Subluxated cuboid

I agree with Kevin's contention here- top image shows occlusion of the sinus tarsi- BTW for those that don't know this is called a positive Kirby's sign, while bottom image shows "bullet hole" through sinus tarsi. Viz top image STJ is maximally pronated, bottom image STJ is supinated- I can't tell if the cuboid has moved.

 

Ted:

To make this a little more scientific for you, and more useful for those of us who are interested in trying to see if a cuboid bone changes position in the foot pre- and post-manipulation, here is what you need to do to really give your little radiographic study some more meaning:

1. Standardize foot and STJ rotational position both pre- and post-manipulation (i.e. it doesn't help when the patient is standing more supinated three months later than when they were standing when you first had radiographs taken of their feet). STJ rotational position will greatly change the appearance of the whole foot (and cuboid) on lateral radiograph....podiatric radiology 101.

2. Take pre-manipulation and post-manipulation radiographs on same day, (i.e. one radiograph before and one radiograph after manipulation) after you feel you have "reduced the subluxed cuboid" by your manipulation technique. Do nothing else to the foot other than manipulating the cuboid. This will minimize other factors and will help you standardize radiographic technique and foot positioning.

3. Take radiograph again on another day to see if your radiographic technique and cuboid measurements change from day to day, regardless of manipulation. In other words, if you were to be shown the lateral radiograph of this patient's foot on any day of the week, and you did not know before looking at the radiographs whether they had symptoms or a clinical exam consistent with a "subluxed cuboid", would you be accurate at determining, by only looking at the radiographs, that their "cuboid had subluxed"??

As you can probably tell from my comments, I feel your radiographs told us absolutely nothing. Your radiographs showed us only that the patient was probably standing with their posterior tibial or anterior tibial muscle firing in the lower radiograph to hold them out of the maximally pronated STJ position. This is clearly evident, as Simon mentioned, in the lower (i.e. post-manipulation) radiograph by the lateral process of the talus not abutting against the floor of the sinus tarsi and by the navicular having much less superimposition over the cuboid when compared to the earlier radiograph.

I am still eagerly awaiting to be impressed with radiographic evidence of a subluxed cuboid, but will not hold my breath. By the way, I'll probably be around for another 20 years..............

 

I agree, look at the superimposition of the fibula in relation to the tibia. It's positioned posteriorly in the supinated view (external leg rotation) and more anterior in the pronated view (internal leg rotation). OR, was the fibula "unsubluxed" as well????

 

Good call, Scorpio. More posterior positioning of fibula relative to tibia on lateral radiograph=STJ more supinated. Thanks for that.

 

Thank you all for your comments.

The observations of radiological changes associated with max pronation vs supinated are noted.

The protocol used in positioning for the x-ray is to repeat the normal angle of gait to try to compare 'apples with apples'. Is the patient standing more supinated in the post x-ray? No doubt. The clinical observation prior to treatment was that the foot couldn't supinate to neutral/vertical calc position due to dorso-lateral tissue contractures associated with the chronic hyper-pronation.

Pre and post x-ray on the same day suggests you are expecting to see a 'gross measurable change' after one treatment(?) I think this is an unrealistic expectation. The amount of physiological tearing of the connective tissues would create massive inflammatory reactions. This is the sort of manipulation performed under anaesthetic (for good reason).

The objective of the manipulation is to cause micro-tears of the contracted tissues to a level the patient can tolerate. This is then repeated consistently to allow the joint to return towards their optimal functional range. The second objective is to stimulate the proprioceptive feedback loop to restore the muscle tone and function of the related muscles (tib post, tib ant, peroneals, long flexors and intrinsic foot flexors).

This example was not meant to show 'cuboid position' ONLY. I don't believe you can isolate a change in one bone without affecting others. This is why I spelt out the rationale behind manipulating the talus, navic, cuneiforms and cuboid. Only through doing this the patient is now actually able to supinate her foot to neutral and beyond. Her current RCSP now hovers around vertical without any conscious attempt to invert her foot. This is the proprioceptive capability restored.

