Navicular Bone Pain When I Walk
From Wikipedia, the free encyclopedia The fabella is present in 10% to 30% of individuals. An accessory bone or supernumerary bone is a bone that is not normally present in the body, but can be found as a variant in a significant number of people. It poses a risk of being misdiagnosed as bone fractures on radiography,
Contents
- 1 Why does the navicular bone hurt?
- 2 Does navicular pain come and go?
- 3 Does navicular get worse with age?
- 4 What happens if a navicular fracture is left untreated?
- 5 Does navicular show up on xrays?
- 6 Can you walk on a stress fracture?
- 7 Does navicular get worse with age?
- 8 Does accessory navicular pain go away?
Accessory Navicular Syndrome – Accessory navicular syndrome is the result of an extra bone or piece of cartilage alongside the navicular bone. This is a congenital condition and is present at birth. It occurs in 4 to 14% of the population. Most people who have accessory navicular syndrome do not know it exists unless the extra bone causes a problem.
- Trauma, foot or ankle sprain, and chronic irritation from footwear rubbing on this extra bone can cause pain.
- Having flat feet, or fallen arches can also cause strain on the tendon that connects to the bone, which can cause accessory navicular syndrome to worsen and create more inflammation and pain.
Symptoms of accessory navicular syndrome include:
Pain or throbbing in the midfoot and arch—typically during/after activityVisible prominence or bump on the inner side of the foot, above the archRedness and swelling of the bony prominence
In adolescence, cartilage calcifies, which turns into bone. Often it is during this process when symptoms of accessory navicular syndrome appear. Some people don’t experience symptoms until later in life. History of pain, examination, and X-rays can confirm the diagnosis of accessory navicular syndrome.
- Ice to reduce swelling, anti-inflammatory medications, physical therapy to strengthen muscles and decrease inflammation, as well as immobilization in a cast may be used to treat symptoms.
- Another option for treatment is a custom orthotic device, which is inserted into the shoe to provide arch support.
If symptoms reappear after conservative treatment, surgery to remove the extra navicular bone may be needed.
You will find that the swelling is often worse at the end of the day, elevating your ankle will help with this. You may walk on the foot as comfort allows but you will find it easier to walk with crutches in the early stages.
How Is a Navicular Stress Fracture Diagnosed? – Your doctor will examine your child’s foot and ankle. The navicular bone may be tender to touch and there may be pain with hopping and standing on the toes. Sometimes x-rays show the fracture, but not always. If suspicion is high, your doctor may consider an MRI, a CT scan or a bone scan.
Signs and Symptoms – Horses with navicular syndrome exhibit lameness, but it is of a specific type. Rarely, navicular syndrome lameness comes on suddenly. Usually, it is a gradual, intermittent lameness. What starts as a horse being somewhat “off” progresses over time. The lameness may appear to switch legs. Suspect navicular syndrome if the horse displays any of the following:
- Pointing a toe while at rest
- Development of short-strided gait
- Difficulty when turning
- Problems going downhill
- Increased stumbling
- Rigidity in the neck and poll
- Gait changes when trotting circles
- Becoming uncooperative with the farrier
Unlike laminitis, when a horse tries to keep weight off the toe, equines with navicular syndrome try to put their toes down first to avoid weight on their heels. The horse may end up with a snubbed toe in conjunction with a tall heel derived from stepping toe first.
