Navicular Pain: Accessory Bones and The Right Xray Views

This patient has 6 months of arch pain right where the posterior tibial tendon attaches into the navicular in front of the ankle. The 2 X-rays demonstrate how standard foot X-rays, commonly ordered in emergency rooms or by standard protocols may not reveal the problem. 

This is a standard oblique foot X-ray which shows the outside of the foot better than the inside. Even though the pain was the inside of the foot, and even though I ordered an oblique view to isolate the inside of the foot, I still got the standard oblique view since it is ordered 1000 times more than other obliques. The marker highlights where the pain is, only it is hidden behind the bones.

After sending the patient down to X-ray again, and writing more on another prescription pad,  I was able to get the correct oblique. The marker shows clearly an accessory navicular bone, demineralized, and probably the cause of  pain. Of course, I am now ordering an MRI to look deeper at the 3 Dimensional and tissue activity components. But, this example clearly shows how standard X-rays may not always show the problem, especially when specialized X-rays are needed and not routinely done at any institution. X-rays are normally correct when positive, but may be wrong when read as negative in the face of chronic pain.