How can a runner tell the difference between a cuboid stress fracture or calcaneocuboid joint arthritis? Well, that’s what we’re talking about today on the Doc on the Run podcast.
If you call me and you tell me, I think I have a cuboid stress fracture, the first thing I’d say is, well, maybe, but it is pretty unlikely. In fact, cuboid stress fractures are less than 1% of all the stress fractures that happen in the foot in athletes. So it’s pretty rare. One thing you can get that’s actually more common is arthritis within the joint. That’s also pretty rare, but you’ve got to know the difference.
What we’re talking about is the cuboid bone. So the cuboid is this little irregular bone sitting over here sandwiched in between the fourth and fifth metatarsal bones and the heel bone. And so when you pronate and you squish it, you can actually get a stress fracture in the cuboid bone.
Now the calcaneocuboid joint is this joint that is basically irregular. It’s a saddle-shape joint, but if you get arthritis in that joint when you move, when your foot pronates and supinates, or if it really pronates, it can actually compress the joint and cause pain. There are a couple of things that you can get in there that are arthritis, meaning damage to the cartilage, damage under the bone, or inflammation within the tissue that surrounds the joint, that we call arthritis, are all forms of arthritis. But it makes a big difference in what’s happening.
So as a good example, I saw a guy who is an Ironman triathlete. I’ve actually seen two athletes that had this, where it’s a very rare thing, but when we’re looking at your foot, I think it’s helpful to draw some pictures. You can make comments on my drawings if you want. I know they’re terrible. I am not an artist. I am a podiatrist.
The heel bone sits back here in the front of the heel bone, the part that connects with the calcaneocuboid joint. Well, that’s what we call the anterior process of the calcaneus. The name’s not important, but it is where the cuboid sits up against there, like that. Then you have surfaces for the fifth metatarsal bone and the fourth metatarsal bone to bump up against it. So if you get a stress fracture in the cuboid, you get inflammation within the bone.
The swelling within the bone causes pain basically. You can also, if you look at it from the top, we’re looking at your foot. What you have is the anterior process of the calcaneus is sitting over here like this. Cuboid is sitting right here, and then you have the fourth and fifth metatarsal bones lining up like that.
So again, the cuboid is going to be painful over here in this area. So you’re going to have pain there. You’re going to have pain here, if you have a stress fracture. Well, the problem is if you have inflammation or irritation within the joint, you can also get pain. Now to blow this up into a bigger picture, to sort of show you what happened with this Ironman triathlete guy I was telling you about. What he had was very interesting in that the part of the cuboid that was bumping up against this joint, well, it had developed some cystic changes, or basically a little hollow spot in the bone, underneath the cartilage. He had a little bitty rip in the cartilage and he had this soft spot here.
Whenever he was walking, since the bone is supposed to be solid and it was solid everywhere except there, when he was walking, he would have pain. So keep in mind this was a guy that was an Ironman triathlete and he was doing Ironman races. I was doing Ironman races at the time, so he wanted me to see him. I looked at him and I actually asked him, “What’s your goal?” He said, “I want to be able to walk to the bus stop without stopping to rest because of the pain.” He literally couldn’t even walk to the bus stop that was less than a block away without stopping.
Now, I had to do surgery on him. He did not get better with any of the other things and I was lucky. This is not skill. It was luck that he got better with this. But what I had to do is, I went in, I opened the joint, actually went through the cartilage, filled this all in with bone graft material, and then sewed it up, and he healed, and it was fine. And years later, he wrote a really nice review and posted on Facebook and stuff, where he said he was doing Ironman triathlons again and he couldn’t walk to the bus stop. But that’s a different problem.
If you have that, by the way, a calcaneocuboid joint irritation like this, because of a cystic change under there, is not great. I saw another person who was an athlete that had this problem, and same thing. It’s like if we injected, the joint would calm down, but that is risky for several reasons. But in the end, she had to have surgery to fix it. That’s way worse than a cuboid stress fracture.
A cuboid stress fracture, it is very vascular, that bone, so it heals pretty quickly. So if you can just leave it alone for a period of time, those will usually heal pretty quickly. But that’s the worst kind of form of arthritis that we think about where something’s really irreversibly damaged, like you’ve worn all the cartilage away, but you can also get irritation of the lining of the joint.
If you have the joint capsule that holds the fluid in the joint and the lining of that joint capsule gets inflamed and irritated, then sometimes we can just inject it and with corticosteroids and it shrinks down that inflammation in the lining of the joint and it all goes away and it’s no problem. So a synovial or joint lining issue can be part of the problem and we call it arthritis.
You can have bone weakness under the joint surface. We call it arthritis. You can have a rip or tear or damage to the cartilage and we call it arthritis. Or you can even have some bone spurring on the side that indicates that it’s really worn out the cartilage and it’s trying to stop that motion. That’s also arthritis. But they all hurt in the same place. So if you’re a runner and you have this problem, you’re trying to figure out, well, which could it be?
