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Sunday, October 21, 2012

Foot Pain in 8 year old: Email Advice

Dear Dr. Blake,

I was googling around the internet for "accessory navicular bone" and happened upon your wonderful website.  My husband and I have been dealing with our daughter's chronic ankle pain for 2 years now and I'm ready for a diagnosis already.  As a parent, it is extremely frustrating to have doctor's tell you that your child's pain is a) not real b) just a sprain or c) "let's do some PT and see what happens."  All of her x-rays have been "normal," and we recently received news that the MRI we were finally granted (AMEN!!) of the ankle was "normal" as well.  She cried when we told her everything came back normal. . . The only finding so far is that she has an accessory navicular bone in the ankle that causes her pain.  DING DING DING!  Wow- once I started looking up information about this little bone, I was floored.  The only issue is that I can't seem to find any information about children with this problem.  And, we are waiting waiting waiting for an appointment with the foot and ankle specialists at Duke, who are booked from now until February (this email was sent October 20th).  In the meantime, I'd love to be able to figure out some way to help her. . . because I KNOW she is in pain.

Dr Blake's comment: Pain from an accessory navicular bone normally presents in children around 13-14 at the earliest. The accessory navicular bone is on the arch side (big toe side of the foot) where the powerful posterior tibial tendon attaches, it is the main tendon in supporting the arch of the foot. Very important!! We know that the accessory navicular bone can cause direct pain where it attaches to the normal navicular bone, or cause tendon pain since the extra bone disrupts the normal attachment, weakening the tendon, causing the tendon to strain easier. This is usually an easy diagnosis when the patient points to the accessory navicular and says it hurts right here!!! You got to make it easy for us patients!!
     However, the pain that your daughter presents with is on the opposite side of the foot and ankle (outside or lateral side). This presentation, along with negative X-rays and MRI, leads me to suspect a mechanical cause of her pain like over pronation (perhaps indirectly caused by the accessory navicular bone. 

This was sent on my request and X-rays and MRI are on the way. Here the patient clearly notes pain on the lateral side of the foot/ankle. The common diagnoses for the age group is lateral ankle impingement pain, peroneal tendonitis, calcaneal apophysitis, sinus tarsitis, and calcaneocuboid joint sprain. 

About 2 years ago she was diagnosed with a "tibial growth plate fracture" (suspected since it was never visible on x-ray), and put in a cast for 3 weeks.  At that time, pain was located on the medial ankle and in her heel.  Following immobilzation, she was fine for exactly 1 year.  The pain returned again, only this time it had migrated to the outside of her ankle.
Dr Blake's comment: The immobilization had fixed the tibial growth plate fracture. The new pain, one year later, is 99% not related to the original problem, especially since it is in a totally different area. 

 This completed perplexed the orthopedist and he sent us home, assuming that she had either strained it or just liked visiting the doctor on a regular basis.  Fast forward through almost a year of soccer games, swim team, summer trips to the water park, and flip flops and we are officially in AGONY.
Dr Blake's comment: At least now the picture is getting clearer. 1 year ago she injured herself with a new injury, has had no treatment for that injury, and is not getting better. Since the injury involves no broken bones, bones sticking out of the foot, or torn tendons, the treating doc figured a little time will heal the problem. 95% of the time, it probably does. Your daughter fits into the 5% that really needed more treatment. 

 Since I refuse to go back to the orthopedist who dismissed us, we've been back to the pediatrician's office, had more X-rays (normal), seen an exercise science specialist ("Go back and play soccer.  You're fine.  I guess we can try PT too."),  seen a sports medicine PT ("Um. . . I don't work with 8 year olds and I'm not sure how to treat a problem without a proper diagnosis."), and FINALLY we raised enough hell to get her an MRI, which is of course normal. 

In looking at her ankles, her right ankle is definitely turned in now and the arch is flattened.
Here is the photo of the back of the legs/feet. Both heels are pronated (ankle bones collapsing in). As the arches collapse, from the back you can see more of the fifth toe. 

That overpronation is much clearer on this photo with the right side leaning inward. Golden Rule of Foot: When the pain can be from asymmetrical pronation, fix that first and see if the pain is diminished. 

 Is there anything we can do while we wait until February to see the Holy Grail of (adult) ankle specialists at Duke?  When your child comes to you everyday in pain, it's heartbreaking.  

Thanks in advance for any direction.  

Mary from North Carolina (name changed for privacy)

Dr Blake's response:

Mary, I am definitely on board to help. And will answer this email on my blog Sunday or Monday. Definitely send me a photo of her foot pointing to the area she feels the pain, a short video probably is best. Please send me the xrays and MRI on CD to Dr Rich Blake 900 Hyde Street San Francisco, Calif, 94109. Also, tell me about her average day, how she feels waking up, when the pain starts, is there swelling, how it feels after she rests it, etc. Any info helpful. Rich

Mary's Response: 

Thanks so much for taking a look at our daughter Dr. Blake.  I've attached a few pictures which will hopefully be helpful.   In response to your questions, our daughter seems okay in the morning, but then any activity like walking or running seems to result in pain.  At this point, just walking around the grocery store seems to be painful.  By bedtime she often complains the most and sometimes says that falling asleep is difficult due to the pain.  Most nights, she helps herself to an ice pack before going to bed.  She also sometimes complains about pain behind her knee after prolonged walking.  I am planning to get my hands on  X-ray and MRI on Monday and I will send them to you next week.  

Thanks again,

Dr Blake's comment: I will look forward to seeing the films. However, with no obvious swelling at any time, I most common problem is a mechanically induced pain syndrome in one of the structures mentioned above. It can be caused by the accessory navicular weakening the arch, but there are many other causes of arch collapse. A biomechanics expert in that neck of the woods is Dr Doug Milch, a podiatrist in Ashville. Please look him up, and perhaps he can refer you to someone closer. You have to start with designing an insert which she wears with any weight bearing for minimum of 4 months, and it could be longer, that completely eliminates the pronation on that right side. It is easy actually if you are into biomechanics. Once the biomechanics are stabilized, then you can effectively work on strength and anti-inflammatory. I hope this helps. Definitely have her ice pack that area for 10 minutes 3 times a day until you get the inserts. Let me know if there are any problems with this referral. Dr Rich Blake


  1. When people who suffer from over-pronation stand or walk, the arches collapse with every step they take, and the ankles roll inwards.

  2. Thank you for posting such a wonderful article with us. I had foot pain about 3 months ago. I used to do treatment but the pain remain the same. Now, I searched about home remedies natural cure and I found the article below
    check this article and provide me the suggestion what should i do ?

    1. Thanks for sharing this link for my readers. This is not my area of expertise, but I am sure some of these natural solutions will help. You have to experiment doing one new treatment for 2 weeks, and if you are not convinced it is helping, then try another. If you think it helps, continue for another 2 weeks and see if the improvement continues, or plateaus. If plateaus, try another, but continue the first one. Gradually, you may find a combination of 3-4 will work for you. It is worth being Sherlock Holmes. It is Elementary!! Rich

  3. What is your email address Dr. Blake? I tried sending my email to:, it says it's not valid. Thank you.

    1. That is the website. Try the gmail account: Thanks Rich

  4. My son has a protrusion on the outside of both feet about midway down between his pinkey toe and his heel. He has it on both feet but only the on his right foot hurts. It seems to be something hard like bone or cartilage. He is in a lot of pain and it might take some time before we can see a doctor. Please respond as soon as you can. Thanks


Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.