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Accessory navicular bone

The accessory navicular bone, also known as os naviculare or os tibiale externum, is a congenital accessory ossicle located on the medial aspect of the navicular bone in the foot, often embedded within or adjacent to the posterior tibial tendon.^[1] It is classified into three main types based on its size, shape, and connection to the navicular: Type I, a small (2-3 mm) round or oval ossicle within the tendon's substance; Type II, a larger (at least 6 mm) triangular or heart-shaped bone connected by a synchondrosis (cartilaginous bridge); and Type III, a fully fused enlargement of the navicular's tuberosity (cornuate navicular).^[2]^[3] This condition is relatively common, with a pooled prevalence of approximately 17.5% among individuals and 12.6% among feet, though estimates vary by population (higher in East Asian groups at up to 45%) and is often bilateral in about 50-70% of cases.^[3]^[1] While many cases are asymptomatic, the accessory navicular can lead to accessory navicular syndrome when it becomes symptomatic, typically during adolescence as the ossicle ossifies and causes irritation.^[4] The development of the accessory navicular is congenital, arising from a secondary ossification center of the navicular tuberosity that fails to fully fuse, and it may become painful due to factors such as trauma (e.g., ankle sprains), overuse, flatfoot deformity, or ill-fitting footwear that increases friction on the posterior tibial tendon insertion.^[2]^[4] Symptoms primarily include medial midfoot pain exacerbated by weight-bearing activities, localized swelling, redness, and tenderness over the navicular prominence, sometimes accompanied by a visible or palpable bony bump and difficulty with footwear.^[2] Type II is most commonly associated with symptoms due to its partial connection and potential for tendon misalignment, while Type I is least symptomatic.^[3]^[1] Diagnosis typically involves clinical evaluation, including history of foot pain and physical examination for tenderness along the posterior tibial tendon, confirmed by imaging such as weight-bearing X-rays to visualize the ossicle and assess alignment, with MRI useful for evaluating tendon pathology or soft tissue inflammation if needed.^[4] Initial management is conservative, focusing on non-surgical approaches like rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), immobilization in a cast or boot for 4-6 weeks, custom orthotics or arch supports to reduce tendon stress, and physical therapy to strengthen the foot.^[2]^[4] Surgery, such as excision of the accessory bone with reattachment of the posterior tibial tendon, is reserved for persistent cases unresponsive to 3-6 months of conservative treatment and has high success rates, with recovery involving 4-6 weeks of postoperative immobilization.^[2]^[4]

Overview and Anatomy

Definition

The accessory navicular bone is a congenital anatomical variant consisting of an extra ossicle situated on the medial aspect of the navicular bone in the midfoot.^[4]^[5] It represents a common developmental anomaly present at birth, occurring in a small percentage of the population without typically causing issues unless irritated.^[2]^[4] This ossicle originates embryologically from a secondary ossification center in the navicular tuberosity that fails to fuse with the main body of the navicular bone during childhood development.^[3]^[6]^[7] The incomplete union results in a separate bone fragment, which is a normal variant in foot anatomy rather than a pathological condition.^[8] Historically, the accessory navicular bone has been known by several names, including os naviculare and os tibiale externum.^[9]^[10] When symptomatic, it may form part of accessory navicular syndrome, characterized by irritation of the posterior tibial tendon where it inserts near the navicular.^[11]^[12]

Location and Structure

The accessory navicular bone is situated at the navicular tuberosity on the medial aspect of the midfoot, immediately posterior to the posteromedial tuberosity of the tarsal navicular bone.^[9] It lies adjacent to the medial surface of the navicular bone and is typically embedded within or in close proximity to the distal fibers of the posterior tibial tendon sheath.^[3] This positioning places it in the medial midfoot region, near the attachments of supporting structures that contribute to foot stability. Structurally, the accessory navicular is an extra ossicle that varies in size, generally ranging from 4 to 20 mm in length and 4 to 12 mm in width, with typical dimensions around 8 to 12 mm for more prominent forms.^[10]^[13] It consists of an osseous core but may appear partially or wholly cartilaginous if ossification is incomplete, and it is often connected to the navicular by a thin synchondrosis of fibrocartilage or hyaline cartilage measuring 1 to 3 mm.^[2]^[3] In density, it resembles cortical bone but can exhibit variability based on its developmental stage. The accessory navicular arises congenitally from a secondary ossification center of the navicular tuberosity that fails to fuse with the primary bone during childhood, typically between ages 8 and 13.^[7]^[3] In relation to surrounding anatomy, the accessory navicular is positioned medially and posteriorly to the primary navicular bone, without direct participation in its articulations. The primary navicular, a boat-shaped tarsal bone, forms the talonavicular joint proximally with the talus head and contributes to the transverse tarsal joint distally by articulating with the three cuneiform bones, thereby supporting the medial longitudinal arch of the foot.^[6] The accessory bone's medial protrusion may subtly alter the contour of this arch. It lies in close proximity to the calcaneus via indirect connections and near the spring ligament (plantar calcaneonavicular ligament), which spans from the sustentaculum tali of the calcaneus to the navicular's inferior surface to reinforce the arch.^[5]^[14] The posterior tibial tendon often inserts broadly onto the accessory navicular, integrating it into the tendon's pathway.^[9]

