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| Table of Contents: 1. Cuboid Syndrome Overview
2. Email: Cuboid Correspondence
3. Cuboid Photos 4. My (Former) Cuboid Syndrome 5. Cuboid Q & A 6. Video: Cuboid manipulation | |
| 1. Cuboid Syndrome Overview CUBOID SYNDROME AND RECURRENT ANKLE SPRAIN SIDE VIEW OF THE LATERAL (OUTSIDE) SIDE OF THE RIGHT FOOT. THIS IS A FLEXIBLE PLASTIC ANATOMICAL MODEL. I PLACED A LOOSE CUBOID BONE JUST BELOW THE CUBOID IN THE FOOT AND ANKLE MODEL. NOTE THE VERY LARGE CALCANEAL BONE TO THE LEFT (BEHIND). I TRULY ADVOCATE THE EVALUATION AND TREATMENT OF ANY MOTION RESTRICTION OF THE SUBTALAR JOINT (CUBOID AND TALUS) IN THE PRESENCE OF CUBOID SYNDROME. THE LITERATURE IGNORES THIS RELEVANT CONCEPT. CLOSE UP OF THE JOINT BETWEEN THE CALCANEUS (L) AND THE CUBOID (R), IN THIS VIEW FROM THE BOTTOM OF THE FOOT THE CUBOID IS ON THE LEFT AND THE CALCANEUS ON THE RIGHT. CALCANEUS ON LEFT AND CUBOID ON RIGHT THIS IMAGE SHOWS THE UNDERSURFACE OF THE FOOT. THUMB WITH AN UPSIDE DOWN "L" IS THE CUBOID. IT ARTICULATES WITH THE 4TH AND 5TH METATARSALS BELOW AND WITH THE MEDIAL CUNIEFORM AND NAVICULAR. NOTE THAT THESE JOINTS ARE MUCH MORE PLANAR. THIS FLATNESS INDICATES THAT THE PRIMARY MOTION WITH BE AN UP AND DOWN GLIDE. THIS OBLIQUE VIEW OF THE UNDERSURFACE OF THE FOOT GIVES A SLIGHTLY DIFFERENT PERSPECTIVE. I want to make a very important point. The cuboid is profoundly influenced by the calcaneus. The calcaneus is much larger and has a much greater mechanical advantage on the cuboid, inducing rotation. If you look at the joint formed by cuboid and calcaneus, you will see that it allows rotation, which participates in both functional pronation and functional supination. If a cuboid is chronically symptomatic, and it requires repeat treatment, look at the calcaneus. Work on restoring calcaneal eversion/valgus. The secret? Does anyone know this? One can easily restore normal calcalneal valgus/eversion and by mobilizing the sub talar joint; the joint where the calcaneus and the bottom of the talus connect. However, I do address all other major motions of the foot and ankle which are described below (See Major Motions of the Foot and Ankle in the section titled: Cuboid Syndrome). With client lying prone (face down), or kneeling on a treatment table, with feet off the edge. Clasp the back of the calcaneus, where the achilles tendon is. Take the calcaneus into inferior distraction to maximize space between the inferior talus and the calcaneus, then abduct it repeatedly at end-range 30 times. In performing calcaneal abduction the front of the calcaneus is moving laterally. Therefore, the posterior aspect of the calcaneues moves towards midline (back of the left heel moves toward the right, back of the right heel moves left). Magic! Retest calcaneal tilt (valgus) and it will be noticeably improved. It is very rare that I am unable to restore normal calcaneal motion. Teach the client to do same in weight-bearing, stacking internal rotation throguhout the lower extremity, and actively enhancing functional pronation. Image a line connecting the hip, the knee, the ankle. repeat the exercise going from supination into full pronation and back, repeating 30-100 times. It is easily done 100x in 2-3 minutes. Strenthening is easily achieved by adding resistance tubing, etc. 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. I will be happy to post it. I have done literature searches but have not encountered that statement. I went to do a web search to find a quotable definition of cuboid syndrome and came upon my post on the topic from 2006. Taken from Physiobase* www.physiobase.com Please see their privacy policy below, at the very bottome of this entire post. I do not believe that I am in violation by posting this. I did clean it up a little and added some.
