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Cuboid stress fractures occur due to repetitive stress on the cuboid bone. The cuboid bone is one of the midfoot bones on the outside of the foot. Cuboid stress fractures are often seen in athletes and active individuals.
If there is too much force on the cuboid bone during repetitive activities such as jumping, dancing, and sports, stress fractures can happen.
Diagnosis of cuboid stress fractures can be difficult. It’s important to diagnose them quickly to achieve the best possible outcomes.
Isolated cuboid stress fractures are rare. Cuboid stress fracture incidence is <1% of all fractures (1).
What Causes a Cuboid Stress Fracture?
Repetitive overload on the outside of the foot caused by certain activities (marching, running, jumping, dancing) can fatigue the cuboid bone causing it to fracture.
A stress fracture usually occurs due to athletic injuries as well. Certain factors like poor bone quality, overly flat feet, and excessively high-arched feet can also cause additional stress to be placed on the cuboid bone.
Pediatric cuboid fractures can occur in children who are just learning how to walk and are accidentally placing excess pressure on the outside of the foot.
Many factors can increase the chance of sustaining a cuboid stress fracture. These factors include increased age, starting a new training regimen too fast, osteoporosis, and footwear.
Symptoms of Cuboid Stress Fractures
Symptoms of cuboid fracture can be vague. Pain from a cuboid stress fracture may feel dull and achy, with localized swelling along the lateral aspect (outer) of the foot. Stress fractures should always be considered in a patient presenting with lateral foot pain.
Walking may be difficult due to persistent pain. The pain may worsen with activities, and improve with rest. The pain associated with a stress fracture may last several weeks.
Management of Cuboid Stress Fractures
Cuboid Fracture Test
The cuboid fracture test can help diagnose the presence of a cuboid fracture. Your doctor will stabilize your heel, and apply pressure to the outer aspect of the cuboid bone with your foot abducted (pulled away from the body).
If there is pain and instability upon performing this test, this suggests that a stress fracture is present. This test is also known as the “Nutcracker Test”.
X-ray
If you suspect that you have a stress fracture you should visit your local medical foot doctor. Your doctor will obtain x-rays of your foot and view if a fracture is visible. Oftentimes, stress fractures are not visible until 3 weeks after the pain starts.
This is because stress fractures happen from repetitive stress on the bone that occurs over time. X-ray changes may not be obvious initially because a stress reaction in the bone happens first, followed by a fracture line.
A “stress fracture” is a condition characterized by an incomplete crack in the cuboid bone.
MRI scan
If x-ray findings are unclear, your doctor may choose to order a Magnetic Resonance Imaging scan (MRI) of the foot. An MRI can provide detailed images of the bone and soft tissue structures in the foot. An MRI is also helpful to identify any injuries to tendons and ligaments near the cuboid bone as well.
CT scan
A Computed Tomography scan (CT scan) can also be ordered to help identify a stress fracture. CT scans provide detailed images of the outer and inner portions of the bones. A CT scan can also be helpful to see if the fracture is healing several weeks after the diagnosis.
Bone Scan
A bone scan may be ordered to diagnose a cuboid stress fracture. A bone scan is a test that uses a radioactive tracer to create images of the bones. The tracer is injected into a vein, and it collects in areas of the bones that are actively growing. A dark area can be seen in the area of the fracture.
Ultrasound
Occasionally, an ultrasound for stress fractures can be beneficial. Stress fracture ultrasound results would reveal changes in the shape of the bone and identify fracture lines in the bone. An ultrasound can also show swelling and fluid in the area of the cuboid bone, which can indicate a stress fracture.
Cuboid Bone Fracture Treatment
Treatment for cuboid bone stress fractures depends on whether the broken bone is non-displaced (fracture is in proper alignment) or displaced (the fracture fragments are shifted).
Luckily, cuboid stress fractures are among the quickest stress fractures to heal and generally carry a good prognosis. The cuboid is a vascular bone, which means the blood supply to the bone is good. This allows it to heal well.
Non-Displaced
Most stress fractures are often non-displaced and can be treated conservatively. When there is a fracture, the bone takes 4 to 6 weeks to heal.
Your doctor will instruct you to stay non-weight bearing in a cast for 4 to 6 weeks. Your doctor will order x-rays every 3 weeks in the clinic to assess bone healing.
If the fracture is healing appropriately, your doctor will allow you to start weight-bearing on your heel in a cast boot for an additional two weeks before transitioning to an athletic shoe two weeks after that.
You will need to limit your activity initially until you are able to walk pain-free. Cuboid injuries should be taken seriously and activities should not be resumed prematurely.
Displaced
If your fracture is displaced, your doctor will recommend surgery. This is because surgery is required to realign the fracture fragments so that they can heal properly. Your doctor will perform the surgery in the operating room under anesthesia.
You will need to remain off of your foot in a cast for 6-8 weeks after the surgery. You can then transition weight bearing as tolerated in a cast boot for another 2 weeks before transitioning into an athletic shoe.
Physical Therapy
Physical therapy will be needed after sustaining a cuboid stress fracture. This is because being non-weight bearing on the foot for several weeks can affect balance and also make the leg muscles weak.
Physical therapy will be needed 3 times a week for 1 month to improve strength, improve balance in the foot, and decrease pain.
Exercises will also be recommended to help improve strength and range of motion.
Stress fracture activity should be limited until you are fully capable of walking comfortably. Return to sport time can take 8-12 weeks. That’s why it’s important to diagnose the fracture as soon as possible.
As you can see, full healing time for cuboid fractures can take anywhere from 8-12 weeks.
Complications of Stress Fractures
Complications of stress fractures include painful nonunions, meaning that the fracture does not heal properly. Nonunions will often require surgery to fix.
Other complications include excess bone callus formation at the fracture site. A bone callus forms at a stress fracture site as a response to the injury. The body’s healing process involves the formation of a hard callus of bone, cartilage, and fibrous tissue at the fracture site to protect it and promote healing.
The callus helps to immobilize the fracture site, which allows for the healing of the broken bone. However, if you walk too early with a stress fracture, too much bone callus can form, causing pain.
Skin wounds and infections can occur from prolonged wear of a cast that is not well-fitted.
Nerve injury is another complication that can occur from sustaining a cuboid fracture. This can cause burning/tingling pain in the area of the fracture. Luckily, complications from isolated stress fractures are rare.
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References
- Lau H, Dreyer MA. Cuboid Stress Fractures. 2022 Sep 28. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. https://pubmed.ncbi.nlm.nih.gov/31194407/
- Pountos I, Panteli M, Giannoudis PV. Cuboid Injuries. Indian J Orthop. 2018 May-Jun;52(3):297-303. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5961267/
- Angoules AG, Angoules NA, Georgoudis M, Kapetanakis S. Update on diagnosis and management of cuboid fractures. World J Orthop. 2019 Feb 18;10(2):71-80.https://pubmed.ncbi.nlm.nih.gov/30788224/
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