We are looking to create long term adaptive change. The idea that a subluxated cuboid is 'out' and a manipulation puts it back 'in' is simply a physiological impossibility and I suspect this is the thinking behind the comments to see a pre/post change. (This sort of change is evident on a luxation such as a dislocated finger on the football field which then gets 'put back in'.) After a treatment, there is often a release of tension in the joint due to the cavitation that occurs but this does not mean a gross physiological positional change has occurred.

Taking the x-rays on other days would certainly address the question of what changes are in fact being affected. I'm mindful of trying to make a 3D assessment from a 2D image and trying to eliminate the other influences that could be contributing to positional changes.

Is an x-ray the definitive test for a subluxated cuboid? I think not. Can an x-ray give us some empirical evidence as to the position of a bone? I'd like to think possibly. The lateral w-b view of the cuboid makes it more difficult because of the super-imposition factor. A 2D subluxation of a hinge joint, e.g. the 1st MtPJ is more clearly evident. I'll ask Admin to post a couple of views of this subluxation pattern FYI.

Cheers,

Ted

 

Ted:

Three days ago, you made the following statement:

Then today, you posted the following:

These two statements seem contradictory to each other. Maybe you can explain yourself by answering one question for me:

Can a "subluxed cuboid" be diagnosed by radiograph?

If your answer is yes, then you need to show me some evidence. I'm still waiting to be impressed...........

 

Kevin,

Oh yes, I see what you mean.

In the 1st quote;

'We routinely x-ray clients as part of our pre-treatment assessment and as part of our post-treatment evaluation'

I meant after a 3 month treatment plan, not after one manipulation session.

We use x-rays to confirm our clinical findings and use them as one of the reference points in our objective assessment of treatment results.

I'll send Admin a new example of pre and post tx x-rays that do not have the supinated stance position as highlighted by the posterior position of the fibula. They show the difference in cyma line, distance between the cuboid's plantar surface and the floor, and the relationship between the cuboid and the styloid process.

I think it's unrealistic to expect to see a change in the cuboid 'only' with the rest of the foot staying exactly the same. This makes the art of interpreting the x-rays all the more interesting...

I'm awaiting for your state of 'impressed-ness!'

Ted

 

These two statements seem contradictory to each other. Maybe you can explain yourself by answering one question for me:

Can a "subluxed cuboid" be diagnosed by radiograph?

If your answer is yes, then you need to show me some evidence. I'm still waiting to be impressed...........[/QUOTE]

Kevin,

I agree with your comments regarding the x-rays posted.

I do however have a patient with what could be described as a "subluxed cuboid". I have loads of pictures i could post but cannot figure how to??? Advice please!

Simon

 

Using Manage Attachments and A Few Birthday Wishes

Simon D.:

When you post a reply, there is a box below the box you write your message in titled "additional options" that again has another little box within it called "manage attachments" that allows you to upload certain file types. I think Craig has made these files a certain size to not hog up his server too much. One of my birthday wishes is that these file size limits were a little bigger so I could post some nicer quality photos. You should be able to get some photos posted this way as long as the jpgs are under about 90 kilobytes. By the way, when I do my drawings in CorelDraw, I convert them to WMF (windows meta file) format to use in my PowerPoint presentations since they are compressed very nicely in this format without a degradation in quality. Another one of my birthday wishes of mine is to be able to post to this site using my WMF drawings.....I have hundreds of them.

 

Kevin,

thanks for the advice, picture attatched hopefully!

 

lateral view

 

another image

 

Andrew - I have a patient with 'cuboid syndrome' symptoms that are persisting following an ankle injury 6 months ago (she cannot remember if there was a lateral inversion). Please could you explain in detail what these 2 additions to an orthosis are and what optimum material you would suggest:
'a nice simple Feehry extension' under the cuboid and
a 'long extrinsic Denton extension' under the 5th ray.
Many thanks
Penny

 

subluxed cuboid

For those who have sprained ankles and have subsequent cuboid syndromes, I think it is important to consider the Peroneous longus may have been stressed to the degree it may have scar tissue keeping it from working the way it should...in fact it may be pulling paticulary hard to plantarflex the first met when it should be relaxed. Stretching, massage or physio can be helpful. As well, consider if the gastrocs and soleous are tight or were similarly stresed.

