The Accessory Navicular and its Pertinence to Dancers

Chelsea Alley Dance 342 Kinesiology and Related Sciences for Dancers Brigham Young University

The Accessory Navicular

There are 27 bones in the adult human foot; 27 bones that make up an amazing structure that supports and cushions the body, as well as allows locomotion. No foot is perfect, however. Through muscular imbalances and structural deviations, it is possible for a foot to not function as perfectly as it should. For example, the foot can have accessory ossicles known as supernumerary bones. Usually asymptomatic, they can merely be definitive extra bones. However, with enough cause, an accessory ossicle can begin to cause painful symptoms and may need to be treated. Because of their nature, these supernumerary bones may have special significance to active individuals especially those in their adolescent years. The os tibiale externum (more commonly referred to as the accessory navicular) is the largest of the skeletal ossifications that can be found in the foot. It is located on the medial side of the primary navicular at the usual insertion of the posterior tibial tendon. A congenital anomaly, it is an extra bone that develops along with a fetus and is present at birth (Sechrest). Usually, the presence of an accessory navicular does not cause pain in most of the affected population, it is asymptomatic. There are three types of these specific ossicles. Type I, also known as naviculare secundarium, is a small sesamoid bone implanted in the posterior tibial tendon. It is not attached to the navicular at all, but falls right over the navicular tuberosity. It measures somewhere between two and three millimeters (Worsley). A Type II accessory navicular is a separate bone that develops from its own ossification center and is attached to the primary navicular by a
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mixture of hyaline cartilage and fibrocartilage called the synchondrosis. It can be triangular or heart-shaped and measures between nine and twelve millimeters. Type III is an actual enlargement of the navicular tuberosity (Evans, Averett, and Sanders 360). Most studies show that the accessory navicular is present in approximately 10-15% of the population (Evans, Averett, and Sanders 360). Generally, it will not ossify until around age nine and will begin to show up on x-rays and bone scans at about that time (Wheeless). What is an accessory navicular linked with and what are its implications? Although the accessory navicular is most often asymptomatic and does not cause pain, it does have several structural implications on the foot. Because of its location, the accessory navicular can cause unusual stress on the surrounding structures. In a normal foot, the upper fibers of the posterior tibial tendon attach on the navicular tuberosity (Musil 60). With the presence of an accessory navicular, however, the tendon attaches instead to the ossification. What this actually means for the structure of the foot is a question that is still being researched today. It would seem that an accessory navicular is commonly related to pes planus. Frederick Kidner, in 1929, first theorized that the presence of an accessory navicular could be the cause of pes planus. He believed that the accessory navicular would disrupt the natural pull of the posterior tibial tendon by displacing the attachment and causing a drop in the longitudinal arch of the foot (Macnicol and Voutsinas 218). This particular theory has been widely debated, however. The posterior tibial tendon does support the medial arch (Musil), but some are unsure as to how much the accessory navicular would inhibit the posterior tibial tendon from supporting the arch. However, because of the fact that an accessory navicular is present in 19% of those
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with pes planus (Evans, Averett, and Sanders 360), many agree with Kidner and believe that the posterior tibialis and its tendon increase arch height and are therefore affected by its presence. Others have suggested that other ligamentous structures like the plantar calcaneal navicular ligament and the deltoid ligament that support the longitudinal arch also have displaced attachments because of the accessory navicular, letting the arch fall lower than normal (Evans, Averett, and Sanders 360). Further, the presence of an accessory navicular is significantly more frequent in people with a posterior tibial tendon tear which is an injury that can lead to pes planus by allowing the plantar calcaneal navicular ligament to stretch too far and not be as supportive of the arch. The posterior tibial tendon also stabilizes the midtarsal joint. The disruption of its attachment by the accessory navicular could interrupt that pulley system and lead to an unstable midtarsal and foot and perhaps pes planus (Evans, Averett, and Sanders 360). As of yet, however, it is unproven whether the presence of an accessory navicular actually causes pes planus or not. Often, following surgery and the removal of the ossicle, arch height has improved in patients, but it cannot be said definitively if the accessory navicular was the cause of the pes planus, or merely one of a list of factors that contributed (Macnicol and Voutsinas 225). The accessory navicular can also be linked to pronation (which is also connected with pes planus) because of the imbalance of the structures affected by the ossicle. The abnormal pull on the posterior tibial tendon by the accessory navicular could also possibly cause hallux limitus, a deformity at the head of the big toe that causes decreased dorsiflexion (Evans, Averett, and Sanders 359). Several studies have suggested the two conditions are linked, but hallux limitus is also closely related to pes planus and could be attributed more directly to the flatfoot rather than stemming from the presence of an accessory navicular.
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In diagnosing posterior tibial tendonitis, a doctor will usually check X-rays for an accessory navicular (Swedan 96). Once again, however, it cannot be said for sure if the accessory navicular predisposes a patient to this condition and causes posterior tibial tendonitis or whether the accessory navicular is irritated by the posterior tibial tendonitis. In short, the presence of the accessory navicular, although closely related to pes planus and other such conditions, cannot be said for sure to cause any serious problems until it becomes symptomatic and begins to cause pain. What causes the accessory navicular to become symptomatic? Most of the affected population will go their entire lives without having any problems or even knowing that they have an accessory navicular. In fact, the accessory navicular will only make its presence known by becoming symptomatic in one-one thousandth of the population (Macnicol and Voutsinas 225). A symptomatic accessory navicular also seems to be more common in women possibly because of the type of shoes they wear or their greater ligamentous laxity (Macnicol and Voutsinas 225). The accessory navicular will ossify sometime between ages nine and eleven, and symptoms will usually begin to arise at this time or shortly thereafter, making a symptomatic accessory navicular a problem for adolescent athletes or dancers. The foot will become very tender over the area of the navicular tuberosity and it can be described as a deep bruise-like pain at the instep of the foot anytime it bears weight during walking or exercise. Symptoms are especially associated with the Type II accessory navicular because the ossicle is overly large, consisting of a completely separate bone and the synchondrosis between the two. There are several factors that can cause the accessory navicular to become
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symptomatic. Shoes and other footwear can put a lot of pressure on the prominence and can cause symptoms to arise. Pes Planus can also put a lot of stress on the area and cause a type of foot strain that will result in pain (Macnicol and Voutsinas 225). In a lot of cases, some sort of trauma will catalyze the symptoms; an injury can cause something similar to a fracture in the fibrous tissue connecting the accessory navicular to the primary navicular. The fibrous connective tissue has poor ability to heal and will continue to degenerate. Its breakdown allows slight movement between the two bones and makes that bony joint unstable (Sechrest). With the insertion of the posterior tibial tendon on the accessory navicular, it will continue to place pulling stress on the fibrous connective tissue. This breakdown of the synchondrosis is believed to be the main cause of the pain and swelling associated with a symptomatic accessory navicular. In physically active people, the symptoms can be exaggerated or even caused by the impact and stress during high-level activity. How is the accessory navicular diagnosed? Once a patient begins to experience pain, there are several methods of diagnosis. The most simple (and first indicator) is palpation directly over the navicular tuberosity. If the patient experiences a high level of tenderness and pain, it is likely that the cause is an accessory navicular. A trained professional can also analyze subtalar motion and determine if any unexpected movement is related to the presence of an accessory navicular. Once the bone has ossified, it can be seen quite easily on X-rays. Usually, an X-ray is all that is needed to definitively diagnose the presence of an accessory navicular (Wheeless). What treatments are available for a symptomatic accessory navicular?

