C

CASE REVIEW
Joe J. Piccininni, EdD, CAT(C)
Management Strategies for Cuboid Syndrome
Jennifer L. Roney, MS, ATC • University of Utah; Melissa L. Yamashiro, ATC • Orthopedic
Specialty Group; and Charlie A. Hicks-Little, PhD, ATC • University of Utah
C
uboid syndrome refers to a subluxation
of the cuboid or calcaneo-cuboid joint dysfunction.1,2 Cuboid syndrome only accounts
for 4% of sports-related foot injuries, but
represents 17% of foot injuries among ballet
dancers.2,3 The purpose of this report is to
present an effective management strategy
for cuboid syndrome.
The stability of the
Key Points
articulation between the
cuboid and the distal
Cuboid syndrome is rarely found in athportion of the calcaletes, other than ballet dancers.
neus is maintained by
Current management options include
a number of ligaments
manual techniques, taping, padding, and
and a joint capsule.
orthotics.
The peroneus longus
tendon runs through
The “four mini-stirrup” taping can help
the peroneal groove on
manage cuboid syndrome.
the plantar aspect of the
cuboid. 1,4 The line of
pull on the peroneal longus produces medial
and inferior rotation of the cuboid around
the oblique axis of the transverse tarsal joint,
which is an important aspect of foot function
during gait.1,4,5 At heel-strike, the subtalar joint
is supinated and body weight is concentrated
on the lateral aspect of the heel. During the
transition from heel-strike to midstance, the
subtalar joint pronates and the body weight
is shifted to the medial aspect of the foot. The
cuboid is most susceptible to displacement
when tension within the peroneus longus
tendon exerts more force than the passive
stabilizers of the calcaneo-cuboid joint.5-7 Any
joint that primarily relies on passive stabilizers is predisposed to hypermobility.4 Newell
and Woodle3 reported that nearly all cases
of cuboid syndrome were associated with
pes planus. Pronation of the subtalar joint
provides the peroneal longus muscle with a
greater mechanical advantage.5 The intrinsic
foot muscles, predominantly the flexors, are
believed to play an important role in stabilizing the transverse tarsal joint during gait.4
Current conservative management of
cuboid syndrome includes manual therapy,
taping, padding, and use of an orthosis.5-10
Newell and Woodle 3 described a cuboid
manipulation technique that was later
referred to as the “black snake heel whip.”1
The patient stands with the affected leg in
a knee-flexed, non-weight-bearing position.
The clinician grasps the forefoot, placing the
thumbs on the plantar aspect of the cuboid
and wrapping the fingers around to the dorsal
aspect of the midfoot. The clinician applies
a quick plantar flexion force to the ankle
as the thumbs push the cuboid in a dorsal
direction.3 This technique was modified by
Jennings and Davies,8 who placed the patient
in a prone position on a plinth with the knee
of the affected leg flexed to approximately 90
degrees. The clinician extends the patient’s
knee while plantar-flexing the affected foot. 8
A self-mobilization technique was described
by Marshall.9
Mobilization techniques are widely as
advocated for treatment of cuboid subluxation, but other conservative measures have
also been suggested.5-10 There is no widely
recognized procedure for cuboid taping. Marshall9 described a J-strapping technique that
© 2010 Human Kinetics - ATT 15(5), pp. 10-13
10  SEPTEMBER 2010
Athletic Therapy Today
has been found to be very beneficial. Other researchers
have suggested using a “low-dye” taping technique
to both support the joints of the midfoot that form
the medial longitudinal arch.10 Newell and Woodle3
suggested the use of a cuboid pad, or wedge, to add
stability to the lateral column of foot joints. This pad is
typically constructed from one-fourth inch closed-cell
foam or felt and incorporated with a taping technique.3
Some clinicians advocate long-term utilization of an
orthosis to foot in a neutral position, thereby decreasing the amount of tension generated by the peroneus
longus tendon.1,3,10
Other conservative treatment options mentioned
in the literature include massage, cryotherapy, and
therapeutic exercise.5-10 Although outcome studies
have not been conducted to document the effectiveness of any of these management strategies, they may
decrease pain and inflammation within the calcaneocuboid joint. Lacking a widely-recognized standard for
conservative management, clinicians may be forced to
take a “trial and error” approach to treatment. Assuming that laxity develops in the passive stabilizers of
the calcaneo-cuboid joint in dancers and runners, it is
logical to hypothesize that taping of the mid-foot and
strengthening of the intrinsic foot muscles and extrinsic lower leg muscles may help to prevent recurrent
subluxations of the cuboid.
