What is the initial treatment for foot accessory navicular syndrome?

Initial Treatment for Foot Accessory Navicular Syndrome

The initial treatment for foot accessory navicular syndrome should include conservative measures such as rest, ice, elevation, orthotic devices, and activity modification to relieve pain and reduce inflammation. 1, 2

Understanding Accessory Navicular Syndrome

• Accessory navicular is an extra bone or piece of cartilage on the inner side of the foot that can become painful, especially when the posterior tibialis tendon inserts onto this accessory bone, causing increased strain 1
• There are three types of accessory navicular bones:
  • Type I: An ossicle within the posterior tibial tendon
  • Type II: Forms a synchondrosis (cartilage connection) with the navicular bone (most commonly symptomatic)
  • Type III: "Cornuate navicular" representing a possible end stage of Type II 3

Diagnostic Approach

• Radiography of the foot is the appropriate initial imaging study for suspected accessory navicular syndrome 4
• MRI without IV contrast is usually appropriate as the next imaging study after negative or equivocal radiographs to visualize:
  • Bone marrow edema within the ossicle
  • The synchondrosis between the accessory bone and navicular
  • Associated tendon pathology 4
• MRI allows optimal visualization of both bony structures and soft tissues, making it valuable for assessment 5

Conservative Treatment Algorithm

1. Initial Pain Management:

   • Rest and activity modification to reduce stress on the affected area 2
   • Ice application for 15-20 minutes several times daily to reduce inflammation 1
   • Elevation of the foot to minimize swelling 1
   • Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief 5, 2

2. Mechanical Support:

   • Orthotic devices or arch supports to stabilize the foot and reduce strain on the posterior tibialis tendon 2
   • Shoe modifications to reduce pressure on the medial aspect of the foot 6
   • Taping or bracing techniques to provide additional support 2

3. Physical Therapy:

   • Stretching exercises for the posterior tibialis tendon and Achilles tendon 6
   • Progressive strengthening of foot and ankle muscles 2
   • Joint mobilization techniques to improve foot mechanics 2

4. Activity Modification:

   • Temporary reduction in high-impact activities that exacerbate symptoms 1
   • Gradual return to activities as symptoms improve 2

When to Consider Advanced Treatment

• Conservative treatment should be attempted for 6-8 weeks before considering surgical options 6, 7
• If conservative measures fail to provide relief, surgical intervention may be necessary 8
• Surgical options include:
  • Simple excision of the accessory navicular with anatomic repair of the posterior tibialis tendon 8
  • Kidner procedure (excision with transposition of the posterior tibial tendon) 7
• Both surgical approaches have shown high satisfaction rates and significant improvement in pain scores 8, 7

Common Pitfalls and Caveats

• Failure to identify accompanying foot deformities (such as planovalgus or hindfoot valgus) that may require additional treatment 7
• Inadequate conservative management before considering surgical options 7
• Overlooking accessory navicular syndrome as a potential cause of medial foot pain, especially in patients with altered biomechanics 1
• Insufficient follow-up to ensure proper healing and rehabilitation 2