Avascular necrosis of the cuboid in a ballerina

Shah, Selina MD, BS, Kaiser Permanente, West Hollywood, CA, United States

A 28 year old female dancer presented with a 7 month history of worsening right lateral foot pain. She described the pain as an intense snapping sensation that would occur spontaneously without a specific trigger. Intermittent periods of rest did not relieve the pain, so she was referred for consultation. 

Examination of the right foot and ankle revealed no swelling or ecchymoses. The lateral gutter of her ankle, cuboid, and medial cuneiform were tender to palpation. She was not tender to palpation medially. She had full dorsiflexion, plantarflexion, inversion and eversion. Fluoroscopic inversion stress testing revealed approximately 4mm of laxity compared to the left. 

Radiographs of the foot and ankle revealed an old avulsion fracture of the lateral malleolus. An MRI revealed abnormal signal in the right cuboid and right medial cuneiform consistent with avascular necrosis vs. stress fracture. A triple-phase bone scan correlated with the MRI findings. 

The patient was treated with an initial period of non-weightbearing with no improvement.  She underwent a right ankle lateral ligament reconstruction via modified Bromstrom procedure, drilling of the cuboid, and resection of the lateral malleolar fragment. She has progressed post-operatively and is gradually returning to dance, pain-free.

This is the first reported case of avascular necrosis of the cuboid based on a thorough literature search. This young dancer may have developed avascular necrosis of the cuboid secondary to altered mechanics of the ankle and foot from the instability and proprioceptive deficits due to an untreated grade III lateral ankle sprain that she suffered 4 years prior. 

Avascular necrosis of the cuboid should be included in the differential of a dancer presenting with lateral foot pain. The evaluation and management of this case can serve as a model for future patients presenting with lateral foot pain.