(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 othera 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.
After restoring normal motion, stability, strength, blance, endurance, proprioception, etc it is very appropriate to look up the kinetic chain and find out where the body has adapted or compensated for this pattern and treat what you find. Typically I end up treating the pelvis/SI and upper cervical spine, though if the pattern is not chronic; the distal compensation may reflexively resolve with no direct effort on my part. I hope this has been additive to the body of knowledge. There are some very good articles in the recent literature to guide rehabilitation, such as in JOSPT 2007.
Cuboid syndrome refers to the disruption of the normal function of the calcaneal-cuboid joint (CC joint). Disruption of the CC joint is often called subluxation. Cuboid syndrome can be found described in the literature as a sequella of inversion sprains of the ankle. Also, cuboid syndrome is found described in dance (ballet) literature.
Cuboid syndrome is somewhat uncommon and is poorly defined in the literature. When conditions are poorly defined in the literature, this usually means that there is a lack of agreement among doctors as to the eitiology (reason for the condition) and the treatment.
Treatment Of Cuboid Syndrome
Cuboid syndrome is treated by reducing (realigning) the subluxation of the CC joint and stabilizing the reduction. Reduction of the subluxation can be accomplished by manipulating the joint. Manipulation is performed with the patient in a prone (face down) position. The doctor cradles the foot in his/her hands and places both thumbs beneath the CC joint. The CC joint is then manipulated by a forceful movement, moving the leg at the knee and the ankle while applying pressure with the thumbs at the plantar (bottom) aspect of the CC joint.
Reduction of the subluxation can be maintained with taping, and padding. Prescription orthotics (arch supports) are helpful in preventing a recurrence of cuboid syndrome. Occasionally, cortisone injections may be helpful in reducing inflammation associated with the subluxation of the CC joint. Patients are instructed to avoid going barefoot or wearing shoes with low heels. Small (less that 1/2") heel lifts can also be helpful.
Chronic cuboid syndrome is called tarsitis (inflammation of the tarsal bones). Tarsitis results from excessive intrinsic load, often called CT band syndrome. Tarsitis is just one of many symptoms of CT band syndrome. For additional information regarding chronic cuboid syndrome (tarsitis), please read our article on CT band syndrome.
The response to treatment of cuboid syndrome depends upon the eitiology and onset of symptoms. Acute onset of cuboid syndrome, say from an ankle sprain, may respond dramatically to manipulation. If cuboid syndrome is due to chronic, excessive intrinsic load (CT band syndrome) treatment such as manipulation may be less effective and take longer to see results.
Nomenclature:
Cuboid - named after its' square shape. The cuboid has historically been used in games as a dice.
Chopart's Joint - includes the talo-navicular joint and the calcaneal-cuboid joint. Named after the French surgeon Francois Chopart (1743-1795).
CT band - 'calf to toes' band. Describes a band consisting of the calf, Achilles tendon, ankle and plantar fascia.
Extrinsic load - any load delivered to the foot that is exclusive of intrinsic load. Extrinsic load includes the duration of time on your fee, number of steps taken in a day, body weight, etc.
Intrinsic load - load that is intrinsic to the normal mechanical function of the leg and foot. Most intrinsic load is derived from the calf and delivered to the foot via the Achilles tendon. Other sources of intrinsic load include the other plantar flexor muscles and tendons of the foot such as the peroneals and posterior tibialis.
Subluxation - motion of a joint that is irregular and not in alignment with the normal range of motion of the joint.
Tarsal bone - the large bones of the rear foot including the calcaneus, talus, navicular and cuboid.
