Ankle Sprain? No, It's Cuboid Syndrome

R cuboid bone in the foot

I had a patient who came to our clinic today complaining of pain in the outside of his left foot. He thought he had sprained his ankle about 3 weeks ago while playing football barefoot. He rested, iced it  etc but it did not seem to get a lot better.

He then went to a Sports Doctor who diagnosed him with an ankle sprain and suggested that he see a Physiotherapist, which he did, but the one he saw did not make his ankle any better.

He still had most discomfort/ pain on the outer part of his left foot/ankle. Pain was worse during the push off phase of walking. He also couldn't run properly without pain.

However, his ankle proprioception (or joint position sense) was also not affected. Usually for ankle sprains, a patient's proprioception is usually worse on the affected side.

After a thorough assessment I found his ankle joint to be stable and free of pain. His pain increased on firm palpation of his left cuboid bone. The left cuboid also was sitting in a lower position compared to his right foot.

I explained to him that he did not sprain his ankle but instead there was probably a subluxation (or mild dislocation) in his cuboid bone. (I had actually seen two other cases of cuboid syndrome in the last few months).

The cuboid bone sits at the outer aspect of the mid foot and his connected to adjacent bones by strong connective tissue and ligaments (see picture above). During certain weight bearing activities like running, excessive forces placed on the cuboid bone (from the peroneal longus muscle especially) can sublux (or dislocate) the cuboid bone. This is exactly what happened to my patient. I've also seen this condition fairly frequently in ballet dancers that I've treated before.

How did I treat my patient? After the diagnosis, this is the easy part, or so I thought. I got him to lie on his tummy and gently tried to coax (or mobilise) his cuboid back into where it should be sitting. For some strange reason, it took a lot longer than I expected. My last two patients with cuboid syndromes had their cuboids back into position in less than five minutes.

It took me almost 20 minutes before my patient, his mother and I heard a loud click (of course I felt it with my hands too) suggesting I had relocated the bone.

I got my patient to stand up and try and he gave me a big smile after trying to walk and run. Job done, next patient waiting .....

Have a look at the reference below if you want to know more about cuboid syndrome.

Reference

Durall CJ (2011). Examination And Treatment Of Cuboid Syndrome. A Literature Review. Sports Health. 3(6): 514-519. DOI: 10.1177/1941738111405965.

MEAT vs RICE

RICE (rest, ice, compression & elevation) is a standard treatment protocol for acute sports injuries. But, what if I say that for ligaments and tendons, RICE can actually hinder the healing process. Please read on if you like to find out a little more.

Muscles have very good blood supply while tendons and ligaments have very poor blood supply. So if you reduce blood supply (and hence decrease blood flow & nutrients) to ligaments & tendons by administering RICE, ligaments and tendons may take a longer time to heal as a result.

The MEAT (movement, exercise, analgesics & treatment) protocol on the other hand is proposed to be superior to treating ligaments and tendons.

Movement -  The key here is controlled movement. Controlled movement of the affected area/ limb will stimulate blood flow to the ligaments & tendons while allowing for the regenerating collagen fibres (or scar tissue) to be laid in the areas of stress to improve recovery.

The authors in a study of patients with ankle ligament sprains had better treatment outcomes (less swelling, and quicker return to sports) with controlled functional movement treatment compared to immobilization (Kerkhoffs et al, 2002).

Exercise - Again here the key is controlled & correctly prescribed exercises. Range of motion, strength and especially proprioception (joint position sense) help improve function and weight bearing in patients with acute ankle sprains (Bleakley et al, 2010).

Analgesics - It is suggested that natural analgesics such as proteolytic enzymes e.g. bromelain (found in pineapples), papain (found in papayas) and not anti inflammatory medications (which can hinder healing) be used as natural analgesics decrease the painful swelling but do not stop the natural inflammatory reactions to lead to healing. Codeine (a narcotic) can also be used, although large amounts may cause constipation.

Treatment - Well, not much to add here except to say that you need a competent physiotherapist (that's why you need us at Physio & Sports Solutions) to implement evidenced-based treatments to assist in your recovery and quick return to sports.

It is important for me to point out that RICE should still be used in acute muscle strains & injuries. It would be best to incorporate both RICE & MEAT in the treatment of soft tissue injuries depending on where the injury is, which stage the injury is at and what the injury is.

References

Bleakley CT et al (2010). Effect Of Accelerated Rehabilitation On Function After Ankle Sprain: Randomised Controlled Trial. BMJ 340: c1964

Caring Medical and Rehabilitation Services (2010). MEAT vs RICE Treatments. Retrived from http://www.caringmedical.com/symptoms/meatvsrice.asp

Kerkhoffs GMMJ et al (2002). Immobilisation And Functional Treatment For Acute Ankle Ligament Sprains In Adults. Cochrane Database of Systematic Reviews 2002, Issue 3.