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    Move Forward Guide

    Physical Therapist's Guide to Cuboid Syndrome

    Cuboid syndrome is a condition caused by a problem with the cuboid bone, producing pain on the outer side, and possibly underside, of the foot. The cuboid bone is part of the calcaneocuboid joint that helps you maintain foot mobility when walking. Problems can develop with the cuboid bone that make it shift and dislodge from its normal position, causing pain and difficulty standing or walking. Cuboid syndrome most often affects athletes and dancers, although anyone can experience it. Age does not seem to play a role in developing the syndrome.

    The prevalence of cuboid injuries in the United States is not clear; however, it has been diagnosed in 6.7% of patients with inversion ankle sprains (when the ankle rolls outward and the foot rolls inward). Approximately 4% of athletes who report foot injuries have symptoms from the cuboid bone. Cuboid syndrome is found in about 17% of professional ballet dancers. It can occur from trauma or without any recalled injury. Physical therapists design individualized treatment programs to help people with cuboid syndrome reduce their pain, regain lost strength and movement, and get back to their normal lives.


     

    What Is Cuboid Syndrome?

    The cuboid bone is one of the 26 bones of the foot. It is located on the outer side of the foot, about halfway between the pinky toe and the heel bone. The cuboid bone moves and shifts to a small degree during normal foot motion. Certain forceful movements or prolonged positions can cause the cuboid bone to move too far, which interferes with its normal position or motion. This causes immediate foot pain, which can feel worse when standing or walking on the foot.

    Cuboid syndrome often occurs suddenly. It may occur with ankle sprains, as the foot rolls in, or when a person stomps the foot hard onto a hard surface, such as concrete, particularly if the person is wearing rigid or high-heeled shoes. Hard landings onto the feet from a jump, or falling from a height onto the feet can also create enough force to affect the cuboid bone’s position and cause a problem.

    A cuboid bone injury can develop from maintaining prolonged foot positions, such as standing or walking in high heels, or remaining in a toe-pointed (ballet dancer’s) position, for a long time. Peroneal tendon problems, such as weakness, tendonitis, or tendinopathy, also can contribute to, or occur at the same time as, cuboid syndrome.

    The majority of people who suffer cuboid syndrome have flat feet, although the condition can even occur in people with very high arches.

     

    How Does it Feel?

    Cuboid syndrome causes sharp pain on the outer side, and possibly underside, of the foot. The pain does not usually spread to the rest of the foot or leg. It often starts quite suddenly and lasts throughout the day. Pain can worsen with standing or walking, and can make walking on the foot impossible. The pain is often completely relieved by taking weight off the foot. When not putting weight on the foot, a person can usually move the foot around freely and with little to no pain. Without treatment, however, the pain during standing and walking can persist for days, weeks, or longer.

    Surgery is not usually necessary for treatment of cuboid syndrome. Your physical therapist can help determine if cuboid syndrome is present, and design the correct treatment program for you, based on your particular condition and goals.

     

    Signs and Symptoms

    Cuboid syndrome can cause any of the following symptoms:

    • Sharp pain on the outer side, and possibly underside, of the foot
    • Increased pain when standing and/or walking
    • Limping when walking, or an inability to walk on the foot at all
    • Reduced pain when no weight is put on the foot
    • Possible mild swelling on the outer side of the foot
     

    How Is It Diagnosed?

    Your physical therapist will conduct a thorough evaluation that includes taking your health history. Your therapist will also ask you detailed questions about your injury, such as:

    • How and when did the pain start?
    • What type of discomfort do you feel, and where do you feel it?
    • What can’t you do right now, in your daily life, work, or sport, due to the pain?

    Your physical therapist will perform tests on your body to find physical problems, such as:

    • Misalignment of the cuboid bone
    • Weakness or tightness in the muscles of the foot and leg
    • Joint stiffness
    • Difficulty standing and/or walking

    If your physical therapist finds any of the above problems, physical therapy treatment may begin right away, to help get you on the road to recovery and back to your normal activities.

    If more severe problems are suspected or found, your physical therapist may collaborate with a physician to obtain special diagnostic testing, such as an X-ray. Physical therapists work closely with physicians and other health care providers to make certain that you receive an accurate diagnosis and proper treatment.

