Navicular deformity

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Patient is a 25y.o. male with a 15 mm LLD (CT). The navicular deformity is asymmetrical and present on the short leg side. Symptoms 6/12 are isolated to the short leg with ankle and Talonavicular joint pain. MRI shows no other rearfoot deformity. I have attached x-ray.

I plan to stabilise the talonavicular joint via orthoses and footwear and encourage a strengthening program when asymptomatic.

I would like to read more about this type of deformity however I’m unsure of search terms.

Any suggestions would be helpful. Are the wise aware of any published research referring to this type of deformity?

Thank you for the guidance.

 

Re: Flat talonavicular & navicular cuneiform ball & socket joint

Is there increased navicular drop and drift in this foot ?

 

Re: Flat talonavicular & navicular cuneiform ball & socket joint

Relative to the longer leg: Yes

 

Any other x-ray views?

What are the Rearfoot RoM's and ankle RoM like?

 

Unremarkable ROM. The deformity would have been missed without and x-ray. The x-ray report, not surprisingly, stated WNL.

 

What did the MR scan show? Any sign of avascular necrosis of the navicular? Any degenerative joint disease? Any history of trauma?

Have you isolated the exact point of pain, and if so how? Whilst the head of the talus does not appear entirely normal (pretty flat), the area highlighted on your x-ray is the navicularcuneiform joint(s). This appears potentially congenital/ developmental, with smooth lines and well preserved joint space (wider dorsally on this non-weightbearing view).

 

of intrest is the flattened talar head and ball-and-socket like navicular cuneiform joint.

 

Thank you for your interest;

MRI saw bone bruising at posterior medial tibia and dorsal navicular which i believe to be a chronic response. No history of navicular trauma otherwise. The presenting symptoms are gradually settling with conservative stabilisation measures.

Is this rare, or have I just not seen allot of them? I have seen it once before, the patient had a history of avascular necrosis.

Can you point me in the direction of any text concerning this type of deformity?

Thank you,

 

Maybe Mueller-Weiss syndrome???

Mueller-Weiss syndrome: an uncommon cause of midfoot pain, J Foot Ankle Surg. 1998 Nov-Dec;37(6):535-9

Cheers,
Ian

 

Hello,
I was under the impression that Mueller-Weiss was more of an adult-onset avascular necrosis of the navicular though? This would show up on the MR scan (increased signal on T2 fat suppressed, reduced signal on T1 images). I would have thought the MR scan would be pretty sensitive for this, especially given x-ray findings?

If smilingtoes can have another look at the MR scan and report back it might help? I'm guessing this wasn't the case as it wasn't mentioned in any of the previous posts?

 

thanks i'll ask the patient for the MRIs and post a few photos. In the mean time i'll have a look at Mueller-Weiss Syndrome.

much appreciated

 

With the MRI scan showing only mild changes, I would suggest you make him a good orthosis which is slightly inverted, has a medial heel skive, has a well-formed medial longitudinal arch and also a reverse Morton's extension/valgus forefoot extension to reduce the dorsal compression forces at the naviculo-cuneiform joint and talo-navicular joint. I don't think I have ever seen a radiograph quite like this one so it seems rare to me.

CT scan is the diagnositic imaging method of choice for such osseous anomalies. It would be nice to make sure all the joint spaces around the navicular have good articular thickness. If the orthosis does not make him asymptomatic or much less symptomatic, then a camwalker brace for 4-6 weeks should calm his foot down enough to allow the orthosis to give him more pain relief. What types of sports activities is this young man involved in?

And Smilingtoes....do you have a name? This greatly helps motivating us to help you further.

 

A couple of comments:

Don't treat x-rays. If the pain is proximal to that point then you might be able to ignore the unusual x-ray findings.

There is usually a lot of overlap of the proximal ends of the cuneiform bones so that you don't usually see such a wide joint space at the cuneiform navicular joint. (Look at the 1st met-cun and 2nd Met cun joints in the x-ray. The joint can be seen but the other bones around it make it hard to visualize the joint spaces of the met cuneiform joints. Perhaps, the person has an unusually flat anterior aspect of the navicular that was caught by a perfectly angulated x-ray beam. Correlation with the a-p view may help.

Regards,

Eric

 

Sam asked earlier if there were any other views; if there are, would you mind posting them for our review? Thank you.

Rob

 

Rob:

:welcome:

Good to have you contributing here on Podiatry Arena. Looking forward to your expert comments on such cases.:drinks

 

Thank you all for your helpful comments.

I will certainly ask the patient to lend me his films the next time he attends to provide a more complete representation of his foot structure.

I plan to address his symptoms by making a functional orthotic which will more closely hug the symptomatic talonavicular joint combining a ‘Kirby Skive’, encouraging improved mechanical advantage of Tibialis Posterior and allow a greater range of freedom at the navicular cuneiform joint. Close attention will be afforded to reducing cuboid eversion encouraging greater stability for the peroneal muscles.

Even though I have practiced for over 16 years I was unaware of the unique nature of this presentation. While I have come across miss shaped navicular’s before they have all presented with a history of pathology.

heres my details, although I still like to see the toes smile.

Angus Chard FAAPSM
Research Masters Candidate
Discipline of Exercise and Sports Science
Faculty of Health Sciences, The University of Sydney
PO Box 170, Lidcombe, NSW 1825, Australia
E: bcha8278@uni.sydney.edu.au

private practice:
564 Old Northern Rd
Dural 2158 NSW Australia
P: +61 2 9651 3227
F: +61 2 9651 3210