The first steps in treating an accessory navicular should be non-surgical. Changes in footwear can help alleviate the symptoms if the pain is stemming from compression on the ossification. Another option is arch support shoe inserts or an orthotic device that shields the accessory navicular (Wheeless). Doctors can also prescribe anti-inflammatory medications in order to reduce the swelling and pain in the area (Sechrest). Another interesting option to explore consists of exercises to strengthen the intrinsic foot muscles and lateral leg rotators; doing this can often alleviate the stress that is placed on the posterior tibial tendon and the accessory navicular (Macnicol and Voutsinas 225). Because of the slow healing rate of the synchondrosis, a period of rest from physical activity and cast immobilization for about six weeks is often recommended (Wheeless). If none of these treatments help the pain, the next step would be surgical correction of the bone. The first operation developed that could help with a symptomatic accessory navicular actually started as a surgical endeavor to reroute the posterior tibial tendon in order to improve a foot with pes planus. The Kidner procedure is a complex operation that includes actual removal of the accessory navicular and suturing the tendon to the underside of the navicular (Macnicol and Voutsinas 218). The actual effectiveness of this particular surgery in increasing arch height has been widely debated, as have Kidners theories in general. It does eradicate pain caused by the accessory navicular, but it is a bit excessive if pes planus is not the greatest worry. The modified Kidner procedure has the same foundation, but as the name suggests, there are several adaptations that can be involved in order to concentrate more specifically on removing the bone and decreasing healing time. The modified Kidner Procedure is an out-patient surgery that takes about an hour. Patients have to wear a splint or cast for about six weeks after surgery and the