In the cast workup, ensure the cuboid area is preserved, or even notched a bit more. The lateral column ahead of it should be somewhat scooped to ensure the lateral forefoot is getting enough ground reaction when it should. And also so that the foot does not slide laterally. SOmetimes an additioinal poron or EVA cuboid cookie / wedge is more tolerable than a deep excavation in the cast and then the shell..it is also adjustable. I very often use a cork 2-5 to balance thre forefoot or unweight the first.

Ensure the footgear is not part of the problem because it well could be the cuprit that caused it in the first place... footgear with good lateral and rearfoot stability is very important during the rehab.

Best regards,
Freeman Churchill

 

Dear Dikoson,

From these pictures, this looks like a cuboid 'luxation' rather than a 'sub'-luxation. There is a significant mechanical distortion as shown by the plantar ulceration. While mobilisation would benefit the functional capabilities of the CCJ orthotic assistance to support and control the weightbearing surface would certainly be indicated too.

Ted Jed.

 

Kevin,

I wonder what your view of the most recent lateral cuboid views I've had posted is? Is this the sort of result you were anticipating?

Cheers,

Ted

 

Ted,

the heel appears to be contacting the surface in the first, but not the second view?

Could you tell us more about the differences (WB etc).


Ron

 

Ted:

I just wish your radiographic technique was consistent. It appears as if the angle of the central beam relative to the transverse plane is different in the two views. Better work on your technique.

 

Wow Kevin, your tolerance levels are exquisite. The pre xray view measures 7.0mm from the most plantar aspect of the calcaneus while the post xray view measures 8.0mm. The superior surfaces of the talar dome remain identical in both views. So a difference in the central beam angle may be up to 2 degrees difference?

Would such a difference result in the 1.5mm and 2.0mm differences between the cuboid's plantar surface:styloid prominence (proximal) and styloid process (plantar)?

We don't have the luxury of taking our own films - we rely on an independent radiology facility. They have 2 rooms for lateral foot views and each one has a different platform for the patient to stand on. This is the reason for the difference in the translucency of the weight bearing surfaces between the films.

Are you saying that you don't see any valid signs of change in the 2 views?

Regards,

Ted

 

Hi Ron,

The films are taken in the normal angle of gait in a weightbearing position. It is attempted to be performed consistently to compare 'apples with apples'. We use an independent radiology facility. They have 2 rooms for lateral foot views and each one has a different platform for the patient to stand on. This is the reason for the difference in the translucency of the weight bearing surfaces between the films.

The actual stance positions are the same. Does this clarify things for you?

Regards,
Ted

 

Ted:

I think that your standing platform differences are evidence of central beam irregularities between your two x-ray rooms. Did you look at the superimposition of the tibia over the talus, navicular over the cuboid and medial cuneiform over the fifth metatarsal base on the two lateral radiographs? This is likely due to varying angles or positions of the central beam of the x-ray machines relative to the foot.

For scientific study, x-rays must be done by the same technician, same machine and with the central beam pointing exactly to the same location on the foot if you want to use radiographs for this type of comparison. Remember, plain film radiographs are nothing more than two-dimensional shadows of the foot skeleton and are, for that reason, very susceptible to positioning errors of the x-ray tube and foot.

By the way, Ted, please tell us exactly what objective criteria you are using on the lateral radiograph that shows the cuboid moving from a subluxed to a non-subluxed position??