Anatomy:
The calcaneal-cuboid joint (CC joint) is located on the lateral (outside) aspect of the foot. The CC joint can be found immediately below the outside of the ankle and about two fingers distal (towards the toes). The CC joint is a broad, flat joint build to bear load. The joint has very little movement or motion. The CC joint is surrounded by a number of stout ligaments that are intended to limit motion and stabilize the joint. On the plantar aspect (bottom) of the joint are the long plantar ligament and calcaneal-cuboid ligament. The lateral side (outside) of the joint is stabilized by the dorsal calcaneal-cuboid ligament. The dorsal aspect (top) of the cuboid is stabilized by the dorsal cuneo-cuboid ligament, the tarso-metatarsal ligaments, dorsal cuboideo-navicular ligament and miscellaneous inter-tarsal ligaments.
The CC joint is also stabilized by a number of contiguous structures that pass above, below or along the cuboid. The most significant of these is the peroneus longus tendon that wraps along the lateral and plantar aspects of the cuboid. The cuboid is essentially help in a sling by the peroneus longus tendon. Other structures include the peroneus brevis tendon, dorsal and plantar musculature and retinaculum.
Biomechanics:
Cuboid syndrome occurs at the calcaneal-cuboid joint (CC joint) on the lateral or outside of the foot. The CC joint functions together with the talo-navicular joint (TN joint) and the subtalar joint (STJ) to deliver load to the forefoot. The function of these joints is to deliver load that can be converted into action; walking, running etc. For additional definitions of load in relationship to the normal function of the foot and leg, please refer to our article on CT band syndrome.
Cuboid syndrome occurs when the calcaneal-cuboid joint is unable to carry the load that is applied to it. The result is that the calcaneal-cuboid joint subluxes (moves out of its' normal position).
Symptoms:
The onset of cuboid syndrome may be due to an acute injury of the lower extremity such as an inversion sprain of the ankle. Occasionally the symptoms of cuboid syndrome occur without an obvious injury. The symptoms of cuboid syndrome are very similar to the symptoms of a sprain. Pain is significant when weight is first applied to the foot. Pain increases with the toe off phase of gait as the weight of the body and load from the calf muscle are delivered to the lateral (outside) column of the foot.
Cuboid syndrome rarely presents with bruising or swelling. The location of cuboid syndrome (at the calcaneal cuboid joint) can be pin pointed by this simple method; visualize a line extending from the outside ankle bone (fibula) to the floor. The calcaneal cuboid joint is approximately two fingers from this line distal (towards the toes).
Differential Diagnosis:
Calcaneal stress fracture
Sinus tarsi syndrome
Peroneal tendonitis
Partial peroneal tendon rupture
5th metatarsal avulsion fracture
Compression neuropathy of the sural nerve
Cuboid fracture
Os peroneum
Gout
Tarsal coalition
Tarsitis
References:
1. Stone DA, Kamenski R, Shaw J, Nachazel KMJ, Conti SF, Fu FH. Sports Injuries, Mechanics, Prevention, Treatment-Second Edition. Philadelphia, Lippincott Williams and Wilkin; 2001. pp381-397.
2. Leerar, PJ. Differential Diagnosis of Tarsal Coalition versus Cuboid Syndrome In An Adolescent Athlete. J Orthop Sports Phys Ther 2001; 31(12)
3. Marshall P, Hamilton WG. Cuboid Subluxation In Ballet Dancers. Am J Sport Med 1992; 20(2).
4. Mooney M, Maffey-Ward L. Cuboid Plantar And Dorsal Subluxations: Assesment And Treatment. J Ortho Sports Phys Ther 1994; 20(4).
About the author:
Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Dr. Oster is medical director of www.Myfootshop.com and is in active practice in Granville, Ohio.
