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Cuboid pain

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  #1  
Old 11th March 2013, 10:40 AM
FTSE FTSE is offline
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Default Cuboid pain

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I mostly see corns-n-callus but I'd like to be more confident with the occasional MSK case that walks in. Can anyone offer any advice on how I should progress this one?

A 52 y/o white male with a history of episodic pain in the cuboid region of left foot.
He runs 3 times a week, typically a total of 25 miles per week. He also cycles about 40 miles a week. Running is on-road during the winter, both running and cycling routes includes steep hills. Also does some dog-walking.
He does not feel any pain while running but it comes on soon after and persists for a variable time (2 days to 2 weeks). It is painful to walk on barefoot, less so walking in supportive shoes and not at all (curiously?) running. There is no pain non-weightbearing.
I am not an experienced biomech pod but over the last 6 months I have twice successfully manipulated the cuboid (surprising myself!). My last attempt however was unsuccessful and the symptoms seem worse, perhaps because they are persisting for longer from a failed manipulation, or perhaps because the diagnosis is amiss. The current episode has been going on for 2 weeks now.
I am wary of manipulating again without further insight, in case I do more harm than good. As a stop-gap I have strapped a small pad of high density poron over the cuboid, in probably a forlorn attempt to stabilise the joint. The patient says he felt more confident running with the strapping on, but afterwards at home it was as painful as before.
No relevant medical history.
There is no swelling and no difference that I can feel between the left and right feet in the cuboid area. The tenderness is very localised. Feet are mildly pronated (and he runs wearing a basic orthosis with a 3deg medial rearfoot wedge). Ankle dorsiflexion is good with knee bent but limited when straight. End of range dorsiflexion brings on the cuboid pain slightly but no other foot movements provoke it. First MPJ feels good weight-bearing and non, although heavy medial IPJ callus suggests some issue there.

Unsurprisingly his preference is to find relief without having to stop running. It's only in writing this up here that I can see one obvious thing would be to try him wearing good shoes indoors for a couple of weeks - I've always thought of it as a post-exercise effect when perhaps it's more a lack-of-support effect?? He's tried Ibuprofen tablets and gel to not much effect.

What else should I consider as cause and what else should I try as treatment.

Thanks for any advice!
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  #2  
Old 11th March 2013, 08:33 PM
Greg Fyfe Greg Fyfe is offline
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Default Re: Cuboid pain

Hi

I'm not an MSK expert either, a couple of thoughts tho'

Is the cycling contributing? does he wear cleated shoes and whats the foot placement on pedals?
Possibly trigger points in Extensor dig' brevis or Flex' dig' min'/brev' that may respond to dry needling.

May be worth considering peroneals as well. Depending on where your tenderness is located

Also mobilise talo'calc' and tibial calc' joints if you haven't already

An X ray or Ultrasound might be worthwhile as well.

Regards
Greg
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Old 11th March 2013, 11:04 PM
kirstyq kirstyq is offline
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Question Re: Cuboid pain

Does your patient run on their toes? Perhaps it is weight bearing through the heel that causes grief. Perhaps a heel raise could be of some benefit? Is dorsiflexion through the MTJ causing pain?
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Old 11th March 2013, 11:39 PM
Greg Fyfe Greg Fyfe is offline
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Default Re: Cuboid pain

sorry I meant tibial talar joint rather than "tibio calc' "




Cheers
Greg

Last edited by Greg Fyfe : 11th March 2013 at 11:40 PM. Reason: deleted text
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Old 12th March 2013, 04:14 AM
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fabio.alberzoni fabio.alberzoni is offline
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Default Re: Cuboid pain

What MSK stands for?

thanks
fabio
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Old 12th March 2013, 04:29 AM
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David Smith David Smith is offline
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Default Re: Cuboid pain

FTSE (How's the financial market doing?)

Quote:
I have strapped a small pad of high density poron over the cuboid,
Quote:
There is no swelling and no difference that I can feel between the left and right feet in the cuboid area. The tenderness is very localised. Feet are mildly pronated (and he runs wearing a basic orthosis with a 3deg medial rearfoot wedge). Ankle dorsiflexion is good with knee bent but limited when straight. End of range dorsiflexion brings on the cuboid pain slightly but no other foot movements provoke it. First MPJ feels good weight-bearing and non, although heavy medial IPJ callus suggests some issue there.
Could be lateral column compression syndrome and so the plantar cuboid pad is a good start - but just to be sure - you did mean you put it under the cuboid (plantar) and not over i.e. on the dorsal aspect didn't you?

For more on compression syndromes go here:

http://www.podiatry-arena.com/podiat...ead.php?t=1980

But really we need more infor: For instance where exactly is the pain? What tissue do you suspect is painful? When you say the pain can be elicited by end range dorsiflexion do you mean purely dorsiflexion or is this end range pronation pushing manually on sub 4th 5th MPJ. Where exactly is the pain during this manoeuvre? What do you see the foot doing in gait, what are the biometrics and anatomical variations? Perhaps you can better describe the foot in Rootian terms if that is what you are familiar with e.g. uncompensated rearfoot varus, compensated forefoot varus, forefoot supinatus and inverted STN etc.

There are quite a few soft tissues in the cuboid area, and may be excessively stressed by a multitude of biomechanical aetiologies e.g. there could be peroneus longus pain caused by excessive pronation moments or excessive supination moments, there could be compression syndrome caused by STJ pronation and forefoot abduction moments or a compliant lateral column with a valgus forefoot and a supinating STJ etc etc.

Look here for more evaluation of lateral column pain: http://www.podiatrytoday.com/article/3691

Regards Dave Smith
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Old 12th March 2013, 04:34 AM
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Default Re: Cuboid pain

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Originally Posted by fabio.alberzoni View Post
What MSK stands for? thanks fabio
Fabio

In UK nowadays all Musculo skeletal pathologies come under the broad term of MSK. Even Rheumatoid and arthritic conditions come under this umbrella.

Dave Smith
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Old 13th March 2013, 01:29 PM
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Default Re: Cuboid pain

I would consider X-ray and MRI for further work up. Stress fracture, neuritis, tear in per. longus tendon, and the catch all phrase cuboid syndrome (kind of like skin splints) are all possibilities.

Have this runner switch to biking or pool running or crutches for a while longer. Doesn't that cure most things for runners?
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