Treatment and Return to Activity – Therapeutic intervention in navicular stress fractures has been clearly defined 1, 13, 18, 19 ( Table 2 ),13 In 86 percent of cases of nondisplaced navicular stress fracture, six weeks in a well-molded non–weight-bearing cast results in healing.1 If clinical healing has occurred and there is no tenderness at the “N” spot after six weeks in the cast, functional rehabilitation may begin 1 ( Table 3 1 ), The patient should be reassessed every two weeks and, if there is no increase in tenderness at the “N” spot, can typically return to full activity six weeks after removal of the cast. If the navicular bone remains tender, the patient should be kept in the non–weight-bearing cast for two more weeks and clinically reexamined after that time.1, 5, 13, 19, 24 Navicular disease in horses is also known as Navicular syndrome. The result is the inflammation or degeneration of the navicular bone and its surrounding tissues, typically in the front feet of the horse. This disease can lead to significant or disabling lameness of a horse. The navicular bone is located between the pedal bone and the deep digital flexor tendon (DDFT). See figure 1. With an infected hoof, you can expect to see contracted width of the foot, tendon tears or necrotic appearance, and chronic inflammation of the area surrounding the navicular bone. This disease is believed to be genetic but can occur due to the conformation of the distal limbs. Structure associated with Navicular syndrome includes excessively long toes, under-run heels, and a “broken back” hoof-pastern axis. It is more common in mature riding horses (between the age of 8 and 10 years old) and is associated more commonly with certain breeds such as warmbloods, Quarter horses, and thoroughbreds. Damage to the navicular bone may occur due to limited blood supply or trauma to the navicular bone. Pain and lameness can also occur in the deep flexor tendon, navicular bursa, or navicular ligaments (Carson). Typically, when a horse develops navicular disease, they will show signs through low-grade bilateral lameness. Another sign would be head-bobbing, especially at the trot. The progression of navicular disease is slow, and lameness may only be noticeable from time to time. For example, working a horse on hard ground or in a small circle may accentuate the frontal lameness of the animal. Navicular does not always occur in both hooves, and one foot may develop a harsher disease. Diagnosis is obtained by looking at the animal’s history and genetics and observing their movement. Horses that have navicular appear to place their toes down first to remove pressure from their heels. Another method to determine if a horse has navicular is nerve blocks. Nerve blocks are the injection of a local anesthetic around the nerves on the back half of the foot that surrounds the navicular bone. Once the anesthetic is applied, lameness improves. Blocking the coffin joint may also improve lameness in horses with navicular. Veterinarians have been able to show the deterioration of the navicular bone through radiograph footage. Figure 2 shows a radiograph of navicular. Using radiographs is highly debated when determining navicular disease because some horses may not show signs on a radiograph. More recently, magnetic resonance imagining (MRI) is used to find navicular. When looking at treatments, it’s important to remember that navicular is a degenerative disease and therefore is not curable. Most procedures are to designed to help the horse feel less pain while being worked. Phenylbutazone, an anti-inflammatory and pain reducer, is used for short periods. However, there are more permanent options available. The most effective treatment is proper shoeing designed for navicular problems. It’s essential that the horse’s hooves are balanced and land level on the ground. Broken-back or broken-forward pastern angles, under-run, or contracted heels be corrected. Typically, an egg bar shoe adds heel support. Shock-absorbing pads and wedges are used with shoes to raise the heel and remove direct pressure on the navicular bone. Injection of the coffin joint with steroids has improved soundness in approximately one-third of horses with navicular (Belknap). A neurectomy relieves all pain and prolongs the usefulness of the horse. Several complications can occur, such as painful neuroma formation, rupture of the deep digital flexor tendon, and injuries to the distal limbs with a neurectomy. Prevention of navicular disease includes maintaining a balanced foot, heel support, and exercising the horse on the ground with sound footing. Kentucky Equine Research Staff. Navicular Syndrome in Horses – Kentucky Equine Research Belknap, J.K. Navicular Disease in Horses – Musculoskeletal System.” Merck Veterinary Manual Carson, D.M. Navicular Syndrome in Horses Healing: It normally takes 6 to 8 weeks for this fracture to heal. Smoking will slow down your healing. We would advise that you stop smoking while your fracture heals. Symptoms – Symptoms of a navicular stress fracture usually involve a dull, aching pain in the ankle or at the middle or top of the foot. In the early stages, pain often occurs only with activity. In the later stages, pain may be constant. Other common symptoms include: • Swelling or bruising over the middle part of the foot • Limping Barefoot rehabilitation – Barefooting has been spectacularly successful with navicular rehabilitation. Barefooting works by returning correct function to the back part of the foot. This is achieved by restoring correct movement. How is correct movement returned? By removing any disease or deformity and providing immediate comfort (either rubber laneways or padded boots) until such time as a horse can land comfortably on its landing gear. Heel first landing is the default position for horses. Remove the discomfort and correct movement will return – a simple solution to a complex and for many years a baffling problem. With barefoot rehab, the outcome has been so consistently successful, that bold statements can be made about navicular If barefoot rehab was to be widely adopted, navicular disease will become a dinosaur. There is probably no reason for a navicular horse to be de-nerved or euthanased. : Navicular syndrome – The Barefoot Blacksmith
Figure 1: Lower leg structures in the horse
Figure 2: Belknap, J. Navicular Disease in Horses – Musculoskeletal System
What is the navicular? – The navicular is a small bone on the inner part of your mid-foot (see picture below). A navicular stress fracture is an overuse injury that develops when you work the bone too hard and it doesn’t get enough time to recover between training sessions. The navicular bone
As with osteoarthritis, navicular syndrome is a degenerative condition that worsens over time. It is therefore not possible to cure navicular syndrome.