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All trademarks and service marks appearing on this web site are the property of their respective owners. 2. Email: Cuboid Correspondence Here is a very encouraging email I received on July 2, 2009. Minor changes made to hide the identity of the sender. Good Morning, Xxxxx was not a big fan of the cuboid pad that I taped on her orthotic. After watching your video though, she has been manipulating her food by tensing it and spreading her toes, and has actually been able to move the cuboid "back in" on occasions when it is "out." The interesting thing is that she has done more running and playing in the past two weeks than she has for a long time. But her condition seems to be improving. We have tried not taping it for two practice sessions now and she reports no pain. About 8 months ago we went to Dr. Xxxxx in Santa Xxxxxx for one visit. I don't think he'd ever heard of cuboid syndrome. He said he thought that her foot was weak. He gave her some excercises to do. With the series of manipulations and x-rays that he did, he showed me by comparing x-rays, how the cuboid dropped about 1/8 (2 mm). He said that her foot was sound and that the x-rays showed no structural problems. Following this visit, she had no problems or pain on the field until about three weeks later when she tweaked it when someone stepped on her foot. She continued with the excercises and the pain came and went. I asked her about the right (uninvolved foot). She never has pain there and she can't manipulate it the way she does the left. She says she can't move the cuboid up and down (on either foot) with the manipulation she does on the left, though again, she reports being able to "work it back in now when it is out." We are considering a trip to Vegas. Let me talk to my wife and see what our schedule is for the second half of July. Jim COMMENT: Because her problem is recurrent, she probably has the Type II Cuboid Syndrome which I have named and described. Her positive results give me reason to be very optinmistic that this is a resolvable problem. I have 2 more case studies to post, soon.... 3. Cuboid Photos Lateral view of right cuboid. Arrow Points to the right cuboid, lookin from the outside of the right foot.. Top view of left cuboid. Outside view of left foot. Left thumb is on the calcaneus (heel) the largest bone in the foot. right thumb is on hte cuboid. I am distractiin the joint and you can see the very curved joint surface. the "take home message" is that the calcaneus is much larger and has a powerful influence on the cuboid. It is very important to evaluate mobility of the calcaneus and restore normal mobility when able, as opposed to just restoring mobility of the cuboid, in presentations of cuboid syndrome. The goal here is prevention of recurrence, not just relief of acute symptoms. Lateral view of right foot with intact cuboid and solitary cuboid below. View from bottom of foot. Note the curved surface where the calcaneus (large bone top left) joins the cuboid, whereas other bones that connect to the cuboid have a fairly flat (planar) shape. 4. MY (FORMER) CUBOID SYNDROME I developed a Cuboid Syndrome in response to an injury that resulted in a complete tear of the right talofibular ligament. This ligament on the lateral ankle is the one that is most commonly involved with an ankle sprain. I feel very strongly that the Type II Cuboid Syndrome is responsible for failed rehabilitation after an ankle injury, known as "recurrent ankle sprain", among other terms. Fortunately, I resolved my own Type II Cuboid syndrome when I developed this approach years back and my cuboid has not been symptomatic for a very long time. I did address alll of the other motions that were lacking. My surgical repair was in 1981, my self treatment of the Type II Cuboid Syndrome, several years later. Ankle is doing great! I do think that having had the problem helped me to gain a deeper (empirical) understanding of the problem. The other accessory motions I treated were: superior glide of the fibula posterior glide of the distal fibula (lateral malleolus) screened the superior fibula for ant/post glide, cannot recal findings posterior glide of the talus adduction of the talus inferior glide and pronation of the cuboid pronation of the mid foot especially navicular screened sup/inf glide of the cunbieforms screened 5th ray, no tx necessary medial g;ide of the talus calcaneal (sub-talar joint) abduction which restored calcaneal valgus/eversion It is a bit late, and I am wondering if I am missing a component! I still stretch the heel cord almost daily, in 2 positions and stretch the posterior capsule of the knee and also