foot cannot bear weight for most of that time. The size of the bone removed determines how long the patient must wait before beginning to walk again (Oster). Although the modified Kidner procedure is the most common operation to treat an accessory navicular today (Sechrest), there is current research into other methods. A study done in 2005 showed that percutaneous drilling may be another viable option. Avoiding a large incision, a Kirschner wire enters the foot posterior to the accessory navicular and is used to push, or drill, through the synchondrosis between five and seven times in order to cause microbleeding in the connective tissue and stimulate cytokines to fuse the two with actual bone. Bone union between the accessory navicular and the primary navicular would eliminate the pain associated with a degenerative synchondrosis and undesirable movement (Nakayama, Sugimoto, Takakura, Tanaka, and Kasanami 534). This study reported that percutaneous drilling was effective, especially for a type II accessory navicular and should be tried before the Kidner procedure because the drilling is less invasive, easier to perform, and comes with less complications (Nakayama, Sugimoto, Takakura, Tanaka, and Kasanami 535). Several studies have also shown that simple excision of the accessory navicular is just as effective as the Kidner procedure and not as traumatic for the posterior tibial tendon. Instead of rerouting the tendon and suturing to a different part of the bone, a simple excision merely removes the bone out from under the tendon and leaves the tendon insertion intact (Micheli 214). A simple excision will relieve painful symptoms, but it is considered most effective if it also involves recontouring of the navicular, or trimming of the medial border of the bone to reduce the abnormal prominence (Macnicol and Voutsinas 225). Patients are encouraged to resume weight-bearing as soon as the wound is healed and postoperative care is much less elaborate.

