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Keywords

Clinical Practice in Athletic Training

Abstract

Background: The accessory navicular is an extra bone located posterior and medial to the navicular tuberosity. The prevalence of accessory navicular has been reported to be 4 - 21% in the general population though this anatomical variant may often be overlooked during differential diagnosis. This case presents a female collegiate field hockey patient that was initially diagnosed with a midfoot sprain but was later determined to have an accessory navicular bone which required surgical removal. Patient: A 19-year-old female Division I collegiate field hockey patient presented to the athletic training clinic with pain in her left medial foot. The patient could not recall a specific MOI and reported noticing the pain after an in-season game. Patient had no previous injury history to her left foot or ankle. Physical examination revealed mild edema over the left navicular bone with point tenderness on the navicular, medial cuneiform, and the anterior aspect of the deltoid ligament complex. Pain was reported with eversion during active and passive ROM. MMT of the peroneus longus and brevis, and anterior tibialis revealed 5/5 strength; posterior tibialis and peroneal tertius measured 4/5 strength. Further evaluation revealed navicular pain during metatarsal glides (1st and 2nd), Kleiger’s, and Eversion Talar Tilt Tests. Results for the calcaneal bump and lower leg compression squeeze tests were negative. Intervention & Treatment: The patient was treated for a midfoot sprain and permitted to participate in sport-related activities as tolerated. Initial therapy focused on pain and edema control and strengthening the muscles of the foot and ankle. Prior to sport activity, a donut pad was placed over the navicular and a modified teardrop low dye arch tape was applied. At 3 weeks post-injury, the patient reported increased pain that was now present after sport-related activities and during the toe-off phase of walking. Additionally, the patient reported pain in her left Achilles tendon and stated she purposely altered her running gait to decrease impact on her medial foot. Over the next 2 weeks, rehabilitation was modified to include soft tissue therapy consisting of dry needling over the Achilles tendon and midfoot area and instrument assisted soft tissue mobilization to the posterior lower leg. Additionally, a joint decision was made by the team physician, athletic trainer, coach, and patient to allow the patient to continue play throughout the remainder of the season as tolerated. Management would include continued rehabilitation and taping prior to activity, and administration of a walking boot which was to be worn at the start each week as needed. Activity modification included having the patient routinely complete non-impact conditioning in place of practice to maximize her health for end-of-week game play. Diagnostic imaging taken at 8 weeks post-injury revealed an os supranaviculare, which would require surgical excision. Following the season, the patient underwent a modified Kidner Procedure to remove the accessory navicular. Outcomes or other Comparison: Due to increasing pain and unresponsiveness to conservative treatment, the patient was discovered to have an accessory navicular bone. However, the injury management plan was successful in permitting the patient to play the entire competitive season as tolerated. Conclusion: In this case, the patient originally presented with findings consistent with a medial midfoot sprain though the presence of an accessory navicular bone would ultimately be discovered. Following the season, the patient underwent a modified Kidner Procedure to remove the accessory navicular bone. Clinical Bottom Line: Symptomatic accessory naviculars have been reported to occur more frequently in young, active women though diagnosis is often missed or delayed. In cases where a patient presents with medial midfoot pain with no specific MOI, and is unresponsive to therapeutic treatment, the athletic trainer should consider the potential involvement of an accessory navicular.

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