Swelling and pain at the Cuboid / 5th metatarsal joint - lateral side of foot

by Brett
(Sacramento, CA)

Lengthy description to follow as I have been forced, by my podiatrist and primary, to research my injury myself. Any advice would be appreciated.

Following an inversion sprain to my right ankle/foot (classic basketball jumping sprain), I was eventually diagnosed (via MRI and bone scan) to have multiple fractures of the medial side of the cuboid bone. After 6 weeks of walking (in ankle support) on what was initially diagnosed as a sprain, I was prescribed to 8 weeks of non-weight bearing in an e-boot and crutches by a podiatrist.

Being an athlete, the following were prescribed for rehab:
* Physical therapy
Determined that immobilization of cuboid/5th met joint eliminated pain in
lateral column pain. Tape was used to lift base of 5th met and lower cuboid.
However, a subluxed cuboid was never identified.
* Range of Motion graduated into resistance band exercises
* Contrast bathing of foot and ankle
* A prescribed muscle stimulator to facilitate muscle recovery with no clinical
guidance by physical therapy as to the application of the tx method. Stimulation
was performed on the peroneus longus, gastrocnemius and tibialis anterior.

Chronic symptoms:
Swelling at the cuboid / 5th metatarsal joint after approximately 1 - 2 hours of weight bearing in supportive running shoe.
Sharp and burning pain at joint
Shooting pain from tip of 5th toe (broken in 4 months earlier)

As long as I don't spend too much time on my feet the pain is bearable. Taping as described above works as well. Again, it is the use of the foot, standing on it or flexing it to operate the gas peddle of a car that causes the pain. The pain generally subsides with rest.

Due to proprioception problems following weeks of disuse, I broke my 3rd toe at the base by the metatarsal joint. The toe was splinted (as a finger would be) as to avoid flexation and allow bone to heal at the joint. Taping of splint required taping around ball of foot at head of 5th met immobilizing the 5th met. Taping produced relief from pain and swelling at cuboid / 5th met joint. My podiatrist is most likely going to try and reproduce my splint. Once he saw it, he promoted its continued use and included it in his tx.

It presents as classic cuboid syndrome but podiatry doesn't diagnose it as that. I've been forced to do my own research due to my podiatrists inability to identify the pain source (even prior to the diagnosis of the fracture). This has been going on for 10 months of referrals to specialists (i.e. pain specialists) who said I shouldn't have been referred to them. All delays in addressing the problem.

Podiatry says I have a c-shaped foot with a high arch and are pushing me into orthotics which I have NEVER needed before for either foot. I'm an
overpronator so a good stabilizing running shoe and firm insert works just fine.

Podiatry tried to pawn the pain off as RSD/CRPS however physical medicine and pain specialists have ruled that out. According to Phys Med and Pain Clinic, there is no excessive surface sensitivity or temperature to support RSD even though recent bone scan shows uptake in the region. Even radiology ruled out RSD.

Continued visits to podiatry are unproductive and I am being pushed back onto my primary care physician who can do nothing more than prescribe Norco. Podiatry repeatedly wants to put me on neurontin or tramadol both of which contradict with my anti-depressant. Basically, I'm being forced to research my own injury and push my primary doctor for the appropriate referrals...

I don't want a pharmacological solution. If I did I'd enjoy a life addicted to Norco (already showing signs of tolerance). I need to get back on my feet running. It's my life style and psychological necessity. I'm no hypochondriac and WILL run through the pain if I have too but the pain that follows makes running an "infrequent" activity.

Where do I go from here when I'm getting shut down by the doctors? Techniques to diagnose the source? Treat it?

I have NO history of prior foot of ankle injury. In over 40 years.

I'm pushing for electromyography and DITI (Digital Infrared Thermal Imaging) which has been useful in diagnosing sources of pain in elite athletes. But, the almightly HMO (K.P.) likes the cheap pharmacological route.

I've had 2 MRIs, 2 CT Scans (one at 2.5mm, one < 1mm), 2 bone scans, multiple x-rays. I can't get anyone look beyond what they want to see and TRY to identify any abnormalities. I have all of my radio-logical studies on DVD including fully operational 3D MRI and Ct-scans

I'm open for referrals to non-network specialists in Northern California. Sports medicine spec., orthopedics with foot ankle specialization, a DPM who looks at feet as a runner would. A doctor who treats the person as a complete system and not a a pain in the foot.

As of now, I'm lost and don't see this as an athletic career terminating injury as the doctors would lead me to believe due to their indifference.

RESPONSE

Hi Brett,

In spite of your long and thorough description and history of your injury I pretty much made up my mind early on as to what your problem sounds like and that would be a displaced cuboid.
If you read my section on cuboid syndrome, you will find this is a condition that is really not diagnostic via conventional radiology but more than likely based on clinical presentation.
The fact that physical therapy taped your foot in such a manner to alter the alignment of the cuboid and fifth metatarsal bone and that eliminated the pain, pretty much sounds like a displaced cuboid.
Your big problem is that you are not dealing with any doctors who truly understand the condition. I would suggest you call around your area looking for an foot specialist who deals with sports medicine, call the office and ask straight out,"does the doctor treat cuboid syndrome?" and make an appointment with the one that answers yes.
Assuming the cuboid fractures have healed, then the cuboid somehow needs to be stabilized. This is usually done through a specially devised orthotic that is built in such a manner to keep the cuboid in the position it needs to be place in.
Eventually it may settle back in permanently and I suppose even surgery is not out of the question, but I would start with the orthotic first.

Marc Mitnick DPM
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