Cuboid Syndrome

The symptoms of cuboid syndrome resemble a ligament sprain ¹, and the two often arrive together. So the useful question usually isn't "which one?" but "is there a cuboid problem that my ankle sprain rehab isn't touching?"

Clues that point towards the cuboid ¹:

• The pain sits on the outer midfoot, between the heel and the bases of your fourth and fifth toe bones, rather than around the ankle bone itself.
• It's worst at push-off and with side-to-side movement, and hopping on that foot provokes it.
• You're limping to protect it, even though the ankle itself feels better.

None of those clues confirms it. There are no definitive diagnostic tests ¹, and X-rays are of little value for finding cuboid syndrome ². Two hands-on tests have been described, the midtarsal adduction and supination tests, but their diagnostic accuracy hasn't been determined ¹. Diagnosis comes down to your history, a cluster of signs and a clinician who's thinking of it ¹. Checking how the cuboid moves against its neighbours by hand is part of that ⁵.

Other conditions that can look similar, and need ruling out, include ¹:

• a fracture of the cuboid, heel bone or fourth or fifth metatarsal
• a Lisfranc injury to the midfoot
• peroneal tendinopathy (irritation of the tendons down the outside of the leg)
• plantar fasciitis
• sinus tarsi syndrome, gout, and nerve entrapment on the outside or sole of the foot.

This one is diagnosed in the clinic room, from your history and your signs and symptoms. A scan won't do it ¹. Alongside the two tests described above, a clinician feels for tenderness on top of and underneath the cuboid and along the peroneus longus tendon that wraps around it, checks whether turning your foot in or out against resistance hurts, and watches you walk and hop ¹. We may also glide the cuboid gently up and down. That can be sore, and the bone moves less when it's 'locked' ¹.

An X-ray still has a job: ruling out a fracture or another bony problem ¹. CT and MRI haven't made the diagnosis any easier, partly because harmless variations in outer-foot anatomy are common ¹.

Our approach follows what the literature recommends, with the evidence caveat above kept in view.

Cuboid syndrome is treated along The Well Motion Recovery Path™. Your foot moves up a phase when it passes that phase's test, whatever the calendar says.

• Reset: starts at your first visit. Assessment, then cuboid manipulation once any sprain swelling has settled ¹, with taping or a cuboid pad supporting the foot afterwards ^1,2. Expect the manipulation to be quick, and the foot to need a quiet spell after it ¹. We move you on once you can walk and push off without the pain building.
• Rebuild: progressive exercise through sports physiotherapy: foot and ankle strengthening, plus calf and peroneal stretching ^1,2. Expect hopping and side-to-side movement to feel normal last. We move you on when the foot does what your daily tasks ask of it.
• Return: running, dancing, court sport, or a full day on your feet at work. We test push-off, hopping and change of direction at the speed your activity needs. You leave with a taping or padding plan and home exercises aimed at recurrence ¹.

How long it usually takes. No trial has measured it. The only figure comes from one 2005 case series with no comparison group: all 7 athletes returned to sport after 1 to 2 treatments, with no recurrence over a mean 5.7 months ³. Longer-standing cases may need more sessions ², so that figure is no promise.

Nothing here has been tested in a trial. What's written about cuboid syndrome is mostly case reports ¹, so each step goes after a factor that literature links to it:

• Stretch and strengthen. Stretching the calf, hamstring and peroneus longus muscles, and strengthening the muscles in and around the foot, may help prevent a recurrence ¹.
• Give yourself recovery time. Inadequate recovery from exercise is on the list of things that may make cuboid syndrome more likely, next to how hard, how long and how often you train ¹. So space out the heavy sessions.
• Watch the ground and the shoe. Uneven training surfaces are on that list too, along with poorly fitting or poorly made shoes and orthoses ¹.
• Mention outer-foot pain that outlasts a sprain. Pain around the cuboid once the ankle itself has settled should raise suspicion of cuboid syndrome ¹.