THE BACK PAGE RESEARCH REVIEW Manual therapy for midfoot pain REVIEWED BY SHAWN THISTLE Study title: Two examples of ‘cuboid syndrome’ with active bony pathology: Why did manual therapy help? Authors: Matthews MLG & Claus AP Publication information: Manual Therapy 2014; 19(5): 494-8. C uboid syndrome is a term that vaguely describes a clinical presentation of lateral midfoot pain caused by a hypothesized disrup-tion of calcaneo-cuboid joint congru-ency. Symptoms are theorized to pres-ent subsequent to sudden traumatic overload, or repetitive overuse. Following are two cases involving the same patient, who presented twice with cuboid syndrome (once on each side) with radiological demonstration of ac-tive bone pathology as a unique exam-ple of lateral midfoot pain, treated with targeted physical/manual therapy. A middle-aged female suffering from an insidious onset of right lateral midfoot pain presented to a physical therapy clinic with a provisional diagnosis of a proximal cuboid stress fracture, demon-strated via plain film and bone scan. The patient presented to a physio-therapist in January 2007 with a rated 8/10 pain that was aggravated by all weight bearing activities. The examination revealed antalgic gait, with right foot pain in the stance phase. Palpation revealed boggy swell-ing on the dorsal-lateral aspect of the right foot. Dorsal-to-plantar digital palpation of the cuboid reproduced the patient’s chief complaint. The patient was treated four times over 28 days with cuboid mobilizations First clinical presentation in the plantar-to-dorsal direction, soft tissue therapy to the triceps surae and active patient stretches for dorsiflexion range of motion. Also, a seven-millim-eter woolen felt support was positioned under the cuboid to provide pressure in a plantar-dorsal direction. Low-dye taping for support along with mini-stir-rups to lock off the tape were applied. The patient was educated on the neu-rophysiological mechanism of sensiti-zation that occurs with persistent MSK conditions. The patient was then grad-uated to weight bearing walking activi-ties and heel raise exercises. Subsequent to performing plan-tar-to-dorsal cuboid mobilizations, the patient reported a 60 per cent reduction in pain. By third session, patient re-ported only mild discomfort with toe-off. By fourth treatment, no pain with activities of daily living was reported. home stretches were provided. After second treatment, patient reported a 40 to 50 per cent symptom decrease. She did not need the rocker boot post-treatment. The third treatment necessitated a higher-grade mobilization with a thrust manipulation targeting the cuboid due to a mild recurrence of pain. By the seventh treatment, the patient’s pain and symptoms resolved completely. The authors offer some ideas as to why manual therapy was beneficial in the presence of active bone pathology in this case: 1) Strong evidence exists that man-ual therapy can cause hypoalgesia due to an activation of the central nervous system. The fact that symptom reduc-tion occurred within minutes following treatment supports the theory that neurosensory pain modulation is the primary effective mechanism behind manual therapy, rather than repair of tissue pathology. 2) Authors surmise the bony pathol-ogy present may have contributed a chemical stimulus for nociception, initiating the patient’s pain perception, and a cascade of sensitization of the nervous system. They assert that in-stead of manual therapy having a temporary effect, it might have ad-dressed the neural sensitization pro-cess, leading longer lasting clinical benefit. This was a very novel case of manual therapy proving helpful even in the face of bony pathology. This should remind practitioners to treat the pa-tient – not the image. However, this is just one case report. Clearly, a RCT would allow us to gain further insight into the comparative value of different treatment approaches. www.canadianchiropractor.ca Conclusions, applications Second clinical presentation Three years later, the same patient suf-fered from a similar presentation on the left foot. Radiologists reported a poten-tial early stress fracture without cortical breach. The patient was given a rocker-boot to immobilize the left tarsals. In this case, seven treatments were performed over 54 days. Plantar-dorsal mobilization of the left cuboid was performed, leading to immediate re-duction in symptoms during gait. Deep tissue massage to the triceps surae, felt pad support under the cuboid and DR. SHAWN THISTLE is the founder and CEO of RRS Education (rrseducation.com), which helps busy clinicians integrate current research evidence rationally into practice. He also maintains a practice in Toronto, lectures at CMCC and provides chiropractic medicolegal consulting services. Reach him at: [email protected] 38 Canadian Chiropractor October 2015
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