How does this particular condition pertain to dancers? Because of the time frame, exaggerating influences, and painful symptoms, an accessory navicular can become a major problem for adolescent athletes. Although an accessory navicular can become a problem later in life for adults (Macnicol and Voutsinas 225), as well, it seems to most often manifest itself around the time it ossifies typically in young athletes (Nakayama, Sugimoto, Takakura, Tanaka, and Kasanami 531). This means for young dancers who are beginning to become more involved in the dance field and entering their adolescent years, an accessory navicular could present a problem. Setting the associated pain and inflammation aside for a moment, the presence of an accessory navicular is linked to other problems like pes planus and habitual pronation both conditions which a dancer has to train to counteract and which can lead to structural and functional deviations in other joints. In addition though, I know from personal experience that the pain an accessory navicular causes is almost debilitating. A deep, seizing ache is present any time the foot is weight-bearing, and the area is very tender to the touch at all times. It becomes particularly bad any time the body is doing more activity than a normal walk making dance class and pointe work almost impossible to get through. Dancers have a year-round season and they require a lot from their bodies on a daily basis. Impact and stress on the foot are high. They require a full range of motion to execute movements that are not necessarily normal in the body. Probably one of the most noteworthy factors as to why an accessory navicular would pertain to dancers is that of pointe shoes. As stated earlier, an accessory navicular ossifies somewhere between ages nine and eleven around the time a young ballerina is progressing in her dance career and beginning to train en pointe. The very nature of a pointe shoe is compressive and involves severe impact on the foot, with enough stress and pressure to cause problems with a degenerative synchondrosis. If a young
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dancer has an accessory navicular, it will most likely present itself within the first few years en pointe. Another interesting point that Swedan makes is that there is a lot of medial stress in the feet of dancers who roll in to compensate for inability to turn out at the hip (96). This hyperpronation, as she calls it, may be a cause for symptoms to arise. If this is the only factor for a dancer in causing symptoms, they could be easily alleviated by strengthening the supinators and working to increase rotation from the hip. Also, if a dancer at any age is attempting to alleviate painful symptoms with non-operative treatments, certain exercises should be incorporated to a conditioning program in order to strengthen the instrinsics and leg rotators, as previously discussed. Unfortunately, non-operative measures will usually not solve the symptomatic problems in a highly active individual. Most dancers struggling with accessory navicular problems will end up seeking surgical treatment in order to solve it up front and be able to continue with such a physically active career. From there, a dancer needs to decide with his or her doctor which procedure is going to be the most beneficial and when it would be affordable to take the time for recovery and rehabilitation. With new advances in research and surgery, a complex Kidner procedure and all the time it requires is probably no longer necessary; but any operation does require a recovery and therapy period. It is really left up to a dancers personal decision because an accessory navicular is not as threatening as a more destructive injury that must be addressed right away. It just depends on how long a dancer is willing to endure the pain. In conclusion, accessory ossicles and especially the accessory navicular are not all that uncommon in the general population. Normally, they are not a problem or one that can be fixed without too much intervention. In physically active individuals however, an accessory navicular can be a source of pain and annoyance. Although there is some debate as to whether or
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not the accessory navicular actually causes other problematic conditions, as well as to which treatments are best, there is considerable research on the subject. It is agreed that the accessory navicular is linked with pronation and pes planus and most importantly, there are techniques available that will reduce or eradicate symptoms completely. It is simply something that athletes in general and dancers in particular should be aware of and willing to work with.

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Works Cited Evans, R. D. Lee, Ryan Averett, and Stephanie Sanders. "The Association of Hallux Limitus with the Accessory Navicular." Journal of the American Podiatric Medical Association 92.6 (2002): 359-65. Journal of the American Podiatric Medical Association. Web. 25 Jan. 2010. Macnicol, M. F., and S. Voutsinas. "Surgical Treatment of the Symptomatic Accessory Navicular."The Journal of Bone and Joint Surgery 66-B.2 (1984): 218-26. Print. Micheli, Lyle J., Jason H. Nielson, Claudio Ascani, Bryan K. Matanky, and Peter G. Gerbino. "Treatment of Painful Accessory Navicular: A Modification to Simple Excision." Foot & Ankle Specialist 1.4 (2008): 214-17. Sage Journals Online. Web. 25 Jan. 2010. Musil, Pam. "Muscular System." Lecture. Dance 342 Kinesiology and Related Sciences for Dancers. Provo: Brigham Young University. 59-65. Print. Musil, Pam. "Tibialis Posterior." Muscle Flashcards. Provo: Brigham Young University. Print. Nakayama, Shoichiro, Kazuya Sugimoto, Yoshinori Takakura, Yasuhito Tanaka, and Ryoji Kasanami. "Percutaneous Drilling of Symptomatic Accessory Navicular in Young Athletes."The American Journal of Sports Medicine 33.4 (2005): 531-35. Sage. American Orthopaedic Society for Sports Medicine, 2005. Web. 2 Mar. 2010. Oster, Jeffrey A. "Flatfeet." My Foot Shop. Mar. 2010. Web. 9 Mar. 2010. Sechrest, Randale C. "Accessory Navicular Problems." EOrthopod. Medical Multimedia Group, LLC., 2009. Web. 25 Jan. 2010. Swedan, Nadya. Women's sports medicine and rehabilitation. Gaithersburg, Md: Aspen, 2001. Print. Wheeless, Clifford R. "Accessory Navicular." Wheeless' Textbook of Orthopaedics. Duke Orthopaedics, 6 Jan. 2009. Web. 25 Jan. 2010. Worsley, Neil. "Reporting On: Accessory Articles of the Foot." Synergy (2009). Print.

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