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Cuboid Manipulation
This video demonstrates cuboid manipulation, a technique intended to reduce excessive stiffness of the tarsal joints. The term "manipulation" refers to a low-amplitude (relatively small motions), high-velocity (quick) technique, with the intent to target specific joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during arthrokinematic motion; specifically glide). Cuboid manipulation may be used to address dorsiflexion range of motion, less than optimal longitudinal arch height, and/or abnormal lower extremity muscle activity. For example, research demonstrates that pes planus is correlated with Achilles tendinopathy, and manipulation of the transverse tarsal joints may aid in normalizing activity of the tibialis posterior, tibialis anterior, and peroneal muscles during gait. This technique is recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, etc.) to aid in development of an evidence-based, systematic, integrated, patient-centered, patient-centered, and outcome-driven approach.
Transcript
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This is Brent of the Brookbush Institute,
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in this video we're going to go over
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manipulations or high-velocity thrust techniques. I assume that if you're
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watching this video you're watching it for educational purposes, and that you
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are a licensed professional with high- velocity thrust or manipulation
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techniques in your scope of practice. If you are not sure check with your state
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board. Most physical therapists, chiropractors and osteopaths you're in
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the clear. I believe that ATC's you can't do manipulations in the United States,
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although other countries again check your scope. Of course massage therapists
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and personal trainers these are generally not within your scope. Of
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course you could continue to watch these videos just for educational purposes,
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learn a little Anatomy, learn a little biomechanics. If you're going to do these
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techniques please make sure that you have a good rationale for putting your
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hands on a patient, this should be based on assessment, and if you're going to
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assess I'm hoping that you'll assess, use these interventions and reassess to
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ensure that you're getting the result that you're looking for and have good
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reason to continue using this technique. In this video we're going to do a cuboid
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manipulation. I'm gonna have my friend Yvette come out, she's going to help me
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demonstrate. Remember if I'm doing manipulations, I'm using more than
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passive accessory motion and more than just subjective complaints. We want to
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make sure that we have some sort of movement or postural exam like the
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overhead squat assessment, to see what compensation pattern were actually
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trying to correct, and I like to use continuous interval measures to track
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progress, that's something we can measure objectively. In this case I'd probably
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use the navicular drop test with like a ruler, so I can see how many centimeters
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of height we have between the navicular tubercle and the floor. Now the
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last thing I'm going to go to is of course my passive accessory motion exams, to
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indicate whether this particular joint is stiff, and it's actually several
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joints here. We are manipulating the cuboid bone but we have to keep in mind
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that the cuboid has joints with the calcaneus, the lateral cuneiform and the
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navicular a little bit; and what we're trying to to do is see if it'll tilt
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this way on the combination of those three joints. Now the first thing
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we have to do is be able to palpate the cuboid which is not terribly hard. If
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you just think about the fact that the cuboid is on the lateral
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side of the foot, and essentially on the lateral side of the foot you can palpate
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the calcaneus, the fifth metatarsal or the cuboid. Now what I'll usually do just
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kind of instinctively, is I'll start grabbing at the side of the foot until I
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feel something that feels wedge-shaped. All right like right here
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it feels a little wedge-shaped, but it's not the round long bone of the fifth
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metatarsal. So I got this wedge-shaped bone in it, it'll actually
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wiggle for me. So this will wiggle, this is definitely skin there's no bone here.
