title: Management of foot pain associated with accessory bones of the foot: two clinical case reports.
abstract: METHODS
  Case study.
  
  
  OBJECTIVE
  To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot.
  
  
  BACKGROUND
  Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined.
  
  
  METHODS
  Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status.
  
  
  RESULTS
  The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 100% return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 100% reduction of swelling with ankle girth to normal; 100% range of motion of ankle and subtalar joints. Strength in plantar flexion and eversion remained 20% impaired (80% return to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 100% of strength in hip and ankle, and 100% return of balance. She could squat and jump without pain and she returned to full premorbid activity level.
  
  
  CONCLUSIONS
  Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain.
authors.affiliation: Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, USA. smais@msmc.la.edu
authors.forename: S M
authors.initials: SM
authors.lastname: Requejo
authors.forename: K
authors.initials: K
authors.lastname: Kulig
authors.forename: D B
authors.initials: DB
authors.lastname: Thordarson
mesh_terms: D000328:Adult; D003937:Diagnosis, Differential; D005260:Female; D005534:Foot Diseases / Q000175:diagnosis / Q000534:rehabilitation / Q000628:therapy*; D050723:Fractures, Bone / Q000150:complications / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009443:Neuritis / Q000150:complications; D009989:Orthotic Devices; D010146:Pain / Q000209:etiology / Q000534:rehabilitation; D059408:Pain Management; D010147:Pain Measurement; D026741:Physical Therapy Modalities; D012716:Sesamoid Bones / Q000002:abnormalities* / Q000293:injuries*; D013497:Sural Nerve; D013639:Tarsal Bones / Q000002:abnormalities* / Q000293:injuries* / Q000601:surgery; D013997:Time Factors