Non-operative management – High healing rates of non-displaced navicular fractures have been reported with immobilization and protected weight bearing for 6 to 8 weeks, However, the study includes patients diagnosed by bone scan which could simply be stress reactions typically expected to improve with non-operative treatment.
Furthermore, the study lacks confirmation of healing on cross-sectional imaging. A more recent study provided more support for the non-operative treatment of navicular stress fractures with 19 of 22 patients going on to return to sport at an average of 5.6 months after injury; CT confirmation of fracture healing in these cases was also not presented,
Furthermore, the authors discuss that there remained a fracture line in some cases but that athletes were still able to return to activity without symptoms. The longevity of an athletic career in a patient with an asymptomatic persistent fracture line is yet unknown.
Risks and Complications – The most common complication after treatment of a navicular fracture is a nonunion, or failure of the bone to heal. Continued pain with activity after cast removal is a sign that the bone did not heal. If a nonunion develops, the treatment can be surgery.
- This often involves using a bone graft in the fracture site can help with navicular bone healing.
- Another potential complication is the development of arthritis, resulting from damage to the cartilage that covers the joint connecting the navicular bone to the hindfoot (rear part of the foot).
- A less common complication of navicular fracture is avascular necrosis (AVN), which results from a loss of blood supply to the navicular bone.
AVN causes a collapse of the navicular bone and affects function of the joints in the middle of the foot. It can be difficult to treat.
Abstract – Accessory ossicles of the foot are commonly mistaken for fractures. The accessory navicular is one of the most common accessory ossicles of the foot. There is a higher incidence in women and the finding might be bilateral in 50-90%. This entity is usually asymptomatic, although populations with medial foot pain have a higher prevalence.
- Three types of accessory navicular bone have been described.
- The type II accessory navicular is the most commonly symptomatic variant with localized chronic or acute on chronic medial foot pain and tenderness with associated inflammation of overlying soft tissues.
- Plain radiographic identification of the accessory navicular is insufficient to attribute symptomatology.
Ultrasound allows for comparison with the asymptomatic side and localization of pain. Bone scintigraphy has a high sensitivity but positive findings lack specificity. Magnetic resonance imaging is of high diagnostic value for demonstrating both bone marrow and soft tissue oedema.
by Sally Colby Like many horse maladies, navicular disease has more than one name, including navicular syndrome and podotrochlosis. Dr. Kyla Ortved, assistant professor of large animal surgery at the University of Pennsylvania’s New Bolton Center, said many bones and structures comprise the equine foot, and there’s a much better understanding of how these bones and structures work together.
This has led to deeper understanding of diagnosing and managing navicular syndrome. Ortved explained the roles of structures in the equine foot and how they relate to navicular syndrome. “The deep digital flexor tendon comes down the back of the leg and wraps around the back of the navicular bone and inserts on the coffin bone,” she explained.
“The navicular bone is also supported by the impar ligament that comes off the bottom of it and attaches to the coffin bone. The navicular bursae sit between the navicular bone and the deep digital flexor tendon, and ligaments support the navicular bone on either side.
The navicular bone itself has cartilage on both sides and is part of the coffin joint, then on the back side there’s cartilage where the deep digital flexor runs.” Ortved said the term “navicular” is the most common term because that’s the bone that shows up on X-rays. But soft tissue, which can also be part of the problem, doesn’t show up on X-rays.
The vet can isolate forelimb lameness with a block to the foot, but X-rays might still be normal. MRI allows imaging of all the soft tissue, so a horse that was initially diagnosed with navicular disease can now be diagnosed more accurately as having a tear in the deep digital flexor tendon.
We always say that 90 percent of forelimb lameness originates in the foot, and a lot of foot lameness we see originates in that part of the foot,” said Ortved. “It doesn’t necessarily mean the navicular bone itself – navicular syndrome has been expanded to include other structures in that area of the foot.
We see a lot of it in Thoroughbreds, warmbloods, and Quarter horses.” While there’s no proof that navicular syndrome is inherited, certain conformation faults may lead to higher incidence. One early sign of navicular syndrome is mild lameness, and early recognition provides a good opportunity to intervene.
- Often, navicular syndrome occurs bilaterally in the front feet,” said Ortved.