perform hamstring stretches. Strengthening and endurance exercises for the tibialis anterior and the peroneals (new terminology: fibularis muscles). On occasion I do balance and proprioception activities thought they seem to be fully restored. I do the stretches for a minnimum of 5 minutes, exercises are done 100 reps anti-gravity. It has been a very long time since the foot and ankle were symptomatic. Actually, I do have mild residual symptoms. The skin over the stainless steel screw itches at the scar! 5. Cuboid Syndrome Q & A QUESTION & ANSWER ON CUBOID SYNDROME Q: I find the biomechanics of the foot and ankle to be rather complex and difficult to learn, including the Type II pattern you describe. Can you please give me some suggestions? A: Yes, I would be happy to. I was very blessed to have owned a complete human skeleton very early in my career, and I often referred to it and the 3-dimensional nature of it made it so much easier to learn in ways that simply could not have occurred with 2-dimensional pictures in an anatomy test. Although cadaver dissection is part of our training, it is not the same. The dissection was long ago, the anatomy in my hand is real time. I also purchased several foot models, left and right side of course and kept one of each intact and took the others apart. One I separated by major joints and the other I took completely apart. I enhanced the 3-D nature of the major joints by gluing window screen onto the articular surfaces so that the topographical nature was much more obvious. Looking at it from various angles and then stacking the other proximal bones - in essence – rebuilding the foot and ankle, and then inducing various motions was most helpful. In time I will post some of the photos of the enhanced topography. Q: Can you briefly describe the 2 types of you mention? A: Yes, I am guilty of naming the classical as Type I. It is a wonderful thing for clinician and client as it is painful and limiting, yet treatment is very easy, results are dramatic and long lasting. Typically 1-3 visits are all that are necessary. There are several examples in the literature. In Type I the cuboid is stuck in a manner best described as being whipped laterally about an anterior to posterior axis. The top of the cuboid is prominent, at least on the medial border. Inferior glide cannot be induced, nor can medial rotation. It is not unreasonable to describe the cuboid as being stuck in supination and treatment restores pronation. What I call Type II is more complex and involves all of the major joints of the foot and ankle. Each joint loses a small amount of motion, so the forces are spread out and thus it is not always painful as is a Type I. However there will be some inhibition of muscular strength, endurance, balance and proprioception. There will also be a tendency towards a lateral ankle sprain as this pattern is basically a supinatory pattern and the person is unable to achieve functional pronation (not to be confused with excessive pronation). Functional pronation is the normal pronation that is part of the gait cycle, occurs in standing, etc. Type II are not always painful, many compensate fairly well without any gross gait deviation or pain. However, upon testing the joints, it is not unusual to provoke pain. From the standpoint of prevention these are worthy of treatment. The typical motion losses are described in the separate link titled Cuboid Syndrome. Q: Can you mention the motion restrictions in a Type II ? A: They typically are: Q: You say that a Type one takes 1-3 visits to resolve. Given the complexity of Type II, it must take much longer to correct? A: Actually, most cases respond very quickly, within the same 1-3 visits. Of course the hands-on work takes longer as we are dealing with several motion restrictions as opposed to the “key dysfunction” of a Type I. The exceptions would be someone who has a true laxity that remains after you complete the mobilization. Q: Please explain “key dysfunction”. A: It is a borrowed term from Osteopathy. In this context, you may find several restriction throughout the foot and ankle, yet it is the cuboid restriction that is influencing them all. You could spend an inordinate amount of time chasing various hypomobilities and hypermobilities, but instead; addressing the cuboid resolves all of them. Hence the term “key dysfunction”. In Osteopathy, the term is actually “key lesion”. Q: I thought that a person with a whether a Type I or a Type II had the problem due to preexisting laxity/hypermobility. However, you seem to imply the hypermobility and hypomobility coexist. Is that true? A: Yes. It is important to distinguish between a true hypermobility and