Nutcracker Injury: Diagnosis and Management

When we talk about complex foot injuries, the “nutcracker” fracture of the cuboid bone is one that deserves more attention. Though rare, this injury can significantly affect function and mobility if not diagnosed and managed properly. For clinicians, coaches, and athletes, understanding the mechanism, diagnosis, and rehab principles surrounding a cuboid nutcracker fracture is crucial for effective return-to-play and long-term foot health.

What Is a Nutcracker Fracture?

A “nutcracker” fracture refers to a specific injury mechanism involving the cuboid bone in the lateral midfoot. This fracture typically results from compression between the calcaneus and the base of the fourth and fifth metatarsals, literally “cracking” the cuboid like a nut in a nutcracker. It often co-occurs with other injuries such as lateral or medial ankle sprains, navicular avulsion fractures, and even ligamentous disruptions, making isolated cases relatively rare (Shayegi et al., 2025).

The cuboid bone, though small, plays a key role in lateral column support and in maintaining the integrity of the transverse tarsal joint. When fractured, it can disrupt the normal biomechanics of the foot, leading to prolonged dysfunction if missed or mismanaged.

Mechanism of Injury

Two main mechanisms have been identified for this injury:

1. Inversion Ankle Sprain: Commonly seen in court and field athletes, an inversion injury (where the foot rolls inward) can result in significant traction forces on the lateral foot. These forces may cause avulsion injuries at the calcaneocuboid joint, as well as impaction injuries medially. In high-energy cases, such as in sports or accidents, this mechanism may lead to cuboid fracture with or without associated ligament injuries (Angoules et al., 2019).
2. Plantar Flexion with Axial Load: The second mechanism occurs when the forefoot is forcibly plantarflexed while under axial load, such as landing on a plantar-flexed foot or during horseback riding (Ceroni et al., 2007). This is more common in paediatric populations but can occur in adults under similar loading conditions.

Who’s at Risk?

While rare, nutcracker fractures are more likely to appear in individuals with high foot mobility, poor proprioception, or repeated exposure to high-impact forces, such as athletes, dancers, or those involved in equestrian sports. In paediatric cases, this injury is frequently underdiagnosed because of vague symptoms and subtler radiographic signs (Hsu et al., 2004; Simonian et al., 1995).

Diagnosis

Diagnosis begins with a thorough clinical examination focusing on pain location, swelling, and tenderness over the lateral midfoot. Patients may present with vague lateral foot pain, a limp, or an inability to bear weight.

Imaging is essential for accurate diagnosis:

• X-rays: Standard anteroposterior and oblique foot views may reveal fracture lines but are often inconclusive.
• CT Scan: Provides detailed visualisation of the cuboid and helps assess fracture complexity.
• MRI: Useful in detecting associated soft tissue injuries or in cases with persistent pain despite normal X-rays.

Delayed or missed diagnosis can result in a condition known as an “old nutcracker fracture,” which often requires more invasive intervention due to chronic changes like joint incongruity or lateral column shortening (Yu et al., 2013).

Management

Treatment depends on the severity and displacement of the fracture:

Conservative Management:

• Indicated for non-displaced or minimally displaced fractures.
• Includes: Rest, ice, compression, elevation (RICE), immobilisation in a CAM boot or cast for 4–6 weeks, followed by gradual weight-bearing.
• Rehab focus: Regaining foot mobility, strength in the intrinsic foot muscles, and restoring normal gait mechanics.

Surgical Management:

• Indicated when the lateral column is shortened >3mm, when there is significant displacement or joint surface disruption.
• Surgical options include open reduction internal fixation (ORIF) or bone grafting if needed.

Ceroni et al. (2007) and Hsu et al. (2004) reported positive outcomes with ORIF in paediatric patients when conservative care failed or when structural compromise was evident.

Rehabilitation Principles

Whether managed surgically or non-surgically, rehab is central to recovery. A good program includes:

1. Phase 1: Immobilisation and Protection (0–6 weeks)
   • Offload with a moon boot or crutches
   • Maintain strength in surrounding joints (hip/knee)
   • Gentle isometrics for foot/toe muscles if tolerated
2. Phase 2: Mobilisation and Strength (6–10 weeks)
   • Gradual weight-bearing progression
   • Manual therapy for midfoot mobility
   • Begin with intrinsic and extrinsic foot strengthening
3. Phase 3: Functional Re-training (10–16 weeks)
   • Gait retraining
   • Balance and proprioceptive work
   • Return-to-running progressions (if applicable)
4. Phase 4: Sport-Specific Re-integration (16+ weeks)
   • Jumping, cutting, and landing drills
   • Gradual exposure to training loads
   • Objective testing (e.g., force plate analysis) before full return to play

Clinical Takeaway

Cuboid nutcracker fractures, though rare, are important to recognise early, especially in athletes presenting with vague lateral foot pain post-inversion injury. The diagnostic process relies heavily on imaging, particularly when symptoms don’t match initial radiographic findings. Management should be tailored to injury severity, and rehabilitation must respect the injury’s impact on lateral column biomechanics.

At POGO Physio, we use a combination of high-level clinical reasoning, objective testing (including force plate assessments), and tailored rehab strategies to ensure athletes return not just to sport but to peak performance.

If you or someone you know is struggling with persistent midfoot pain or a tricky ankle sprain that just doesn’t feel right, reach out to our team for a comprehensive assessment.

Abe Ofosu
Physiotherapist (APAM)

 

References

1. Shayegi B, Weerakkody Y, Skandhan A, et al. Nutcracker fracture of the cuboid. Radiopaedia.org. https://doi.org/10.53347/rID-22141
2. Ceroni D, De Rosa V, De Coulon G, Kaelin A. Cuboid nutcracker fracture due to horseback riding in children: case series and review of the literature. J Pediatr Orthop. 2007;27(5):557–561.
3. Hsu J-C, Chang J-H, Wang S-J, Wu S-S. The Nutcracker Fracture of the Cuboid in Children: A Case Report. Foot Ankle Int. 2004;25(6):423-425.
4. Simonian P, Vahey J, Rosenbaum D, Mosca V, Staheli L. Fracture of the cuboid in children. J Bone Joint Surg Br. 1995;77-B(1):104–106.
5. Yu G, Yu T, Yang Y, Yuan F. Old nutcracker fracture of cuboid. Indian J Orthop. 2013;47(3):310–312.
6. Angoules AG, Angoules NA, Georgoudis M, Kapetanakis S. Update on diagnosis and management of cuboid fractures. World J Orthop. 2019;10(2):71–80.