- One foot might be worse than the other, and that’s the one the horse is limping on, or you notice a shorter stride or unwillingness to land after a jump.
- Some horses show an exaggerated response when they’re on hard ground.” Diagnosing a horse with navicular syndrome usually starts with a (nerve) block to identify the source of pain, followed by X-rays.
However, while X-rays can identify issues in the navicular bone itself, they can’t identify any other pathology or injury in that area. “If there are significant changes to the navicular bone on X-ray, there’s a solid answer,” said Ortved. “There may be other things going on, but you can definitely say the horse has a severe navicular issue. The role of MRI should be considered in terms of both necessity and expense, which can be significant. While some horses can undergo an MRI without sedation, many have to undergo general anesthesia, which means higher cost and hospitalization. Recent data show significantly better outcomes in horses exhibiting foot lameness when MRIs are done early.
If the finances are there to support an MRI, the sooner the better – especially if you’re questioning the diagnosis,” said Ortved. “It allows a more clear understanding of what’s going on in the foot and allows you to target treatment more appropriately.” While costs vary, Ortved estimates that in the Northeast, a standing MRI without sedation is usually $2,500 per foot, and up to $3,500 for an MRI under general anesthesia.
Ortved said the fact that horses are athletes makes it difficult to prevent navicular syndrome. “I think you can takes steps to limit the impact and concussive forces on the foot, like avoiding riding on hard ground, which also helps prevent sole bruising,” she said.
“Good shoeing and trimming is key. Horses with excessively long toes put more pressure on the deep digital flexor tendon, and that hits the back of the navicular bone and causes damage.” Pat Reilly, chief of farrier services at the University of Pennsylvania’s New Bolton Center, has worked extensively with competition horses for 25 years and said good outcomes in treating navicular syndrome are more likely when vets and farriers work together.
He added that despite scientific improvements and approaches in shoeing, there is still some art involved in treatment. “A lot of people come to the farrier first,” said Reilly, “but without a diagnosis, we can make a situation worse instead of better.
If I put a bar shoe on a horse that has a little bit of lameness, I’m changing the distribution of force on that foot, and it might make the horse better – but it could make the horse worse. As a farrier, my goal is to take whatever structures the vet identifies as pathologic and try to take some of the force off those structures.
Without a diagnosis, I’m operating in the dark.” Reilly said one word he doesn’t allow in his farrier shop is “balance.” “That suggests that we know exactly what we’re doing, and we don’t,” he said. “The second part of that is (assuming) things are going to stay where we put them – and they don’t.
- Horses’ feet grow.
- X-rays can be useful in identifying where the internal structures are, and especially in identifying distortion of the hoof capsule.
- Farriers have a tendency to focus on the outside of the foot, and we can fit shoes to distortion and not necessarily factor things like bony alignment and the position of the shoe relative to the center of articulation of the coffin bone.” Ortved explained the use of bisphosphonates, drugs used in human medicine for degenerative bone conditions such as osteoporosis and bone fragility disorders.
“Bisphosphonates stop or interfere with the activity of osteoclasts – the cells in bone that break down bone,” she said. “They secrete enzymes that break down the mineral material that makes up bone. The other cells in bone are osteoblasts, and those are responsible for making new bone material.
The disease is usually chronic (develops over a number of months/years) but acute (sudden) injuries can occur in some cases. It is rare in the hind feet and in ponies. Some horses with mild navicular disease will be sound.
Can you walk on a stress fracture?
Self-care at Home – It is important to rest your foot.
Elevate your foot to decrease swelling and pain.Do not do the activity or exercise that caused your fracture.If walking is painful, your doctor may advise you to use crutches to help support your body weight when you walk.
4. What do they look like – clinically? – Patients with acute fractures of the navicular usually present with:
Pain over the dorsal or dorsomedial foot following trauma. Localized swelling and tenderness over the navicular. Difficulty with weight-bearing Increased pain and inability to walk on or push off (ie, plantarflex while weight-bearing) with their toes.
| The differential diagnosis of Köhler Disease (Avascular Necrosis of the Navicular) is suggested more by chronic progressive medial midfoot pain worse with weight-bearing, though it can sometimes present with acute onset of symptoms. There is usually swelling and tenderness over the navicular, with the patient preferring to bear weight through the lateral part of the foot. X-Ray appearance and management are given below. |
| Chronic or progressive medial midfoot pain may also be caused by Accessory Navicular, This is a developmental anomaly in which the tuberosity of the navicular develops as a secondary ossification centre but fails to unite with the main navicular. Whilst asymptomatic in many, pressure from inappropriately narrow footwear can cause chronic pain and tenderness in the medial midfoot with swelling and erythema, with symptoms usually worse with weight-bearing. X-Ray appearance and management are given below. In symptomatic accessory navicular, resisted strength testing of posterior tibial tendon often elicits pain (have the patient invert and plantar flex the foot against resistance) |
As with osteoarthritis, navicular syndrome is a degenerative condition that worsens over time. It is therefore not possible to cure navicular syndrome.
