SUPINATED FOOT AND ANKLE, aka TYPE II CUBOID SYNDROME

(18/2/06 3:59 am)
Jerry's Reply

Cuboid
    
Good answers re the topic of cuboid syndrome. I have treated this for 2 decades, so I have some thoughts. I intended to submit a letter to the editor after the article cited earlier in JOSPT in 2005, but never did. In my opinion, there are essentially 2 basic types of cuboid syndrome. I do not believe that this has been adequately addressed in the literature. For convenience I am going to name one type a TYPE I CUBOID SYNDROME  and the other a TYPE II CUBOID SYNDROME. 

Type I can be symptomatic or asymptomatic.  It responds beautifully to a manipulation of the cuboid, and the cuboid alone.  If painful, the pain resolves very quickly and the treatment is repeated if necessary, 1 or 2 times. Client and clinician are both happy. Recovery is quick.
Basically the cuboid fixation is the key lesion in the foot and ankle complex and restoring mobility directly to the cuboid makes for significant improvement.  Sometimes there is a pattern that appears to involve several other structures in the foot and ankle, yet the manipulation performed only at the cuboid, is almost magical. Retesting the other motion fixations reveals that they are also remarkably improved and they do not require treatment. I affectionately and metaphoriclly refer to the cuboid as "1/2 of a keystone." It has no lateral
structure to articulate with, as it is the most lateral of that row of mid foot bones. When it subluxes laterally with foot and ankle in inversion, there is much to hold it out there, the articulating lateral cunieform and the articulating calcaneus. The navicular also articulates with the cuboid, and the 4th and 5th metatarsals proably play a rather minor role. It is very helpful to have a foot and ankle model that includes the whole foot and a short portion of
the distal tibia and fibula, of course talus and calcaneus included. Take apart the joint leaving the forefoot, the cuneoforms, the navicular and the cuboid as one and the talus and calcaneus are seperate (as is their attachment to the distal tibia and fibula. It is so helpful to learning, to have this semi-disarticulated model in hand. You can put the pieces together and observe how the bones interact. It should be easy to perceive how the cuboid is "out there by itself" being most lateral and it is easy to see how it could be elevated (vertical axis) and laterally rotated about an A-P axis,  remaining stuck in an inversion injury. 

The cuboid can be palpated and compared to the unaffected side. Typically it is more prominent on the painful side and inferior glide spring testing and "pronatory" spring testing reveal fixation (and discomfort). I do not believe that one can NOT accurately perform a
superior glide spring test due to thickness of the soft tissue on the plantar surface of the foot. The typical manipulation is opposite to the way I prefer to mobilize it. The typical manipulation involves a superior thrust from the plantar surface of the foot, see details in other post, below. The typical manipulation appears to enhance the lesion - yet gap the joint and I believe that it recoils back to normal position. I prefer to mobilize it with progressive inferior glide (dorsal to plantar direction)and add medial rotation mobilization, while I attempt to "create space" and coax it back by taking the navicular and the cuboids into medial glide and medial rotation.  

Now a description of what I conveniently refer to as TYPE II CUBOID SYNDROME. This can be symptomatic or asymptomatic, with all grades in between from acute to chronic. The difference is that a supinatory pattern of the foot and ankle complex has set in and efforts to mobilize only the cuboid will fail miserably, will not provide that quick fix, described earlier.
Instead, you have to treat all major articulations and this is where we get into some controversy. This same pattern is commonly encountered in recurrent ankle sprains. I find restrictions (in the oppsite directions) and restore mobility in the following directions:

MAJOR MOTIONS OF THE FOOT AND ANKLE: 

• posterior glide of the talus - the method also mobilizes the calcaneus anteriorly at the same time 
• medial rotation of the talus 
• +/- internal rotation of the talus 
• +/- posterior glide of distal tibia 
• +/- medial rotation of distal tibia 
• posterior glide of the distal malleolus (on rare occasions it is found to be stuck posteriorly thus mobilized nteriorly) 
• +/- ant or post glide of fibular head 
• superior glide of the fibula (not described in the bulk of the literature, but indeed a very relevant, seperate accessory motion - great research project) This does NOT self-correct as a coupled motion with mobilization/Muscle Energy in A-P, or P-A directions. 
• inferior glide and medial rotation of the navicular and then incorporating the cunieoforms 
• inferior glide and medial rotation/medial glide to the cuboid superior/inferior glide to base of 5th metatarsal  
•  last but not least is the calcaneus:

At this point one will typically note that the calcaneus still has restricted eversion and abduction and the secret to restoring valgus/eversion (ultimately to restore normal functional pronation) is actually to mobilize the above bulleted sequence and then the calcaneus 30x into abduction and the valgus/eversion is then restored automatically without directly performing a valgus/eversion force. The abduction is the key - of course, after the above sequence. I think that I might be one of the first to name the abduction as a necessary motion in restoring calcaneal valgus (late 1980's) - I just stumbled on it many years ago in the clinic - but if you have a reference that says otherwise, please let me know. 

Sometimes just before the final mob to the calcaneus I will evaluate and treat if needed, medial glide to the talus working through the distal fibula and just below it as well. After all of the above I go into a weight-bearing context and adress those motions that I can - if I find them to be restricted in weight bearing, such as distal tibia rotation, calcaneal valgus, etc. I teach the client to internally rotate from hip down to distal tibia and gently, repeatedly self-mobilize into pronation 30-100 reps, daily for a week and then as needed. 

There are other flavors in which there is enough laxity in the ligaments that the above is not
effective, fortunatley these are in the minority and I am not referrring to this sub-population is this commentary. There is a great need for more research on the above topic and I think that our profession does not typically look at structures as patterns of motion dysfunction. The Cuboid Syndrome a perfect example in which only one dysfunctional structure (the cuboid) is mentioned and only mobilization to that singular structure is described. I have made a case
for Type II Cuboid Syndrome being a much more complex pattern that requires a dozen or more sequential mobility screens and treatment with mobilization. Terms like hypermobility and hypomobility get tossed around in the literature without adequate clarification, without explaining in detail, the tests are used with the cuboid.