an apparent hypermobility. I had a severe true hypermobility when I completely tore my anterior talofibular ligament and the only lasting cure was surgical. There are lesser grades of true hypermobility due to stretched or partially torn ligaments that take longer to heal. Rehabilitation time of course is longer. The hypermobility has to be dealt with directly. In contrast an apparent hypermobility is one that tests as hypermobile, yet it is a mutable property. Upon restoring mobility in the various directions that the major joints are restricted, the hypermobility is no longer detectable. This is because it was positionally induced and upon restoring normal position and reolving the hypomobilities, the hypermobility also resolves. In essence hypermobility and hypomobility are on opposite side of the midline of the bell curve. Both move towards the mean (regression to the mean) when the hypomobility is treated. You will also find dramatic and quick improvement in muscle function, balance and proprioception. In essence, the hypermobility is dealt with indirectly, specifically; by addressing the hypomobilities. Q: How did you discover the Type II ? A: I do not recall a specific eureka moment, but I always had a penchant for seeking out patterns, rather than just focusing on the symptomatic structure. I learned very early on that the body has to adapt and compensate for injuries and in time those other areas can become symptomatic. Even before going to PT school I plumbed the depths of Osteopathic Manual Medicine, and that undergirds this pattern seeking. Q: How many bones are in the foot and ankle? A: Ignoring sesamoids, which are small “pulley” bones that do not form true joints, there are 28 by my count. Q: How many joints? A: By my count, there are 30. Q: 28 bones and 30 joints? A: Ooops, no, I goofed. I failed to count the articulation between the 2nd & 3rd, 3rd & 4th, and 4th and 5th metatarsals, so 33? Q: Are you counting all of the facets between the calcaneus and talus as one joint? A: Yes. Q: Can I come and have you evaluate my foot and ankle? A: I would be happy to, send me an email at jerryhesch@cox.net Or call me (Pacific Time) 9-5, M-F. If unable to speak, please leave a message and I will return the call. Q: Do orthotics help with Type I and Type II ? A: Somewhat. The type I and II are typically only on one side of the body, right more often than left. Rarely, does it occur bilaterally. So yes an orthotic can control position and mobility to some degree. However, the primary influence of an orthotic is in the sagittal (side view) and frontal (front and back view) planes and much less so in the transverse plane. Thus it is very helpful to have hands-on joint mobilization in addition to orthotics. When I see a client with a Type I or II on one side and they come with 2 distinctly different orthotics I compliment the person who provided them. However, upon restoring functional motion, the orthotic typically does have to be adjusted. Philosophically, I believe it more important to restore the motion potential that a person has, rather than depend on an external device (orthotic) alone. When I see the same orthotic on 2 different foot/ankle presentation, I am a bit reticent to comment. However, as soon as motion is balanced, the orthotics are then rendered more appropriate. Q: Can I purchase a foot model from you? A: Yes, please send me an email. You will save 10%. Q: Why do you not advertise this on the web? A: Too many other priorities, very small profit margin, etc. it is a service more than a business. However, I graciously accept help with the web site! Q: If you are on Pacific Time, isn’t it lunch time? A: Yup, gotta go! Thank you. By the way, how do like the Q & A? 6. VIDEO: CUBOID MANIPULATION In this video I demonstrate the traditional manipulation and contrast it with the technique that I prefer, and I explain why. I also explain why it is very relevant to evaluate calcaneal valgus/varus when treating Cuiboid Syndrome. The video is just over 5 minutes. I shot it with sub optimal conditions, I had severe insomnia as evidenced by my less than ideal attire; my shirt not fully buttoned! Yes, I will reshoot someday. I look forward to adding more video, especially on treating each motion dysfunction throughout the foot and ankle that is typically present with a Type II Cuboid Syndrome (my nomenclature). This video only demonstrates the cuboid mobilization, but it does not show how the calcaneus has to be treated and how the rest of the foot and ankle has to be evaluated and treated. Do not try this, it is for informational puirposes only, for clinicians. | |
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