Mr KH is a 45 year old male, who works as a driver for a delivery service. He likes to play softball on weekends and golfs regularly. About one year ago he experienced a significant weight gain, and at the urging of his wife, made lifestyle changes to lose weight, including one hour walks, three times per week. During one of these walks, he started to experience some discomfort in his right heel which he initially ignored. Over the next few weeks, the discomfort progressed to pain, including when first arising in the morning and after sitting, and when getting out of his truck to deliver packages. He decreased his walking to 30 minutes, tried new running shoes, stretching, icing and over the counter pain medications, but the problem progressed. During one his walks, while stepping up a curb he experienced a sudden, sharp pain in the right heel extending into the arch and now has difficulty bearing weight on the foot. He went to the emergency room, was referred to a foot specialist, and following x-rays and an MRI of the right foot was diagnosed with a partial rupture of the right plantar fascia. He was placed on disability from his work, and placed in a below knee walking boot and crutches. Following several weeks of NWB and PWB he gradually resumed full weight bearing in shoes and now has more pain along the outside edge of his foot than in the heel. What the heck?
Our patient is 5’11” and weighs 195 pounds. His medical history is non-contributory.He denies smoking, recreational drug use and averages 3-4 alcoholic drinks per week, mostly beer. His circulatory, neurological and dermatological systems are all WNL. Musculoskeletal and biomechanical findings include normal hip and knee range of motion, ankle dorsiflexion is 5 degrees with knee extension and 10 degrees with knee flexion, normal subtalar range of motion, 1st MTPJ ROM is WNL, 4 degree rearfoot varus, and a forefoot valgus of 2 degrees bilateral, with hypermobility of the first ray. Gait is antalgic, favoring the right side. Tenderness is elicited in the right proximal plantar fascia, mild tenderness to the right sinus tarsi, and exquisite tenderness is noted in the right 4th-5th metatarsal Cuboid joint. Muscle strength is WNL all groups around the ankles bilaterally. Weight bearing x-rays of the right foot reveal soft tissue swelling in the proximal plantar fascia and uneven joint space of the Calcaneal-Cuboid joint.
Discussion:
The diagnosis of Cuboid Syndrome is made at this time, secondary to plantar fascia rupture.
https://en.wikipedia.org/wiki/Cuboid_syndrome
Subsequently, the patient was treated with manipulation (Cuboid whip), stretching exercises, taping and eventual injection of corticosteroid and local anesthetic, and is now relatively symptom free and ready to return to work and other daily activities. Functional orthotics were recommended to stabilize foot, and prevent recurrence of the problems. Stable shoes with torsional and longitudinal stability were recommended. Here are some suggestions for orthotic modifications that should be helpful in cases of Cuboid Syndrome;
Cuboid Syndrome or Subluxation is an often overlooked and underdiagnosed entity and usually easily treated, once detected. It frequently occurs secondary to other conditions, such as plantar fasciitis and lateral ankle sprains. Pathology of the Peroneus Longus Tendon may also be associated with this condition. Proper shoes play an important role in prevention and treatment, with emphasis on stability in the midfoot region. Custom functional foot orthotics are also extremely effective, especially when a well placed Cuboid pad is added as a modification.
