The patient is a 17 year old, well developed, well nourished female, 5’ 4” in height, 125 pounds in weight, who presents to the clinic accompanied by her mother with a chief complaint of pain and swelling in the medial arch area of the left foot. She states she has had a “bump” in the area for as long as she can remember, with a similar bump being present on the other foot as well. The “bumps' ' have been non-painful until recently, when approximately three weeks ago , the left foot became swollen, warm and very tender to touch. The patient states she has to limp, has tried using ice, applied a compression bandage and OTC Ibuprofen with only minimal relief. The patient and her mother are very concerned because the patient is an avid soccer player and has aspirations for an athletic college scholarship in women’s soccer. She does not recall a specific incident that may have exacerbated the condition, but she does remember the pain slowly increasing during a match, then subsiding following an initial period of rest but significantly worsening upon waking the following morning. She has not been able to participate in soccer since the initial incident, but is able to use a recumbent stationary bike as well as perform upper body strengthening exercises.
A lower extremity physical examination was performed. Circulatory findings were within normal limits with ¾ + pedal pulses, capillary filling time less than three seconds in all digits, skin tone and temperature was normal in both feet and legs, no varicosities were noted and Homan’s sign was absent. Deep tendon reflexes were equivocal, clonus was absent, Babinski’s sign was absent, sharp/dull discrimination was within normal limits, and Tinel’s sign was absent in both tarsal tunnels.Ankle dorsiflexion was 5 degrees with the knee extended, and 10 degree with the knee flexed bilateral, range of motion of bilateral subtalar, midtarsal, and all metatarsal phalangeal joints was adequate. Mild genu valgum deformity as well as tightening of the hamstrings was noted. Resting Calcaneal stance position of 5 degrees everted is noted, with moderate lowering of the medial arches. Gait was left side antalgic however it was noted that both feet were abducted during gait, with “too many toes” sign being present. The patient was able to perform a single limb calf raise and single limb squat on both sides, however painful on the left side.
Exquisite tenderness was elicited in the area of the chief complaint, as well as mild edema and localized warmth to the area. She was able to plantarflexed/invert the affected foot, as well as resist dorsiflexion/eversion. Tenderness was also elicited in the left sinus tarsi. Bony enlargement of the medial Navicular was noted bilateral. Weight bearing x rays of both feet was performed. Growth plates were not visible, there is a lower Calcaneal inclination, a broken Cyma line, an increase in the Talo-Navcular angle, and elevation of the 1st ray on the lateral view. Enlargement of the Navicular tuberosity is noted, consistent in appearance with Type II Accessory Navicular, subchondral sclerosis of the head of the talus. No sign of acute fracture, tumor/cyst formation, or infection is noted.
The preliminary diagnosis of Accessory Navicular Syndrome was made. The etiology of the condition was explained to the patient and her mother, as well as the transient nature with the possibility of the repeated periods of exacerbation and remission being likely. Due to anxiety related to the potential scholarship, the patient requested an MRI be performed. Results of the MRI confirmed the diagnosis, with no further bony, or soft tissue pathology apparent.
The patient was fitted for a removable cam walker, partial weight bearing to tolerance. A prescription for physical therapy including strengthening exercises for the feet and lower leg muscles was dispensed. During a follow up appointment in two weeks the patient reported 80% improvement of her symptoms. It was recommended to proceed with a scanning for custom made foot orthotics. The next forum post will be a description of the orthotic build for this patient, taking into account the patient’s age, the presence of an enlarged Navicular as well as considerations of the sport of soccer.
