Working Diagnosis:
Closed displaced comminuted fracture of the right cuboid with associated chronic ossific fragments and pseudoarthrosis.

Treatment:
The patient was initially immobilized in a walking boot.

She subsequently underwent uncomplicated surgical excision of multiple osseous fragments adjacent to the cuboid.

Outcome:
Postoperatively, the patient was permitted partial weight-bearing in a postoperative shoe.

At her first postoperative follow-up visit, weight-bearing was advanced as tolerated while continuing use of the postoperative shoe. She later transitioned to a regular supportive shoe as symptoms improved.

The patient was cleared for a gradual return to physical activity, including running and tennis, with emphasis on supportive footwear during athletic participation. She was instructed to follow up as needed.

Author's Comments:
Cuboid fractures are uncommon, accounting for approximately 1% of all foot fractures.3 This low incidence is thought to be related to the cuboid's protected position within the midfoot and the substantial osseous and ligamentous support surrounding the bone.4

This case is unique because imaging demonstrated evidence of both chronic and acute injury. The chronic changes and pseudoarthrosis likely developed during half-marathon training and prolonged repetitive loading, while the acute inversion injury sustained during tennis may have contributed additional structural injury. Although the patient had a history of recreational running, she lacked many traditional risk factors for stress injury, including osteoporosis, Relative Energy Deficiency in Sport, diabetes, or prior foot injury.1

Additionally, cuboid fractures are more commonly associated with higher-energy mechanisms, whereas this patient sustained an acute injury during a relatively low-energy inversion event. This case highlights the importance of considering underlying chronic stress injury when evaluating athletes who present with acute worsening of lateral foot pain following a seemingly minor injury.1,4

Editor's Comments:
This case highlights the importance of considering cuboid pathology in athletes presenting with persistent lateral foot pain, particularly when symptoms predate an acute injury. Although cuboid fractures are uncommon, chronic stress injury may coexist with or predispose patients to acute fracture following a relatively minor traumatic event.1,3

A key teaching point is the value of advanced imaging when radiographs reveal atypical findings or when the clinical presentation suggests more complex pathology. Computed tomography in this case helped differentiate acute injury from chronic osseous changes and guided definitive management. Clinicians should maintain a broad differential diagnosis for lateral foot pain and recognize that seemingly isolated acute injuries may represent the culmination of an underlying chronic stress process.1,4

References:
1. Hoenig et al. Bone stress injuries. Nat Rev Dis Primers. 8, 26 (2022). doi: 10.1038/s41572-022-00352-y

2. Pierre-Jerome et al. MRI of the cuboid bone: Analysis of changes in diabetic versus non-diabetic patients and their clinical significance. Eur J Radiol. 81, 10 (2012). doi: 10.1016/j.ejrad.2011.10.001

3. Court-Brown, Zinna, Ekrol. Classification and epidemiology of mid-foot fractures. The Foot. 16, p 138-141 (2006). doi: 10.1016/j.foot.2006.03.003

4. Borrelli, De , VanPelt . Fracture of the cuboid. J Am Acad Orthop Surg. 20, 7, p472-7. (2012) doi: 10.5435/JAAOS-20-07-472

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