What is the navicular? – The navicular is a small bone on the inner part of your mid-foot (see picture below). A navicular stress fracture is an overuse injury that develops when you work the bone too hard and it doesn’t get enough time to recover between training sessions. The navicular bone
Non-operative management – High healing rates of non-displaced navicular fractures have been reported with immobilization and protected weight bearing for 6 to 8 weeks, However, the study includes patients diagnosed by bone scan which could simply be stress reactions typically expected to improve with non-operative treatment.
Furthermore, the study lacks confirmation of healing on cross-sectional imaging. A more recent study provided more support for the non-operative treatment of navicular stress fractures with 19 of 22 patients going on to return to sport at an average of 5.6 months after injury; CT confirmation of fracture healing in these cases was also not presented,
Furthermore, the authors discuss that there remained a fracture line in some cases but that athletes were still able to return to activity without symptoms. The longevity of an athletic career in a patient with an asymptomatic persistent fracture line is yet unknown.
AN ORTHO-PINION – Over the years, I have had a number of patients who come in with complaints of pain in the inner center part of their arch. Typically, these patients tend to be athletic; however, not all are. Oftentimes, these patients have a bump in this inner center arch area.
- What is this bump and why is it painful? Accessory navicular As infants and children, many of our bones start off as cartilage.
- These cartilage “bones” are difficult to see on x-ray until they become calcified.
- The calcification process occurs at a variety of different times in life depending on the bone.
An accessory navicular is an extra bone that is on the inner center arch of the foot. Up to 2.5 percent of individuals are born with the accessory navicular. Throughout early childhood, this condition is not noticed. However, in adolescence, when the accessory navicular begins to calcify, the bump on the inner aspect of the arch becomes noticed.
- For most, it is never symptomatic.
- However, for some, there is some type of injury — whether a twist, stumble, or fall — that makes the accessory navicular symptomatic.
- There are three different types of accessory navicular.
- This extra cartilage, which is turned into bone, is found attached to the posterior tibial tendon, just medial (inside) the navicular bone.
The accessory navicular can affect the insertion of the posterior tibial tendon. This tendon has the job of keeping your foot aligned and helping to maintain an arch. The accessory navicular can be associated with a normal foot posture and alignment, or sometimes with a flat (pes planus) foot.
- An initial assessment in an orthopaedic office begins with a thorough history and complete physical exam, including an assessment of the posterior tibial tendon and areas of tenderness.
- Associated misalignments of the ankle and foot should be noted.
- Finally, weight-bearing x-rays of the foot will help in making the diagnosis.
Sometimes, an MRI may be needed to see if the posterior tibial tendon is involved with the symptoms or getting more clarity on the anatomy of the accessory navicular. Initial treatment is conservative. With the first episode of symptoms, a medial heel wedge, anti-inflammatories, and physical therapy can be helpful.
- If very painful, a cast or boot may be needed for a short period time before the wedge and physical therapy can be initiated.
- Very rarely is a steroid injection warranted or recommended.
- As the pain improves, patients can resume activities.
- For a minority of patients, an arch support or custom orthotic can help to take some of the extra pressure off of the accessory navicular and the posterior tibial tendon.
For patients who have failed conservative care or who have recurrent symptoms, surgery can be considered. Surgical intervention requires an excision of the accessory navicular and reattachment of the posterior tibial tendon to the navicular. Oftentimes, this is the only procedure necessary.
- However, if there are other deformities, such as a flat foot or forefoot that is abducted, other procedures may be required.
- In summary, an accessory navicular is a fairly uncommon condition which is rarely symptomatic.
- Oftentimes nonsurgical treatment is successful.
- In the minority of cases, surgical intervention is required.
Patients typically do very well with conservative and surgical treatment. Athletic activities can usually be restarted once symptoms have improved or the patient has recovered from surgery. Learn more about Orthotics,
