Navicular pain

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Any takers..?

11 year old girl - average height and build.

Jumped off bed and landed suscessfully (not awkwardly) approx 4 months ago.

Pain since at medial aspect of left navicular. No inflam or discolouration. Area acutely painful to touch. No pain on weightberaing, walking or running. Footwear does not aggravate. 3 x-rays - all normal.

Both feet:

markedly overpronated but not planus (L>R)
Beginnings of juvenile HAV
Prominent navicular (L>R)

Could this be Kohler's? (despite the age - although i would have thought this would have been picked up on x-ray?), CRPS?, missed #? accessory navicular?

 

Unlikely. Was there an accessory navicular on x-ray?

 

My thoughts also. On each of the 3 x-rays the radiographers report was 'normal'.

 

I see patients similar to this about 2-3 times a month in my practice.

A lateral oblique x-ray must be performed to rule out navicular tuberosity/accessory navicular pathology. All the other views may not show any pathology.

Put the young lady into an orthosis or modified prefab orthosis with increased medial arch height and medial heel skive, and the pain will go away in about 95% of cases (unless she doesn't wear the orthoses).

 

Many thanks for your input Kevin.

Given that you've seen conditions such as this before what would your initial thoughts be on diagnosis and further treatment should orthotics be unsuccessful? As an outside chance could it be possibly be Complex Regional Pain Syndrome?

Regards,

Mark

 

CRPS would generally cause much more pain and disability than this child is experiencing. Pain only on palpation in this case is not uncommon in navicular tuberosity pathology in children with pronated feet. Get the lateral oblique x-ray, and put her into a supportive orthosis, have her ice the area 20 minutes twice daily and see her back in 2-3 weeks. My bet is, if she follows your instructions, she will be at least 75% better in 2-3 weeks.

 

Thanks again.

Mark

 

Page

If I have read the details of this case correctly there is no pain with WB but pain with palpation only so I assume that wearing footwear is an issue due to the pressure of the shoe. So would any orthotic potentialy increase pressure at the area and thus cause more pain?

I would also be using an aperture padding set up to ensure no pressure at the area with the orthotics and contemplate topical NSAIDS enclosed in a waterproof dressing to be placed on the sore spot every night for 4-7 days as well as the icing as described by Kevin.

regards

 

Is pain only present on direct palpation of the navicular?

When I was a student a fellow student strained both spring ligaments when she landed following a jump while she was dancing. She got great relief from the pain by using adhesive bandage around the midfoot to 'rest' the area.

Was there any inflammation immediately after she jumped off the bed?

Gordon

 

Don't rely on the report telling you everything. Get the films and look yourself. I have found that accessory ossicles in general are not reported as they are a normal variation. Hope this helps.

Cheers

Nigel