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This is a bone that'll wiggle, and then this one you can
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feel the whole lever move. So now that you have the cuboid,
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really kind of take a second to palpate around. You'll notice it's a pretty
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sizable bone, it feels like almost half the width of the foot. So it
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takes, not this way right, it's only about, maybe on Yvette's little foot here
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maybe an inch and a half long, but it it's almost as wide as like half
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the foot there. So I'll feel around there,
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you kind of feel like, you get this feeling like it has like a little
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curvature to it, so like it's shaped a little like if I turned my hand
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this way, right so I can kind of put my thumb in this little divot and the
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cuboid, or at least it feels that way. So now what I want to check is
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this when I do my passive accessory motion. Of course I can just
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wiggle back and forth, dorsal to plantar. But what I think you are going to find
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is that's not what gets stuck. What gets stuck is the ability to move this way,
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almost like a rotation, and I guess we could call that external rotation of the
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of the cuboid bone, but it's probably more like inversion, e-version
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of the cuboid bone, and I think you'll get this sense that the medial edge
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doesn't want to move the same. So the outside edge will wiggle on you a
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little bit, and then you get to the medial edge and your like that does feel a little
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stuck. So now how do we manipulate this joint? So keep in mind manipulations are
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always about setup first, just because we know where this bone is we don't just
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want to go snap, it's not going to work. Remember we're trying to get range of
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motion back, so we want to lock out all the range of motion she has in a
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particular direction, and then push past the resistance barrier; and the way that
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looks with this this particular joint is I'm going to put the cuboid right here in
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my hand on the outside. I actually like to use my thumb on the inside, so
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I'm just like this and I'll show you this closer on the close-up recap,
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and what I'm going to try to do is twist the cuboid this way. But before I do that,
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I have to lock the cuboid out. So I'm going to take all of the inversion that I
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have up. All right I'm going to take her all the way as far into inversion as I
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possibly can. I'm going to plantar flex the foot as well, not plantar flex the ankle
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plantar flex here, her metatarsals, her transverse tarsal joint. I want to
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take up all the slack in the top of her foot. So I get here and then what you
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want to do is not this right, which is instinctively like plantar to dorsal
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you'd be like yeah that's the manipulation right. But with this particular
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manipulation there's so much leg involved that if I did this, you can
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see it's just got knee extension, that's not what I was trying to do. I want to
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get more inversion at the cuboid so I'm going to take up all the slack on the foot
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here and then this is cool. All you really need to do is just go like that,
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it's a whip. I don't know if you guys heard that, that was actually a pretty a
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pretty loud cavitation for the cuboid. Usually this is one of those ones that
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you'll feel the cavitation and you won't hear it, but I just took up all the slack
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and then I just whipped her foot. Wow. So again, find the cuboid,
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the outside of the cuboid on this part of your hand, so this is going to help
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us turn into inversion from the top side. This side you're going to press the medial
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portion of the bone down this way. I've even seen some people with really great
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technique here use their pisiform hamate like this. My problem is my hands are
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kind of stupidly big, and I can't get that part of my hand into that part of
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this little foot. I just happened to be a lot bigger than Yvette. For some
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of you with less difference between the size of your patient and
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yourself that might work out better, and then you can get to the end range here
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and that would look a little bit more like a PA. You would do a whip but it would be
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more like a PA you do on the spine. So that might be more comfortable for some
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of you, but again you're going to outside, wraps up the outside of the cuboid, here
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I'm going to end up using my thumb on the medial portion, plantar flex all the way.
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Not the ankle necessarily, the foot, invert as far as you can. Again,
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forefoot not necessarily the ankle. Get all the way to end range where you feel
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that lock position, and play with it if you have to for a second like really
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feel like you have the cuboid to a point that it doesn't want to move anymore, and
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then once you're there just give it a little whip.
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Alright stay tuned for the close-up recap. For a close-up recap you
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can see here like if you grab here you got the calcaneus then you got some
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skin, and then right as I get down to about here like I feel bone again, this
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is her fifth metatarsal, this is her cuboid. So I'm going to put my thumb on the
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medial aspect of her cuboid, then I'm going to take this part of my hand, put it
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on the outside of her cuboid, and my goal here is to push this way with this
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finger and then pull up this way with my hand, so that I'm tilting the cuboid this
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way. So we get all set up and then I mentioned before remember we want
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inversion and plantarflexion of the foot, and you can see the difference
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between inversion and plantar flexion of the ankle where you get all this
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calcaneal motion, as opposed to inversion and plantar
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flexion of the foot. You can see the calcaneus stays basically in place.
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So once I get her all locked up I can pull all the way down into end-
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range, and then of course this time the manipulation is not just like a thrust
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PA, we're just going to give the the foot a little whip, and that's it, that was the
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entire manipulation. So take your time getting set up, get your hand over the
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cuboid, get your thumb or you can use pisiform hamate in here if you got
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smaller hands, or at least hands that are smaller compared to the person's foot.
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You're gonna plantarflex and invert the forefoot as far as you possibly can,
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and then just a little whip, and of course you could use something like
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the navicular drop test to go ahead and measure pretest, post-test. A couple of
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points to recap, knowing your Anatomy and knowing your biomechanics will certainly
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help you choose the right technique for the right patient. If you're unsure
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whether manipulations are appropriate due to their higher intensity it's okay
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to do mobilizations. Most research points to manipulations being slightly more
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effective, but mobilizations being very effective, and of course we have those
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videos for you if you want to start with those less-intense techniques. Make sure
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that if you are doing any technique that is based on assessment, and of course
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that you're reassessing ensuring that the technique is effective for the
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patient that you're working on, and when it comes to all manual techniques,
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manipulations maybe more than any other, look for opportunities to get live
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education. Although I know videos are convenient and I'm happy to have these
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up for you to watch, it would be so much more helpful to use those videos as
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a recap of one-on-one attention with somebody who's experienced with
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manipulation techniques. At the very least grab a colleague, grab a friend and
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start practising these before you bring them into clinic and start using them on
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patients and clients. I hope you enjoyed this video, if you have any questions
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