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Accessory navicular

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Asher, Feb 14, 2012.

  1. Asher

    Asher Well-Known Member


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    Hi all,

    I have not seen much in the way of accessory naviculars on xray, diagnosed and treated a few, but not requiring radiographs.

    A GP has referred a 13 year old girl with very painful medial navicular of one week duration, though has had some pain the area on both feet for at least 12 months. She is on crutches and brought in these xrays. I have since accessed the report that notes the accessory navicular and states findings are normal.

    But proximal to the medial navicular tuberosity doesn't look like what I expected, it looks like there is a large breach, as in fracture. Is this normal?

    Any advice would be appreciated!

    Rebecca
     

    Attached Files:

  2. Rob Kidd

    Rob Kidd Well-Known Member

    Whatever else may be said about accessory naviculae, it is important to recognise that, unlike some other accessory bones, there is no possibility of a pylogenetic explanation. That is, the extra bone does not figure in the replitilian homologue, neither the primitive nor the somewhat derived version. By way of example, the os-trigonum (ie the non-fused posterior tubercle of the talus) is representative of the primitve reptilian intermedium bone; in a like manner the cuboid represents a fusion of the two most lateral (caudal in embryological speak) tarsalia bones - numbers 4&5. Thus one must look for another explanation, possible, or even probably involving an ossification in a repair process. For those interested in the reptilian tarsus - which should be all of you, I feel that the best resource is Freddy Wood Jones' book of 1944. Rob
     
  3. drsarbes

    drsarbes Well-Known Member

    Hi Asher:
    As you know there are several types of Acc Naviculars.
    The xray you have is interesting. It would help if we had a couple of more views (a Lateral and a medial oblique projection)
    The line you see may be part of the plantar ridge of the Nav tuberosity, but I agree it does warrant further visualization. Normally three view are taken, which would make it easier to evaluate.

    Also, when I feel the ossicle may be fractured (separated) it helps to take contralateral views for comparison.

    In this age bracket, with acute onset and pain that warrants crutches, she most likely has a separated Acc Navicular that is best treated by removal. This is a common and very successful (and quick healing) procedure. No reason to have your patients limping around for weeks or months waiting for this thing to, perhaps, heal.

    Steve
     
  4. Admin2

    Admin2 Administrator Staff Member

  5. Asher

    Asher Well-Known Member

    Thanks Steve for your help, I will load the other views tonight.

    Rebecca
     
  6. Asher

    Asher Well-Known Member

    Attached are all radiographs for further comment and advice please! I could only upload 5 so please refer to the original post for the DP foot view.

    I'll be doing some reading on accessory navicular tonight.

    Regards

    Rebecca
     

    Attached Files:

  7. drsarbes

    drsarbes Well-Known Member

    Hi
    Navicular is intact. The irregularity you see on the AP is the plantar/proximal ledge.
    For some reason you never see a Medial-Lateral oblique projection which, when done, visualizes the Nav Tuberosity and acc. bone very well.

    Steve
     
  8. Asher

    Asher Well-Known Member

    Thanks Steve!!
     
  9. Berms

    Berms Active Member

    Hi Asher,

    just wondering what the outcome of this case was? What was your treatment choice?

    Thanks
     
  10. Asher

    Asher Well-Known Member

    Hi Berms,

    Issued a pair of full length soft Interpods and got her out of her canvas shoes and into her joggers (the combination of these provide much better transverse plane support - and you would think push on the sore navicular more but obviously the beneficial effect on the tibialis posterior tendon outweighs this) and she is without her crutches now and walking without pain. Not sure if she's back into running yet but if not, well on the way.

    Thanks for your interest.

    Rebecca
     
  11. Berms

    Berms Active Member

    Thanks Rebecca, sounds good. :drinks
     
  12. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Medial foot pain in a runner: a case presentation.
    Miller LK, Harrast MA.
    PM R. 2013 Sep;5(9):801-4.
     
  13. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Magnetic resonance imaging in adolescent symptomatic
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    Mitsuhiko Takahashi, Toshinori Sakai, Koichi Sairyo, Shoichiro Takao,
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  14. Steve The Footman

    Steve The Footman Active Member

    I had a young active patient this week with a painful Navicular Tuberosity. The pain was most severe with a plantar compression. There was no pain on the Navicular body ruling out Kohler's or a Stress Fx. The Post tib tendon and muscle was not sore to palpate. The Navicular Tuberosity was more prominent on the symptomatic side. Pain was only of 2 weeks duration not linked to an event but coincided with new shoes. She had previous orthotics from another podiatrist but never wore them because they were not comfortable to run with. I think in this situation it was more like an adventitious bursitis however without imaging it is not possible to know if there is any edema within the ossicle or separation of the ossicle from the navicular. My treatment was to create a cavity pad within the shoe to offload the tuberosity and to prescribe anti-inflammatory treatment. This has worked well in the past for similar patients. I will find out if it worked at the two week review.
     
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