Case Presentations
Athlete 1
This case series reports the evaluation and management of two female distance runners with differing
presentations of cuboid subluxation. During the 2007
spring track season, a 22-year-old female collegiate
cross country and 1500-meter runner (mass = 52.27
kg, height = 162.6 cm) presented lateral ankle pain
at the base of her fifth metatarsal and extending to the
lateral aspect of the distal one-third of the lower leg.
Her pain was exacerbated by walking, after running
on uneven surfaces, and with extreme ankle inversion.
Athlete 2
During the 2008 summer training camp, a 21-yearold female cross country runner (mass = 59.09 kg,
height = 160 cm), presented pain in the Achilles
tendon approximately 5 cm superior to its insertion,
the inferior aspect of the lateral malleolus, and along
the middle one-third of the plantar surface of the foot.
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She exhibited reduced plantar-flexion and dorsiflexion,
due to pain and muscle tightness.
Differential Diagnosis
Possible conditions included extensor digitorum brevis
or peroneus brevis tendinopathy, fifth metatarsal
ligament injury, sinus tarsai syndrome, stress fracture,
malalignment of the talocrural and subtalar joints,
meniscoid lesion of the ankle, Jones fracture, subluxating peroneal tendons, lateral plantar nerve entrapment,
and Lisfranc sprain.
Treatment
Palpation revealed grinding and hypermobility of the
left cubo-metatarsal joint of the first athlete. The team
physician recommended cross-training for several days
to allow pain to subside, tape application to immobilize
the cuboid during activity, and a wedge-shaped orthotic
to increase foot pronation. A J-strapping technique
was utilized on the first day, but it was not successful.
Low-dye taping with a cuboid wedge was then used.
The athlete reported increased pain after one day with
the wedge, so its use was discontinued. Her foot was
then taped for activity utilizing a “four mini-stirrup”
method (Figure 1). The taping procedure utilized one
strip of moleskin as a stirrup that was pulled laterally from the medial malleolus. Then three strips of
Leukotape© (BSN Medical, Hamburg, Germany) were
used to secure the subtalar joint and transverse tarsal
joint. Along with taping, the athlete participated in a
daily ankle strengthening program (Table 1), followed
by cold whirlpool submersion for pain control. Periodic
petrissage was administered to relieve tightness in the
gastrocnemius, soleus, and peroneal muscles.
For the second athlete, palpation revealed point
tenderness over the calcaneal fat pad, medial longitudinal arch, and along the peroneal tendons of the
foot. Pain was elicited by resisted eversion, and the
amplitude of subtalar motion was less than that of
the uninvolved extremity. The fourth metatarsal head
was depressed and the cuboid was subluxated. The
team physician used the “cuboid whip” mobilization method (Figure 2) to reduce the cuboid. Taping
was recommended for weight-bearing activities until
custom orthotics could be fabricated. Low-dye taping
was initially utilized with poor results, and the foot
was subsequently taped using the “four mini-stirrup”
method. The athlete received custom orthotics two
SEPTEMBER 2010  11
Figure 1 “Four mini stirrup method” taping procedure.
