Research Review: Manual therapy for midfoot pain

Shawn Thistle
October 01, 2015
Written by
Cuboid syndrome is a term that vaguely describes a clinical presentation of lateral midfoot pain caused by a hypothesized disruption of calcaneo-cuboid joint congruency. Symptoms are theorized to present subsequent to sudden traumatic overload, or repetitive overuse. 

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.

Cuboid syndrome is a term that vaguely describes a clinical presentation of lateral midfoot pain caused by a hypothesized disruption of calcaneo-cuboid joint congruency. Symptoms are theorized to present 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 active bone pathology as a unique example of lateral midfoot pain, treated with targeted physical/manual therapy.

First clinical presentation
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, demonstrated via plain film and bone scan.

The patient presented to a physiotherapist 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 swelling 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 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-millimeter woolen felt support was positioned under the cuboid to provide pressure in a plantar-dorsal direction. Low-dye taping for support along with mini-stirrups to lock off the tape were applied. The patient was educated on the neurophysiological mechanism of sensitization that occurs with persistent MSK conditions. The patient was then graduated to weight bearing walking activities and heel raise exercises.

Subsequent to performing plantar-to-dorsal cuboid mobilizations, the patient reported a 60 per cent reduction in pain. By third session, patient reported only mild discomfort with toe-off. By fourth treatment, no pain with activities of daily living was reported.

Second clinical presentation
Three years later, the same patient suffered from a similar presentation on the left foot. Radiologists reported a potential 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 reduction in symptoms during gait. Deep tissue massage to the triceps surae, felt pad support under the cuboid and 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.

Conclusions, applications
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 manual therapy can cause hypoalgesia due to an activation of the central nervous system. The fact that symptom reduction 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 pathology 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 instead of manual therapy having a temporary effect, it might have addressed the neural sensitization process, 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 patient – 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.

Dr. Shawn Thistle is the founder and CEO of RRS Education (, 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: This e-mail address is being protected from spambots. You need JavaScript enabled to view it


0 #1 Dr. Dale Forsythe 2015-10-13 15:07
Hi Dr. Shawn - Activator Methods has had a protocol for over 26 yrs that I know of for checking medial/lateral knee involvement in their basic patient scan and if a lateral knee check is positive, the cuboid on the same side is contacted on the inferior lateral aspect and line of drive is post/sup/medial .

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