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9y.o girl pain at Navicular

Discussion in 'General Issues and Discussion Forum' started by spodd, Aug 23, 2010.

  1. spodd

    spodd Member

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    Hi all,
    Recently have seen a 9y.o girl who is suffering pain around her right navicular particularly in the last month, gradual onset. The area is not tender on palpation, PF/DF/Inv/Ev all pain free as is single leg raise. The pain is only felt after sporting activity and no pain is evident in the mornings or when at rest. Nil swelling. She is an active girl and wears sneakers most of the time.
    A brief gait analysis revealed significant navicular drop on weight bearing and a very flattened MLA on the R >L with excessive rearfoot pronation throughout midstance. RCSP in 5-8 deg everted.
    Am I correct in thinking this is a biomechanical issue and could be related to Tib Post??
    I have discounted stress fracture due to no palpation pain/not sore all of the time
    I have discounted Kohler's for the same reason
    I have advised her to ice the area daily and purchase new supportive sneakers as well as rebooking for full BME with the view to orthotic therapy.

    Any thoughts on the Rx Plan would be very much appreciated
  2. Jeff Root

    Jeff Root Well-Known Member

    At her age, I would consider looking for ligamentous laxity (generalized or limited to foot), a congenital long 1st met resulting in functional hallux limitus, or excessive transverse motion at the mtj due to an atypical mtj axis. If quality, range and direction of motion of the stj looks good, look for hypermobility at the mtj (i.e. a mtj that exhibits much more freedom of motion in open chain exam, especially in the direction of forefoot abduction relative to the rearfoot). These finding could influence your orthotic prescription, should you choose to go that route.

    It is very import to conduct an open chain examination of the motion of the stj, especially to rule out a peroneal spasm. It sounds like you have done that, correct? Also be sure to check range of ankle dorsiflexion, especially compared to opposite side and look for possible limb length discrepancy. Family history (parent's foot type and hx) is also worth looking into. If mom or dad have hallux limitus or rigidus, HAV, or hyper pronated feet, it makes the decision to treat somewhat easier.

    Based on initial information, consider a medial heel skive, decreased medial arch fill (i.e. a higher arched device), a wide arch profile (aka medial flange), reverse morton's extension, high medial heel cup, medial post flare.

    Jeff Root
  3. 1st :welcome: to Podiatry Arena and yes I would agree a Biomex issue

    I agree with Jeff´s orthotic design.

    Spodd if we look at the hx,
    - pain after increased stress
    - Insertion of Tib Post
    - pronated foot type
    -ruled out other system issues = mechancial stress.

    So now we look at the Tib post muscle and it relation to the STJ axis. As the foot pronates the lever arm of the axis to the tib post will reduce, the wotk required by the Tib post must increase to have the same effect. Also the Tib Ant muscle may go from a muscle which creates supination moments at the STJ to one which creates Pronation moments . ie it add to the load on the Tib post.

    So other information to look for would be where the Pronation moments are comming from. ie muscle - eg Peroneus longus or brevis or from Ground reaction Force ( GRF). This may help in prescription of a device.

    So when you have the answers - What you need to do is work out the prescription device and where the Orthotic reaction force (ORF) will need to be placed and why.

    So if the STJ pronation moments are too much, one of the main jobs of the device will be to create a STJ supination moment ( external moment) - The medial Skive, what you need to decide is how much.

    Also what you need to do is look at other ways to reduce the pronation moments and aid the muscles to reduce the load. Reduce navicular drop through increased arch height of the device and as Jeff suggested increased medial flange - longer lever arm of the ORF.

    You have not mention the amount of 1st MTP dorsiflexion stiffness, if this is too high the force required to dorsiflexion the 1st MTP will mean that the windlass mechancism will be less effective- a reverse mortons extension will help with this.

    So same device as Jeff suggested.
  4. Sally Smillie

    Sally Smillie Active Member

    Since you've not mentioned it, I would palpate along the length of tib post tendon, (also on contraction of tib post), and insertion, percuss the nerve at the retinaculum and test the endurance of tib post activity: (SLS heel raises; a child should be able to acheive a good 25+ reps with plenty of heel inversion. Count the reps until heel no longer inverts (at the end range)). You may find she is so weak at tib post that SLS heel raises are impossible, in which case I'd be strengthening this up via double limb lifts until strong enough to progress to SLS (make sure full knee extension is maintained and movement is slow and controlled up and down as we need eccentric and concentric training). At the point where they can do 30 odd reps if symptoms persist, I'd go orthotics all the way. You do get tib post dysfunction in paeds.

    The more common condition you might consider is if she has a Kidner Type 2 navicular (as it is known in orthopaedic circles), or a problem os naviculare. I see quite a lot of this and they respond amazingly well (and fast) to OTS orthoses (I use Vasyli 3/4 red 6 degree with or without addional posting). Do an XR (and read it yourself, don't count on the report). But assuming tenderness on palpation is exclusively over naviular process I'd say this is what it is.
  5. Spodd:

    As the others have mentioned, treatment of his child with over-the-counter or custom foot orthoses is the treatment of choice. The main insertion point for the posterior tibial (PT) tendon is on the navicular tuberosity and, as such, navicular tuberosity pain is very common in active children with pes planus deformity.

    With a pes planus deformity, there will be varying levels of medial deviation of the subtalar joint (STJ) axis. As the STJ becomes more medially deviated, the supination moment arm of the PT tendon relative to the STJ axis becomes smaller. This means that in order for an individual with a smaller PT tendon moment arm to develop equal magnitudes of STJ supination moment as a foot with a normal length PT tendon moment arm, there must be greater tensile force within the PT tendon to generate these moments in the individual with a smaller PT tendon moment arem and a medially deviated STJ axis.

    Other things that help with this pain is have the child to avoid barefoot walking/running, wear a shoe with a higher heel height differential and/or heel lift in order to decrease the tensile force on the PT tendon. I also have the child ice the navicular 20 minutes twice daily.

    Custom orthosis modifications in this young lady may include, as an example:

    -relatively stiff polypropylene shell (4 mm)
    -inverted balancing position of 2-4 degrees
    -3-4 mm medial heel skive
    -16-18 mm heel cups
    -minimal medial arch fill on positive cast

    The goal of the orthosis is to increase the external STJ supination moments, increase the external rearfoot dorsiflexion moments and external forefoot plantarflexion moments so that there will be reduced tensile stress within the PT tendon. With the above treatment plan in place, in my hands over the past 25 years, the cure rate is over 90%.

    Hope this helps.
  6. elizabethbowler1979

    elizabethbowler1979 Welcome New Poster

    I've seen quite a few young kids with symtomatic os navicular and they often report symptoms very similar to this case. They have all tended to respond well to antipronatory devices. However i would get an xray to confirm a- presence of a acessory and b- to rule out other boney issues.

    this is my first post so be nice people
  7. Sally Smillie

    Sally Smillie Active Member

    Welcome Lizbo! :welcome:

    I agree completely. See my earlier post. It's not just os naviculare, look up Kidner syndrome / type 2 Kidner navicular in orthopaedic texts. Responds brilliantly to orthoses.

    Keep posting

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