Sports Medicine
Sports Injury Prevention & Rehabilitation

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Cuboid Stress Fracture

(Also known as Stress Fracture of the Cuboid)
What is a cuboid stress fracture?
A cuboid stress fracture is a condition characterized by an incomplete crack in the cuboid bone.
The cuboid is the anatomical name given to one of the bones in the mid foot. It is located at the outer aspect of the mid foot just in front of the ankle.
Several muscles of the foot and lower leg attach to the cuboid bone. When these muscles contract, a pulling force is exerted on the bone. In addition, weight bearing activity places stress on the cuboid bone. When these forces are excessive or too repetitive, and beyond what the bone can withstand, bony damage can gradually occur. This initially results in a bony stress reaction, however, with continued damage may progress to a cuboid stress fracture.

Cause of a cuboid stress fracture

A stress fracture of the cuboid typically occurs over time with excessive weight bearing activity such as running, sprinting, jumping or dancing. They often occur following a recent increase in activity or change in training conditions (such as surface, footwear or technique changes etc).

Signs and symptoms of a cuboid stress fracture

Patients with this condition typically experience a poorly localized pain in the outer aspect of the mid foot or ankle that increases with impact activity (such as running, jumping, sprinting and hopping) and decreases with rest. Pain may also cause the patient to cease activity.
Occasionally, pain may radiate to the inner aspect of the foot, the sole of the foot, the heel bone or the toes. In severe cases, walking or standing may be enough to aggravate symptoms. Other symptoms may include night ache or pain on firmly touching the cuboid bone.

Diagnosis of a cuboid stress fracture
A thorough subjective and objective examination from a physician may be sufficient to diagnose a cuboid stress fracture. Further investigations such as an X-ray, MRI, CT scan or bone scan are usually required to confirm diagnosis and determine the severity of injury.

Prognosis of a cuboid stress fracture
With appropriate management, most patients with a cuboid stress fracture can have a full recovery (return to sport or full activities) in a period of 3 - 6 months. In more severe cases, recovery may take 1 year, or longer, depending on the intervention required and a range of other factors. In rare cases, some patients may experience ongoing symptoms or complications which may require further management.

Treatment for a cuboid stress fracture

Treatment for a cuboid stress fracture typically involves an initial period of rest from weight bearing activity. This may involve a period of non-weight bearing immobilization in a plaster cast, the use of crutches or a protective boot for a number of weeks. Following this, a gradual increase in weight bearing activity and exercise can usually occur as tolerated, provided symptoms do not increase. This should take place over a period of weeks to months with direction from the treating physiotherapist and will vary depending on the severity of the injury.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the cuboid stress fracture altogether. Immediate, appropriate treatment is essential to ensure a speedy recovery.
Manual "hands-on" therapy from the therapist such as massage, trigger point release techniques, dry needling, joint mobilization, stretches, and electrotherapy can assist with hastening healing, improving range of movement, pain and function and correcting factors contributing to the development of the cuboid stress fracture. This can generally commence once the physiotherapist has indicated it is safe to do so.
Patients should also perform pain free flexibility and strengthening exercises (following the initial period of immobilization) as part of their rehabilitation to ensure an optimal outcome. Alternative activities placing minimal weight bearing forces through the affected bone should also be performed to maintain fitness such as swimming, cycling and water running. The treating therapist can advise which activities are most appropriate for the patient and when they should be commenced.
In the final stages of rehabilitation for a cuboid stress fracture, a gradual return to activity or sport can occur as guided by the treating therapist provided symptoms do not increase. This may involve a gradual return to running program to recondition the cuboid to running in a safe and effective manner.

Appropriate footwear advice and / or the use of orthotics may also be indicated in those patients whose lower limb biomechanics are likely to have contributed to the development of the cuboid stress fracture. Training technique or training methods may also need addressing to decrease the likelihood of injury recurrence.

Contributing factors to the development of a cuboid stress fracture
There are several factors which may contribute to the development of this condition. These need to be assessed and corrected with direction from the treating therapist. Some of these factors include:
  • poor foot posture (especially flat feet or high arches)
  • muscle weakness (particularly of the gluteals, quadriceps, calf and core stabilizers)
  • poor flexibility (particularly of the calf or peroneals)
  • joint stiffness (particularly of the ankle or foot)
  • inappropriate footwear
  • poor running technique
  • inadequate diet
  • inappropriate or excessive training (particularly on hard or uneven surfaces)

Therapy for a cuboid stress fracture
Therapy treatment for patients with this condition is vital to hasten healing, prevent injury recurrence and ensure an optimal outcome. Treatment may comprise:
  • soft tissue massage
  • joint mobilization
  • joint manipulation
  • electrotherapy (e.g. ultrasound)
  • dry needling
  • the use of crutches
  • the use of a protective boot or brace
  • activity modification advice
  • taping
  • biomechanical correction (e.g. the use of orthotics)
  • running technique correction
  • footwear advice
  • exercises to improve strength, balance, flexibility and core stability
  • education
  • a gradual return to running / activity plan

Other intervention for a cuboid stress fracture
Despite appropriate management, some patients with this condition do not improve and require other intervention to ensure an optimal outcome. The treating doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, extended periods of plaster cast immobilization, use of crutches or protective boot, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the cuboid stress fracture. Occasionally, patients with this condition may require surgery to stabilize the stress fracture and aid healing.