the sounds of it, I would manipulate things similarly to the others in this thread.

    Even as one who prides himself on manipulation for specific joint restrictions in very specific planes of anatomical motion, I must agree that the physio thread copied above does really seem to make a bit of a mess out of a fairly simple problem.

    So while I don't agree that this problem is a figment of the clincian's imagination, I would also suggest that manipulation may not solve all of these. Kevin's article from Hollander pointed out why. As for a plantar fasciitis correlation, I do find that manipulation of this joint helps in a lot of cases, however I would very rarely only manipulate the cuboid by itself. I would suggest that the correlation may be explained by the long plantar ligament's attachment to the cuboid and the plantar aspect of the calcaneus, possibly mimicking heel pain. Its relationship to the peroneus longus tendon may also explain why peroneus myofascial work and stretching seems to help alleviate the pain in some of these cases.

  29. StuCurrie,
    Subluxed literally means sub "under" & lux "light" (not displace ). Look it up. Your use of the term subluxation doesn't jive with the real meaning. You first paragraph just doesn't make sense to me. "sub dislocation"?
    Terminology is important. Improper use of terminology makes it difficult to understand many of the contributers to this fine site.
    Tony Jagger
  30. Stu:

    Here is what I wrote:

    I did not say that pain in the calcaneo-cuboid joint (what you call cuboid syndrome) is a figment of a clinician's imagination but that a "subluxed cuboid" is a figment of a clinician's imagination. Do you believe that the cuboid actually is "subluxed" or not aligned correctly in these patients?
  31. StuCurrie

    StuCurrie Active Member

    I agree, terminology is very important and I guess I should clarify. First, I do not use the term subluxation, especially to describe the position of joints. My point was that the word means different things to different people. It can mean a partial or incomplete dislocation to some, a loss of juxtaposition to others, and I think opthamologists use it to describe a condition of the lens.

    But I'm pretty sure the latin root "luxa" does mean dislocate or displace. When I made the post, I was recalling the way the root was taught in school, but here is a link: http://www.phthiraptera.org/Classical Roots/classical_J.html
    If you look it up in a medical dictionary like Dorlands, you will see the latin root “luxatio” meaning dislocate. You'd have to explain to me how the root "under light” would apply more here.

    And I completely agree with you, that it doesn't make sense to use the term to describe a "sub dislocation". I was pointing out how some folks use the term as it seemed to apply to this discussion.

  32. StuCurrie

    StuCurrie Active Member

    Hi Kevin,

    No, I don't. I think we're in the same camp on this one. What I see is that many patients have pain in this area that responds very well to manipulation/mobilization/manual therapies or whatever you would like to term it.

    As for exactly what's going on in the joint, I don't have a definitive answer for that. Your guess is as good as mine. Maybe the cuboid is not moving through it's normal ROM, maybe the joint surfaces are inflammed or maybe it's a fibroadipose synovial fold that's restricting motion. Personally, I would not look for a radiographic malposition or change, but maybe there's someone out there who does document this stuff. If so, I would be very interested in seeing it.

  33. jerseynurse

    jerseynurse Member

    How best should one handle cuboid pain that is due to an imflammed os peroneum since the lateral arch of orthotics put pressure on that area? Should there be a cut out made for relief in that spot?
  34. TedJed

    TedJed Active Member

    I agree on the importance of definitions. Let's use Dorland's 2004 Medical Dictionary's definition of subluxation:

    ‘…not a normal physiological juxtaposition of the articular surface of a joint (demonstrated radiographically).’

    Luxation: 'Dislocation of a joint'

    Clinically, a subluxation of the cuboid interferes with the range and quality of motion of the calcaneo-cuboid joint. This joint does not have a large range of motion and the practitoner's palpation skills play a key role in its clinical determination.

    Just this weekend gone, in teaching a course on Foot Mobilisation Techniques, George Murley, one of the participants and La Trobe Uni staff, presented with reduced motion in the midtarsal region of his right foot. The student working on George called for my assistance. When I checked via palpation, I could sense the limited movement in the MTJ stemming from the CCJ. I adjusted the cuboid, which then improved the motion at the midtarsal area which then adjusted and 'released' subsequently.

    (I define the term 'adjust' as the application of a force to reduce subluxation').

    While I could palpate the change immediately, George also reported an immediate change in the quality of motion in the midtarsal and CCJ.

    I'm going to get some radiographs of a subluxated cuboid before AND after manipulation. We routinely x-ray clients as part of our pre-treatment assessment and as part of our post-treatment evaluation and I can report on the visual changes evident. I'll post these for you all to view.


    Ted Jed
  35. admin

    admin Administrator Staff Member

    Ted - can you do us a favour and not label the x-rays 'before' and 'after' and we can see if we can get it. Tell us later which is which --- thanks
  36. TedJed

    TedJed Active Member

    Good point, will do.

    Oh, I needed to add that the subluxated cuboid I referred to was a 'dorsal subluxation' and this is manipulated in an opposite method to the typical 'plantar-everted' subluxation pattern (resulting from the Peroneus Longus) as described by Craig.

  37. Ted:

    Please provide us with standard weightbearing lateral radiographs of the foot pre- and post-manipulation (non-weightbearing radiographs will be useless) so that we can all see the objective radiographic differences between a "subluxed cuboid" and a "non-subluxated cuboid". I wait to be impressed. :rolleyes:



    I cant wait for these x-rays either, hopefully we can shed some light on this interesting debate. Is there any general consenus of opinion on what can cause a jamming of this joint, i.e. what biomechanical considerations should we be looking for when making a diagnosis of "cuboid syndrome".
  39. admin

    admin Administrator Staff Member

    Ted emailed me the before and after x-rays for posting:


    Here is the message Ted sent with them
  40. Ted:

    You must be kidding, Ted....you think these x-rays demonstrate the effects of your manipulations?? More likely they demontrate the effects of the patient standing maximally pronated at the STJ (above) and supinated from the STJ maximally pronated position (below). The cuboid has moved?? How can you tell??

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