A Curious Case of Midfoot Pain

Case Report

J Fam Med. 2016; 3(9): 1086.

A Curious Case of Midfoot Pain

Silva TW¹, Duggal NS² and Gopalraj RK³*

¹Division of Podiatry, Department of Orthopedics, University of Louisville, USA

²University of Missouri-Kansas City School of Medicine, USA

³Department of Family and Geriatric Medicine, University of Louisville, USA

*Corresponding author: Rangaraj Gopalraj, Department of Family and Geriatric Medicine, University of Louisville, 1941 Bishop Lane, Suite 900, Louisville, Kentucky, 40218, USA

Received: September 16, 2016; Accepted: October 13, 2016; Published: October 17, 2016


The accessory navicular is a congenital malformation caused when a secondary ossification center does not fuse. Depending on size and arrangement of the accessory bone it can be classified into 3 varying types. This condition is normally asymptomatic or reveals itself at an early age. This case report of an elderly woman with a symptomatic and painful accessory navicular highlights the typical clinical presentation, diagnosis and treatment for this curious condition.

Keywords: Accessorynavicular; Osnaviculare syndrome


NSAIDs: Non-Steroidal Anti-Inflammatory Drugs; OTE: Os Tibiale Externum; PTT: Posterior Tibial Tendon

Case Presentation

A 68-year-old female presented with complaints of left ankle and arch pain that has lasted weeks to months. She denied any recent trauma or sprains to the ankle. She first noticed the pain during a weightlifting class. The pain radiated to the arch of the foot. It was associated with swelling along the lateral aspect of the ankle. Despite previously fracturing her right ankle many years ago she has been active, walking at least 10 miles per week. She has a remote history of smoking approximately 1-10 cigarettes per day and has many years earlier. On examination; varicosities were present on the medial and posterior aspects of the left leg. She had tenderness slightly distal and anterior to the left lateral malleolus. There was no focal tenderness over dorsum. X-ray foot revealed an accessory navicular bone. The patient was managed with non-steroidal anti-inflammatory drugs (NSAIDs) for pain, cold compression, ace wrapping, and then referred to podiatry.


The navicular bone is a boat shaped bone in the midfoot that articulates with the cuneiforms and the talus [1]. There is a congenital anatomic variant of the navicular known as the accessory navicular or the os tibiale externum (OTE). The OTE arises from the secondary center of ossification of the navicular at the medial tuberosity, where the posterior tibial tendon (PTT) inserts. It is the second most common accessory bone in the foot, occurring in 4%-21% of the population [2]. Typically the secondary ossification center of the navicular fuses around age 9 for females and age 12 for males. This is traditionally the age in which symptoms start to arise [3].

There are 3 subtypes of OTE that have been described in the literature (Table 1). Type 1 is a small separate ossicle, sometimes described as a sesamoid that is imbedded within the PTT. Type 2 is a larger accessory ossification center, usually triangular in shape that lies in close proximity to the navicular and is connected by a fibrocartilaginous synchrondrosis. Type 3 is a completely incorporated ossicle that results in an enlarged navicular tuberosity; this type is referred to as a cornuate or gorilloid or hooked navicular [4,5]. Types 2 and 3 represent 70% of these accessory navicular deformities with type 1 being the remaining 30% [6]. Types 2 and 3 are also the most common types associated with pathology such as the PTT dysfunction and painin the os naviculare syndrome. Os naviculare syndrome is simply a symptomatic OTE.

Citation:Silva TW, Duggal NS and Gopalraj RK. A Curious Case of Midfoot Pain. J Fam Med. 2016; 3(9): 1086. ISSN: 2380-0658