In short, you’re talking about is it injury in the bone or is there an injury in the joint next to the bone? Again, they’re right next to each other, so it’s kind of hard to tell. And if you think about this, if one way you try to figure out if you have a stress fracture, well, you do something to squish the bone. So we actually manipulate your foot and push it to the side to push the heel bone up against the cuboid on one side and the metatarsals on the other side and we basically try to crush the cuboid. Well, if that hurts, we think, okay, maybe you have a stress fracture, but if you have damage like this, that’s going to hurt, too.
So just doing that diagnosis won’t always tell you, but your history or your story tells us a lot. So first thing is like I would ask you if you called me for webcam consultation, you thought you had one of these two problems, I’d say, okay, well here are the two things that you can really use as indicators of whether or not this is one problem versus another.
The first is how much swelling you have. If you have a lot of swelling, I’m more likely to think that you actually have a stress fracture than if you have an issue within the joint. The joint doesn’t really swell that much, but the stress fracture swells quite a bit. If you’ve had bruising, way more likely to be a stress fracture because the bone cracked and bled under the skin, whereas the joint issue does not do that.
The other thing is what we call this diurnal pain pattern. So this is a thing that’s kind of diagnostic for the calcaneocuboid joint arthritis. And if you talk to somebody who’s old, who has arthritis, they will say that they wake up and they’re very, very stiff and painful in the morning and after they get going and after they’ve had their coffee or their breakfast or read the paper or something, they feel significantly better.
A diurnal pain pattern means that you have pain in the morning. When you get up, it’s stiff, it feels weird, it feels achy, but once you start moving, you brush your teeth, you move around, you get ready for work, well, it feels better. And so you have a period throughout the day where it’s good, but then as you do more activity throughout the day, like when you go run or you go workout or something like that, well, you get that increasing pain with the activity later in the day. So it’s pain early and it’s pain later on in the day with activity. That is more indicative of arthritis than a stress fracture. The stress fracture’s directly correlated to the activity. It may feel better when you wake up, but as soon as you start moving, it hurts more and more and more. The more you’re on it, the more you’re on your feet and certainly the more you run.
Physical exam, again, talking about this doesn’t really tell them apart very well. So even if I grab your foot and manipulate it, well, if you have a cartilage or joint issue, when you compress the cartilage and you compress the joint, it hurts the same way as if you compress a stress fracture in the cuboid bone. So a physical exam is not always that helpful to tell the difference between the two. Now your x-rays can show some changes. So if we look at it and you have these little areas of bone spurring, well, we know that’s a secondary symptom of arthritis. It means that there’s some problem in the joint. Your body’s trying to form bone around it to stop the painful motion in the joint. That doesn’t happen with stress fractures, but it does happen after a long, long period of time of having arthritis in the joint.
A CT scan will show a lot more detail on the extra bone formation, but it’ll also show you fractures way better than X-rays. An MRI will show you inflammation within that cuboid. So if you do an MRI, for example, and we look at the T2 images, the bones are normally dark, if they’re normal on a T2 image and they’re bright white on the cuboid when there’s a cuboid stress fracture. If you look at the other things that we call T1 images, where the bones are white, like this, then the cuboid has a whole bunch of dark discoloration on it on the T1 images. And on the T1 images, it shows anatomic detail better. There might be an actual crack that you can see there, where you might not actually see that same crack on the other set of images.
But the other ones show inflammation better. So the more subtle ones, the MRI gives you two sets of images. One of them picks up really subtle things based on inflammation. The other one picks up like actual cracks and anatomic detail like tears and tendons and things like that. But basically, if you had a cyst in there, well, that you can see. So the triathlete I was telling you about, that was how I finally made his diagnosis, was actually getting an MRI to really evaluate and see, is this point a problem with just the joint or is there a problem with the bone under the joint? He didn’t have a stress fracture, but he did have a cyst in the bone and it was causing the same kind of discomfort and his was continual. So his got worse and worse and worse because the problem got worse.
But we fixed it eventually and that was better. But you have to know what’s wrong. So if you have arthritis, you’ve got to treat that and you treat it differently. I mean, the calcaneocuboid joint arthritis is treated differently than the cuboid stress fracture. So what do you do? Well, think about your story. Think about what it is that caused this. How did it start? What does it feel like during the day? Do you have pain that’s continual? Do you have pain that just hurts when you run? Do you have pain when you first wake up and step out of bed in the morning and then it goes away and kind of comes back later in the day? All of those things point to one thing or another. And then if you get X-rays, it can evaluate that. So if you go see your doctor, they could do X-rays likely in their office.
If you called me and did a webcam visit, if you’re in California or Texas, I would probably order some X-rays, have you got those x-rays. I would look at them online with you, over a webcam visit looking, doing a screen share thing, and we would evaluate them together and figure out whether or not it seems likely you’ve got one of these two problems. And then talk about some things you could do right away to try to get it under control. You don’t want a cuboid stress fracture to go unchecked.
So again, make sure that you get help from somebody who can give you a second opinion, somebody who can walk you through this process, somebody who can help you figure it out if you can’t figure it out on your own. If you like this episode, please like it. Please share it. Please subscribe and I’ll see you in the next training.