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Cuboid Syndrome
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Cuboid syndrome is a painful problem on the outer side of the middle of your foot, where a small bone called the cuboid is thought to shift slightly. It is most often reported in ballet dancers and athletes: about 17 per cent of professional ballet dancers with foot or ankle injuries had it, and about 4 per cent of athletes seen for foot problems. The main symptom is outer foot pain with weak push-off. In a small group of athletes, symptoms eased within 1 to 2 treatments.
What is it?
Cuboid syndrome is a painful problem on the outer side of the middle of your foot. The cuboid is a small bone there, and in this condition it is thought to shift slightly out of its usual position (a partial displacement, sometimes called a subluxation). This can cause pain and make it hard to push off your foot when you walk, run or dance.
Why it happens isn't fully understood. It is thought, but not proven, to involve the joint between the cuboid and your heel bone.
You may also hear it called cuboid subluxation, dropped cuboid, locked cuboid or cuboid fault syndrome. These names all describe the same problem. It is described as common but often not recognised.
Who does it affect?
Cuboid syndrome is most often reported in ballet dancers and other athletes. Among professional ballet dancers with foot or ankle injuries, about 17 per cent had it. Among people with an ankle sprain where the foot was pointed down and rolled inwards, about 6.7 per cent had it. About 4 per cent of athletes seen for foot problems had it.
It may be more common in people with pronated feet (feet that roll inwards, with flatter arches). It can also happen in people with high-arched feet.
These figures come from dancers and athletes. Don't assume they apply to everyone else, as the numbers for other groups aren't known.
Signs and symptoms
The main symptom is pain on the outer side of your foot or ankle. You may also notice that your forefoot feels stiff and that your push-off is weak. Dancers often describe being unable to "work through the foot". Some people also get a tight spasm in the peroneus longus (a muscle along the outer side of the lower leg).
It can start after an ankle sprain, where the foot rolls inwards with the toes pointed down. It is often mistaken for an ankle sprain, or missed when it happens alongside one. Pain on the outer side of the midfoot that lingers after your ankle has settled is a clue.
What causes it?
The usual story starts with an ankle injury. When your foot rolls inwards with your toes pointed down, as in an ankle sprain, the cuboid may be pushed slightly out of place. This can lead to pain and a joint that doesn't move as it should. It can be hard to diagnose.
Some things may make cuboid syndrome more likely. These are possible contributors, not proven causes:
- instability in the middle of your foot
- extra body weight
- shoes or shoe inserts (orthoses) that fit poorly or are poorly made
- heavy training, or training without enough time to recover
- running or training on uneven surfaces
- a foot or ankle sprain
In general foot and ankle pain, activity levels, body weight and footwear are also named as key risk factors. Your podiatrist may ask about any recent ankle injury, changes in your training, the surfaces you use and your shoes.
How is it diagnosed?
Cuboid syndrome is mainly diagnosed from your story and a hands-on check. Your podiatrist will ask about your ankle injury and test how the cuboid and nearby joints move, which is restricted in a typical pattern. Two midfoot movement tests may also be used. It can be hard to diagnose. Moving the cuboid back may also help confirm it.
X-rays add little for cuboid syndrome itself, but may be used to look for a broken bone, which can be missed because foot bones overlap. Swelling and bruising after an injury can point to a broken cuboid.
Outer or midfoot pain has other causes, including a break, gout, arthritis, Charcot foot and a joined bone in the foot, so cuboid syndrome shouldn't be assumed without an assessment. After an injury, see the warning signs in "When to see a podiatrist".
Treatment
Cuboid syndrome is usually treated with simple, hands-on care, not surgery. There are no firm guidelines, and the support for these treatments is limited, so it isn't clear which works best. Decisions should be shared between you and your podiatrist.
Looking after it at home
Cut back activities that bring on the pain. After an ankle injury, avoid long periods with your leg down: keep it raised when you can. A severe sprain may need a few days of short-term protection. After manipulation, avoid running and other hard weight-bearing for several days. Mild soreness may be eased with cold packs or massage.
Treatment from your podiatrist
The usual first treatment is cuboid manipulation, a hands-on technique to move the bone back, including the "cuboid whip". It should be done only by someone trained in it, after a broken bone and other risks have been ruled out. It isn't suitable with a broken bone, bone disease, inflammatory arthritis, gout, or nerve or blood supply problems. It should wait until swelling and bruising have settled and your ankle ligaments have healed enough.
Padding, taping, braces, shoe inserts (orthoses) and exercises may be used alongside it. Your podiatrist will follow up to check the cuboid stays in place.
Other options
If manipulation gives no relief, your foot should be re-examined and the diagnosis reconsidered. It may be a sprain of the ligaments on the outer side of the midfoot. Crutches or a cane to take weight off the foot are advised, and short-term protection may help if the foot feels unstable. No relief is a reason for further assessment, not more self-treatment. It isn't yet clear whether injections or surgery have a role.
Recovery
The outlook looks good once cuboid syndrome has been correctly diagnosed and treated. In a small group of athletes, symptoms eased quickly: all 7 returned to sport after 1 to 2 treatments, and none had the pain come back over the next 2 to 8 months. Some people notice the pain ease or stop straight after the bone is moved.
If you have had symptoms for longer, you may need several sessions over time. Firm recovery timeframes aren't clear yet, so your podiatrist can't promise a set number of visits.
In general foot and ankle problems, people living with extra body weight are more likely to have symptoms that last longer.
Preventing it
There is no sure way to stop cuboid syndrome coming back, but some steps may help. Build your training up gradually and allow enough time to recover. While it settles, avoid uneven surfaces. Check that your shoes and any shoe inserts (orthoses) fit well and are well made.
After the cuboid has been moved back, taping, padding and shoe inserts may help keep it in place. Stretching your calf, hamstring and peroneus longus, and strengthening the small muscles in your foot, may also help. Your podiatrist can show you what suits you, and talk about weight support if it is relevant. These are suggestions, and no best approach has been shown.
When to see a podiatrist
When to book
Book an appointment with your podiatrist if you have pain on the outer side of your foot or midfoot that doesn't settle, especially if you are a dancer or athlete. See your GP soon if you have foot pain with tingling, loss of feeling or weakness, or if you have diabetes and foot pain. The warning signs below are different: follow them.
When to get help sooner
Get urgent medical assessment (see your GP today, or go to an urgent care clinic or the nearest emergency department) if:
- you have diabetes or reduced feeling in your feet and one foot becomes red, hot or swollen, or suddenly changes shape, even if it doesn't hurt (possible Charcot foot)
- your foot or ankle looks badly out of shape, or points at an odd angle, after an injury: go straight away, without waiting for an appointment
- you can't put weight on your foot or take four steps after an injury
- you think you may have broken a bone in your foot or ankle in an injury, for example you heard a crack, or it swelled or bruised badly within minutes
- your foot suddenly looks flatter after an injury
Frequently asked questions
Can a sprain leave my ankle unstable?
Yes. If the ligaments don't regain their strength, the ankle may stay unstable. Up to 40 per cent of people develop symptoms of instability after a sprain. This applies to ankle sprains in general, not only cuboid syndrome.
Can a stuck cuboid cause pain higher up the leg?
Possibly, in some people. Single case reports link long-lasting pain in a leg tendon, and in the knee, to a stiff cuboid. In one, symptoms eased straight after manipulation with exercise. It isn't a general finding.