Cuboid Syndrome: Whip It Good!

Cuboid syndrome is a cause of lateral midfoot pain theorized to arise from a disruption of calcaneocuboid joint integrity due to recurrent or forceful eversion of the cuboid. It may result in limited range of motion of the midtarsal joint due to an impinged or displaced calcaneocuboid labrum (¹).

Manual manipulation of the cuboid may be both diagnostic and therapeutic. One such manipulation is the cuboid whip (³). The patient lies in the prone position, with the knee flexed to 70° to 90° and the ankle in neutral. The practitioner’s fingers interlock over the dorsum of the foot, with the thumbs over the plantar surface of the cuboid while applying a dorsally directed force. It is imperative that the subject's leg is completely relaxed at this point. The “whip” occurs when the knee is quickly extended, the foot plantarflexed, and the subtalar joint slightly supinated while applying a thrust to the cuboid. This should be a quick, firm force; it can be described as trying to quickly tear one piece of tissue paper off a roll. An audible pop may sometimes be heard but is not necessary to achieve proper joint alignment.

An alternative technique can be performed with the patient supine. We have found that if the patient is having pain on the dorsal surface of the cuboid (as opposed to the plantar surface), this technique may be more effective. The patient lies with the affected leg off the table. Again, complete relaxation of the leg is highly important. The practitioner faces the foot, and grasps around it with the fingers placed on the plantar foot and the thumbs at the dorsal aspect of the cuboid. Pressure is applied directly over the cuboid, and gravity is used to distract the foot. The practitioner then applies a quick distraction force while plantarflexing the foot. For a visual example of both techniques view the supplemental video at the Video Gallery here: http://journals.lww.com/acsm-csmr.

Care should be taken to avoid manipulation in the recently injured foot and should only be considered once the acute pain and swelling have partially subsided. This technique can provide substantial resolution of symptoms with a single manipulation; however, multiple manipulations may be needed over time, with the number of manipulations often proportional to the duration of symptoms (^1,2). Gains in pain and function after manipulation should be solidified with physical therapy, including gastrocnemius and soleus stretching, intrinsic foot strengthening, and balance/proprioception exercises. Gait analysis and retraining may be needed for more chronic cases.