 

The criteria I use comes from Gamble & Yale's Clinical Foot Roentgenology 2nd Ed p197:

Normal cuboid position -

1. Continuous cyma line through the MTJ
2. The distal articulation of the cuboid and 5th metatarsal is congruent
3. The joint space between the calc-cuboid is uniform and match at their plantar margins
4. The peroneal groove is delineated by added density

The primary subluxation pattern of the cuboid is in an everted direction along the long axis of the lateral column. On x-ray, this is characterised by:

1. Uneven articulation of the facets of the calc-cuboid
2. The density of the peroneal groove is lost

In the images most recently posted, I note the folowing changes:

1. Changes in the cyma line
2. The uniformity between the calc-cub; there is greater joint space visible at the superior aspect of the joint space in the pre x-ray when compared to the post x-ray.
3. The articulation of the cuboid-5th metatarsal (to highlight this, note the pencil lines on the plantar aspect of the cuboid and the proximal and plantar-most point of the 5th metatarsal.

The quality of the images on screen does not show the changes in the density of the peroneal groove which, even on the actual films is not really evident.

I trust you can see what I am referring to..?

Cheers,
Ted

 

Kirby, Kirby Kirby,

Once again, you say things seem definative to those of us who don't know your modus, yet you haven't the foggiest clue about the subject at hand. Niether do most other folks....no one put it in the text books. (several are right on the mark, however.) The cuboid doesn't sublux, it over rotates. (Finn Bosjen-Moller) Someone on this thread insinuated that it subluxes superiorly. Explain to me how that could happen...does it viod all the laws of physics? If the calcaneus plantar flexes too much and the cuboid over rotates, then lateral x-ray will show exactly what the other gentleman said....it will appear impinged, which is exactly right. Not only that, there will be an incongruency in the joint line...the bottom is wider than the top....the cuboid only appears higher because the rotation put the corner at the top, making it feel high on palpation.

Before you come back at me with the snide little statement about Bosjen -Moller selling snake oil and being wrong about cuboid rotation, let me clarify something. Bosjen-Moller was half right. The part he didn't know about was the function of the intercuneiform ligaments. Yes, there are little, tiny, round ligaments between the tarsal bones and under the capsular ligaments. Since I found only a few references to them, it is possible you don't know what I'm talking about, but you can look it up. It is in the lit. Via these ligaments, the cuboid rotation pulls the lat cun back into the notch made by the nav. and cuboid. When the three articulate, they become stable. The cuboid "appears" to friction lock against the calcaneus.......which is what B-M wrote. Here's a question: Why does what I just said void all the conjecture about the number of STJ axes? Happy hunting.

As for your "little known labrum of the CCjnt," I'll ask you the same thing you ask us...don't quote some obscure writing by a quack that doesn't know a labrum from a fat pad and aereolar tissue, take us a photo. For the record, I can't wait until I have the ok to publish some of the stuff we have been working on these last 3 years. The look on some faces will be priceless. Without giving it all away, we DO have 3-D MRI documentation of the over rotated cuboid....we also have an inferiorily subluxed set of tarsals. And yes, we also have post manipulation images showing the correction....it just takes an MRI with a bit more resolution than the 3mm slice available in the USofA. Don't even ask that I send these to the site , you know perfecdtly well that I cannot and ever hope to have them published. As for your CCjnt labrum......when is the last time you dissected a CCJ? lets see, I dissected my last one....uh......YESTERDAY!! Like I mentioned before, there is a protective fat pad and some aereolar tissue to produce synovial fluid, but NOTHING that resembles a true labrum. Instead of trying to run over these folks who have facts to back up their opinions with overbearing and condecending quotes from arcane papers that no one cares about, why not try reading their work with an open mind. You might find you learn something...that's what this web site is for, is it not.

Kindest regards,
Kevin Miller

 

Kevin,

So nice to see you back on Podiatry Arena contributing again. Your calm and reasoned responses will certainly add to the value of this forum. Hope you had a nice Holiday Season with your family and hope you have a great New Year.

 

Kevin, firstly congratulations on your research. Perhaps I am being naive here, but why do you think that you: "cannot and ever hope to have them [MRI images] published"?

 

First, for Kevin K. Thank you, I am sure that my sharp tounge does not deserve such a gentlemanly reply.