Table 1. Rehabilitation Protocol For Cuboid Syndrome
Intensity
Duration
Exercises
Flexibility
Maximum stretch
3 × 30 sec
Hamstrings, Psoas, Gastrocnemius, Soleus, Hip adductors
and abductors, Gluteus medius, Piriformis, Tibialis anterior
Strength
Maximum controlled
contractions
3 × 10
Marble pickups, Towel scrunches, “Short Foot” squeeze (10
sec hold), Heel raises
3 × 10
Squats (single leg, double leg), Lunges, Side to side hopping
3 × 30 sec
BOSU ball single leg balance
5 × 2 legs
6 point touch, 6 point hop
Balance and
Coordination
days later. She cross-trained for two days, and then
returned to normal training. Continuous ultrasound
(1.2 MHz, 8 min) was administered before practice,
and electrical stimulation (pre-modulated, 15 min)
12  SEPTEMBER 2010
combined with ice was administered for three days to
control pain. After training with both tape and orthotics
for one session, the athlete chose to use only orthotics. Seven days after the cuboid reduction, the athlete
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began a daily ankle strengthening program (Table 1),
followed by cryotherapy for pain control.
Both athletes performed the daily ankle strengthening program for four weeks. Each day, pain perception,
activity level, and treatment were recorded (Table 2).
After four weeks, both athletes reported a decrease in
pain and increase in range of motion. We believe that a
combination of therapeutic modalities, a rehabilitation
strengthening program that is focused on the dynamic
stabilization of the foot and ankle, and our “four mini
stirrup” taping can help manage cuboid syndrome
effectively.
Conclusion
Although relatively rare, cuboid syndrome may be
responsible for midfoot discomfort among athletes.
Treatment options for this condition include manual
therapy techniques, therapeutic modalities, taping and
padding, and the use of an orthosis. Lacking research
evidence for the effectiveness of these therapeutic
measures, clinicians must rely on the anecdotal experiences of other clinicians. 
References
Figure 2 “Cuboid whip” technique.
Table 2. Data Collected During
the Four Weeks of Rehabilitation
for 2 Athletes
Average
Average
Average
Paina Before Pain During Pain After
Average
Miles/Day
Week 1
Athlete 1
3
4
5
8
Athlete 2
5
3
5
8
Athlete 1
3
2
5
7.5
Athlete 2
6
3
4
7
Athlete 1
2
2
2
7
Athlete 2
4
2
3
6.5
Athlete 1
1
2
1
6.5
Athlete 2
1
2
1
7.5
Week 2
1.Blakeslee TJ, Morris JL. Cuboid syndrome and the significance of
midtarsal joint stability. Am J Podiatr Med Assoc. 1987;77:683-642.
2.Patterson SM. Cuboid syndrome: a review of the literature. J Sports
Sci Med. 2006;5:597-606.
3.Newell SG, Woodle A. Cuboid syndrome. Physician Sports Med.
1981;9(4): 71-76.
4.Agar V. Cuboid syndrome: aerrancy of midtarsal joint locking
as a mechanism of injury. Sports Physiother Division Newsletter.
1991;15(6):16-18.
5.Woods A. Cuboid syndrome and techniques used for treatment. Athl
Train JNATA. 1983;18(1):64-5.
6.Marshall P. Cuboid subluxation in ballet dancers. Am J Sports Med.
1992;20(2):169-175.
7.Mooney MA, Maffey-Ward L. Cuboid plantar and dorsal subluxations:
assessment and treatment. J Orthop Sports Phys Ther. 1994;20(4):220226.
8.Jennings J, Davies GJ. Treatment of cuboid syndrome secondary
to lateral ankle sprains: a case series. J Orthop Sports Phys Ther.
2005;35:409-415.
9.Marshall P. Rehabilitation and overuse foot injuries in ballet dancers
and athletes. Clin Sports Med. 1988;7(1):175-191.
10.Subotnick SI. Peroneal cuboid syndrome: an often overlooked cause
of lateral column foot pain. Chiropractic Techniques. 1998;10(4).
Week 3
Week 4
Values reported for pain are on a 0-10 pain scale.
a
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Jennifer Roney is a graduate assistant athletic trainer and teaching
assistant in the Department of Exercise and Sport Science at the University of Utah, in Salt Lake City.
Melissa Yamashiro is a sports medicine specialist at the Orthopedic
Specialty Group in Bountiful, UT.
Charlie Hicks-Little is an assistant professor and Director of the
Graduate Program in Sports Medicine in the Department of Exercise
and Sport Science at the University of Utah in Salt Lake City.
SEPTEMBER 2010  13
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