     

    How Can a Physical Therapist Help?

    Cuboid syndrome often responds to treatment quickly.

    Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but noticeable improvement can be achieved in 1 or 2 clinical visits, with full recovery within a few weeks or less when a proper treatment program is implemented.

    During the first 24 to 48 hours following your diagnosis of cuboid syndrome, your physical therapist may advise you to:

    • Avoid all jumping, hopping, and running activities.
    • Limit prolonged walking.
    • Wear flat, stiff-soled shoes.
    • Stay active around the house, and go on short walks several times per day. Movement will decrease pain and stiffness, and help you feel better.
    • Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.

    Your physical therapist will work with you to:

    Reposition the cuboid and stabilize it. Your physical therapist may use their hands (manual therapy) to reposition the cuboid bone back to its normal position, so that it can move more normally. This can potentially relieve most of the pain, and restore the ability to stand and walk. The physical therapist then may use various exercises and techniques to support the cuboid bone’s corrected position. These may include foot exercises, taping of the foot, and advice on footwear and when to return to activity.

    Reduce pain and other symptoms. Your physical therapist will help you understand how to avoid or modify the activities that caused the injury, so healing can begin. Your physical therapist may use different types of treatments and technologies to control and reduce your pain and symptoms. The focus will be placed on physical therapy, icing, and gentle movement to reduce pain without the need for pain medication.

    Improve motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the foot or in any stiff joints. These might begin with "passive" motions that the physical therapist performs for you to move a joint, and progress to active exercises and stretches that you do yourself. You can perform these motions at home and in your workplace to help hasten healing and pain relief.

    Improve flexibility. Your physical therapist will determine if any muscles in the area are tight, start helping you stretch them, and teach you stretching exercises to do at home.

    Improve strength. If your physical therapist finds any weak muscles, the therapist will choose, and teach you, the correct exercises to steadily restore your strength and agility. When addressing cuboid syndrome, foot and ankle muscle exercises are commonly taught to strengthen the muscles and tendons around the cuboid bone, arch of the foot, and ankle.

    Improve endurance. Restoring muscular endurance is important after an injury. Your physical therapist will develop a program of activities to help you regain the endurance you had before the injury, and improve it.

    Learn a home program. Your physical therapist will teach you strengthening, stretching, and pain-reduction exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.

    Return to activities. Your physical therapist will discuss your activity levels with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. Your physical therapist may teach you how to choose the best footwear, to avoid putting unwanted pressure on the cuboid bone, and to add specialized support such as orthotics.

    Once your pain is gone, it will be important for you to continue your foot exercises at home, to help keep your foot healthy and pain free.

    In all but the most extreme cases, physical therapist treatment provides excellent results. Surgery and pain medication (such as opioid medication) are not usually needed for this condition.

     

    Can this Injury or Condition be Prevented?

    Risk factors for cuboid syndrome include:

    • Foot bone instability
    • A sprained ankle
    • Being overweight
    • Wearing poorly-fitted or poorly-made shoes or orthotics
    • Performing extreme or extended exercises
    • Allowing insufficient recovery time after exercise
    • Conducting physical training on uneven surfaces
    • Wearing high heels or rigid heels
    • Stomping the foot
    • Landing hard on the feet from a jump

    To prevent cuboid syndrome individuals should:

    • Avoid forceful stomping on hard surfaces, such as concrete or rock, especially when wearing rigid heels or high-heeled shoes.
    • Limit forceful stomping activities in general.
    • Perform cool-down and gentle stretching exercises following high-level sport or dance activities.
    • Limit wearing rigid-heeled or high-heeled shoes when running, dancing, prolonged walking, or simply being active.
    • Seek advice on proper footwear.
    • Discuss your occupation with a physical therapist, who can provide an analysis of your job tasks and offer suggestions for reducing your risk of injury.
    • Keep your muscles strong and flexible. Participate in a consistent program of physical activity to maintain a healthy weight and fitness level.

    To prevent recurrence of cuboid syndrome, follow the above advice, and:

    • Continue the new foot exercises that you learned from your physical therapist to maintain your improvements.
    • Continue to do any other home exercises your physical therapist taught you to help maintain your improvements.
    • Continue to be physically active and stay fit.
     