Simon, The stuff will be published,I meant that if I put it out here first I would have a hard time getting it published. Besides, it is going on in two countries and there are laywers involved, so naturally it is a cluster $#@&*@. In short, I was being snide when I said they wouldn't be published because I have been chomping at the bit to get this stuff out there. We have reams of stuff that will either not make it into a paper or will have to be written separatley that bear out the position that the foot bones function plastically, for lack of a better term. Not only that, but the muscle we though operated parts of the foot...don't. They have other functions. Anyway, I can't wait to get it out there because I am sure there will be a huge debate, I would even bet that Kevin K. will take me to task.

 

Look forward to reading this when it is published. Has it been written up and submitted yet? Why are the lawyers involved?

I think I'm right in saying that plastic set can be induced in any material so why should it be such a revelation that bone exhibits plasticity?

 

The lawyers are involved becauseif we so that something CAN be fixed, there needs to be a way to fix it...VOILA (not the instrument - that was humor) we designed something. I am probably in trouble talking about it now.

For many of us, that bone is plastic is no revelation. I have about a dozen feet (dried) of different ages and constructions. Those with "normal" arches have a "textbook" look about them. The old, chronically pronated ones are interesting. Look at any one bone and it seems normal. look at the whole and you can tell that the foot has deformed as a unit....sort of like it was made from play-dogh and got too hot and began to melt. Here is the major part...1) the spine is an engine (Gracovetsky) that drives all other body movement, though it requires much of its energy for motion from impulses created at step phase 2) The body is a tensegrity mechanism (Buckmister Fuller) and can be seen all the way to the cellular level. Given chaos theory and fractals which expalin a lot in evolution and apply it to the cellular level tensegrity mechanisms, and we can see how the body reacts in the same manner. What does this have to do with plasticity? Where does the plastic deformity begin? The place where the tensegrity unit needs to make an adjustment to maintain symetry and efficency in impulse transmission to the spine. Since the foot has more bones that can deform and still transmit SOME force, it usually breaks down first. This revelation is why I have said previously that much of today's foot research is skewed because it is being done on pathomechanical feet whether they hurt or not. A non-painful foot adaptation may cause idopathic back pain, yet the foot is the problem and will ruin gait analysis. Did I make that clear, or was Imore confusing than normal?

 

Can you explain this please?

 

Sorry Simom, typo.

What I was talking about is the recent work in tensegrity theory at the celular level and their explainations at the evolutionary level. Quite facinating, actually, The little tubules we thought were simply for transport are tensile units to support the cell. The reference to chaos theory was to imply fractal theory of which it is part. Fractal theory, as you know, is the scienceof taking an equation and graphint it to get complex structures. This explains trelines, mountains, the petals on flowers, the arrangement of sunflower seeds, and noe, apparently the human body....from the cell to toaltl function as as tensegrity unit. The whole point was to show that the body is a tensegrity unit. It would have been easier had I merely said that, but I have learned a long time ago to explain everything or Kirby will call me on it. When you look at it like that, it becomes easy to see how a cuboid can destroy foot function, and poor foot function can destroy upper kinetic chain function. I hope this is better.

Kevin

 

I was diagnosed with this as a university student following an inversion sprain wearing a clog style shoe where the 5th ray was stabilised and i fell into a hole and wrenched the 5th/cuboid joint and cuboid/calc joint apart due to the stabilisation. a cuboid notch eased the pain without any other strapping, but strapping my foot (a number of ways) did very little. I would now argue a chopart sprain rather than cuboid subluxation but it is rhetorical only.

The cuboid does appear to move during normal gait (nestler et al bone pin study reference should go here) but im not sure it would "start" hurting or dislocate/translocate without some sort of traumatic event.

Ask the chiropractors about the term "sublux" it was invented by a lawyer and many of the better ones will shudder to hear the term banted around as commonly as it is now.

 

Galen Rupp pulled out of mile race with:

Cuboid bone culprit for Galen Rupp: a bit of a scare, but Galen is fine!