Cuboid Manipulation

Patient and Practitioner set-up

1. The patient should be lying prone on a table, with the feet hanging just beyond the end of the table.
2. The table should be at the level of the practitioner's upper thigh.
3. The practitioner should be standing at the end of the table on the patient's affected side.

Passive Motion Assessment

• The arthrokinematic motion assessed prior to cuboid manipulation is medial rotation (inversion). Generally, this motion is assessed using a pincer grip or using the same hand position used for the manipulation.
  • Note: It is not uncommon for plantar flexion/dorsiflexion and dorsal/plantar glide of the lateral edge to feel relatively normal, while dorsal/plantar glide of the medial edge and medial rotation feel hypomobile or difficult to achieve. This mobilization is recommended if dorsal/plantar glide of the medial edge and/or medial rotation feel hypomobile.

Lockout Position:

1. Take a moment to palpate the cuboid.
   1. It may be helpful to look at a model or diagram of the transverse tarsal joints as you attempt to identify the cuboid.
   2. The cuboid can be palpated on the lateral side of the foot, between the calcaneus and the 5th metatarsal head.
   3. The cuboid feels "wedge-shaped". If you are starting your palpation from the calcaneus and sliding toward the toes, the cuboid should be the first bony structure that allows some dorsal to plantar motion (glide of the calcaneocuboid joint).
   4. The cuboid is a sizable bone, only about 2-3cm in length, but is nearly half the width of the foot.
   5. The dorsal side will feel like a bumpy hilltop that slopes toward the lateral side of the foot, and the plantar surface feels as though a lateral ridge is followed by a depressed medial half.
2. Place the dorsal side of the cuboid in the webspace of your outside hand, and allow the fingers of that hand to wrap around the dorsal side of the foot.
3. Place the thumb of the other hand in the depression of the plantar/medial surface of the cuboid, and allow the fingers of that hand to wrap over the fingers of the other hand and the dorsal side of the foot.
4. "Take up" all of the available range of motion (ROM), first for inversion, and then for mid-tarsal dorsiflexion.
   • Note: Taking up the available range of motion is achieved with a combination of pulling up on the dorsal side of the foot and pressing into the medial/plantar aspect of the cuboid (some plantar flexion of the ankle is also acceptable). Use the weight of the patient's foot falling laterally; that is, hip internal rotation to help you achieve end range via calcaneus on cuboid inversion and plantar flexion. Note; this will be the same motion used for the manipulation.
5. The end of transverse tarsal inversion and dorsiflexion ROM is lock-out position for this joint. After a couple of practice attempts at this motion and achieving lock-out you are ready to manipulate.

High-Velocity Thrust

Important Note: 90% of manipulation technique is set-up. If you do not achieve lock-out during set-up, you are unlikely to achieve a successful manipulation.

• The high-velocity portion of this technique is a quick "whip" just beyond the lock-out position achieved in previous steps. Most of the pressure comes from maintaining a rigid thumb on the medial/plantar surface of the cuboid, with the rest of the fingers maintaining transverse tarsal dorsiflexion/inversion. Most of the force comes from the weight and momentum of the patient's own foot, as you flip the foot laterally (hip internal rotation)
  • Note: Although the cavitation in this video is fairly impressive for this little joint, remember that cavitation is not necessary for a successful manipulation. Success is an increase in arthrokinematic motion and a measurable change in ROM.