    Real Life Experiences

    Julie is a 35-year-old dance teacher. She and her tap-dance class were recently invited to perform a holiday show at the local mall. Just a few weeks ago, they began rehearsing in the mall on a concrete floor, after hours. One of the choreographed steps was a forceful stomp, in which the whole foot hits the floor hard to make a loud sound. An hour into rehearsal, when Julie did the stomp step wearing tap shoes with 2-inch heels, she felt immediate pain on the outer side of her left foot. She tried to ignore it and keep dancing, but any weight she put on that foot caused sharp pain and made her leg give out. She had to stop dancing and hold her foot off the ground to control the pain. She led the rest of rehearsal sitting in a chair. She called her physical therapist and made an appointment for the very next day.

    Julie arrived at the physical therapist’s office on crutches, still unable to put weight on her left foot without feeling sharp pain.

    Julie’s physical therapist took a full health history, and asked her questions, including how the injury happened, what shoes she was wearing at the time it started hurting, and if the pain had changed overnight (it had not). He then performed a full examination of her foot and leg, testing strength, flexibility, joint movement, and sensation of the skin in the foot. He gently used his fingers to locate the painful area, and he felt and looked for swelling. He watched Julie try to walk and balance.

    Julie’s physical therapist diagnosed that the cuboid bone in her foot had been jarred, and its change in position was causing her pain and her inability to walk on the foot. He explained that this can be a common problem among dancers and athletes. He also explained that he had found some joint stiffness in the foot and lower leg, and some muscle weakness. He felt that immediate treatment could be very helpful; Julie eagerly agreed.

    Julie’s physical therapist used a specialized manual (hands-on) therapy technique to gently move the cuboid bone to a better position. Julie was immediately able to put most of her weight on the foot, with very little pain. He also applied manual therapy to her heel bone and lower leg. He taught her some simple foot exercises to strengthen her foot and leg muscles. He finished the treatment session by applying a small piece of elastic tape to the foot to help support the cuboid bone. He advised Julie to apply ice to the outer side of the foot a couple of times a day, and taught her a few gentle home exercises to maintain flexibility and keep the pain away. Julie was able to walk out of the clinic without using crutches and without limping, as the pain was gone. She felt only a mild soreness in her foot.

    Julie needed only a couple more treatments during that week, to review her home exercises and learn a few more helpful exercises, and to have the tape reapplied. On her last visit, Julie’s physical therapist retested all the strength and movement problems he had found during the examination, and was pleased to find that Julie’s strength, flexibility, and joint motion were all recovering. He advised her on how to safely return to tap dancing and avoid displacing the cuboid bone again, including using sneakers at first, and then moving to flat-heeled tap shoes before returning to wearing high-heeled tap shoes. He advised her to tap dance for short sessions at first, reduce the force with which she stomps for a while, and to perform the foot exercises he had taught her as a warm-up before dancing.

    Julie was able to return to teaching her dance class the very next week. She gradually and carefully worked her way back to wearing tap shoes and stomping while tap dancing. She was able to perform with her students in their dazzling holiday show, with no pain at all!

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

     

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat people who have this condition. You may want to consider: 

    • A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems. 
    • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you’re looking for a physical therapist:

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with this condition. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse. 
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapy treatment of this condition. The articles report present research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Dann CL, Mazerolle SM, Aerni G, Hubbard J, Miller RS. Examining the impact of a dorsal calcaneocuboid sprain on cuboid syndrome and exploring individual treatment: a case review. Athletic Training & Sports Health Care. 2015;7(2):76–80. Summary of Article.

    Durall CJ. Examination and treatment of cuboid syndrome: a literature review. Sports Health. 2011;3(6): 514–519. Free Article.

    Jennings J, Davies GJ. Treatment of cuboid syndrome secondary to lateral ankle sprains: a case series. J Orthop Sports Phys Ther. 2005;35(7):409–415. Free Article.

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Authored by Andrea Avruskin, PT, DPT. Reviewed by the
    MoveForwardPT.com editorial board.

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