Classification

Type I

Type I accessory navicular is characterized as a small, round or oval sesamoid ossicle, typically measuring 2-3 mm in size, that is embedded within the substance of the posterior tibial tendon and remains completely separate from the navicular bone. This ossicle lacks any cartilaginous or bony connection to the navicular tuberosity.^[15]^[16] The formation of Type I occurs through independent ossification of a separate ossification center, distinct from the primary navicular bone development, resulting in an isolated structure that is frequently identified as an incidental finding on radiographic imaging.^[16] This type represents approximately 30% of all accessory navicular cases within the Geist classification system, which was originally proposed by Emil S. Geist in 1914 and modified by Sella and Lawson in 1987.^[15]^[16] Clinically, Type I accessory navicular exhibits low symptomatic potential and is typically asymptomatic throughout life, as its position within the tendon does not disrupt normal foot mechanics. Rare irritation or discomfort may occur solely in the context of posterior tibial tendon inflammation, such as tendonitis, which can indirectly affect the embedded ossicle.^[16]^[5]

Type II

The Type II accessory navicular, as defined in the Geist classification, is characterized by a larger ossicle, typically triangular or heart-shaped and measuring 8-12 mm in size, that is positioned adjacent to the navicular tuberosity.^[3] This variant forms a pseudo-joint through its connection to the navicular bone via a 1-3 mm synchondrosis composed of fibrocartilage and/or hyaline cartilage, with fibers of the posterior tibial tendon inserting directly onto the ossicle.^[3]^[2] The synchondrosis allows for limited mobility, creating a semi-attached structure that distinguishes it from the isolated Type I and the fully fused Type III variants within the Geist framework.^[3] Developmentally, the Type II accessory navicular arises from a secondary ossification center of the navicular tuberosity that fails to fully unite with the primary navicular bone, typically during ossification between ages 8 and 13.^[3]^[7] This incomplete fusion results in a prominent medial eminence on the midfoot, which can alter local biomechanics and contribute to the high symptomatic potential of this type.^[2] Among accessory navicular cases, Type II represents a substantial proportion, often cited as accounting for 50-70% of instances, and it is responsible for over 70% of symptomatic presentations due to its structural features.^[3] The mobility at the synchondrosis enables micro-motion during weightbearing activities, leading to repetitive shear stress and tension that irritate the posterior tibial tendon insertion and surrounding soft tissues, thereby causing pain.^[15] This tendon irritation manifests as chronic medial foot discomfort, particularly in adolescents and young adults, and underscores the Type II variant's predisposition to clinical issues compared to other types.^[2]^[3]

Type III

Type III accessory navicular, the final category in the Geist classification, is defined by the complete fusion of an ossicle to the navicular bone, forming an enlarged, cornuate (horn-shaped) tuberosity without any separate bony element.^[17] This fused structure creates a prominent medial projection on the navicular's tuberosity, which is stably integrated into the main bone rather than mobile or separate as in other types.^[3] The condition arises from the development of a secondary ossification center that fuses with the navicular but results in an overly prominent tuberosity due to incomplete resorption during growth.^[7] This variant accounts for 20-30% of all accessory navicular cases, making it less common than Type II but still notable in foot anatomy variations.^[18] The permanent bony prominence often leads to variable symptomatology, primarily influenced by the size of the tuberosity and mechanical pressure from the posterior tibialis tendon, which inserts nearby and can become irritated over the enlarged area.^[2] While many individuals remain asymptomatic, larger prominences may cause medial foot pain, especially with activity or ill-fitting footwear, though symptoms are generally milder than in non-fused types due to the lack of a mobile ossicle.^[3] The fused enlargement alters the medial arch profile of the foot, potentially contributing to pes planus (flatfoot) by disrupting the normal support provided by the navicular tuberosity and posterior tibialis tendon complex.^[19] This structural change can affect load distribution during weight-bearing, though the direct causal link to flatfoot varies by individual biomechanics and is not universal.^[20]

Epidemiology

Prevalence

The accessory navicular bone is a common anatomical variant, with overall prevalence estimates ranging from 4% to 21% in the general population based on radiographic and cadaveric studies.^[9] A 2024 meta-analysis of 39 studies covering 11,015 patients and 36,837 feet reported a pooled prevalence of 17.5% (95% CI: 11.5–25.7%) among patients and 12.6% (95% CI: 10.1–15.5%) among feet, drawing from both radiographic (12.2%) and cadaveric (9.5%) data, though no significant differences were found between these study types.^[21] Higher rates, up to 34%, have been observed in specific radiographic studies of adult populations, particularly in Asian cohorts, suggesting potential ethnic variations in detection or incidence.^[22] Prevalence is notably elevated in symptomatic cohorts, where imaging is more frequently performed, reaching 17.5% in patient-based studies compared to lower cadaveric rates, indicating selection bias toward those with foot complaints.^[21] Bilateral occurrence is common, affecting 50–70% of cases, which points to a genetic or developmental etiology rather than sporadic formation.^[5] ^[21] This bilaterality is consistent across genders, with approximately 50% of affected individuals showing involvement on both feet in meta-analytic data.^[21] A recent meta-analysis found no statistically significant differences between X-ray and cadaveric methods, attributing variations to study populations rather than technique.^[21] The condition is predominantly asymptomatic, occurring in the vast majority of cases without clinical notice, leading to underdiagnosis in the general population where routine foot imaging is absent.^[21] This underestimation is exacerbated by reliance on plain films, which may miss subtle variants, potentially lowering reported prevalences in unselected groups.^[23] Among symptomatic cases, the Type II variant is the most prevalent form, accounting for over 70% of presentations.^[3] Recent studies as of 2025 confirm prevalence variations, such as 15.1% in Japanese children and 24.5% in the Indian population.^[24] ^[25]

Demographics

No significant gender differences in prevalence have been identified in comprehensive meta-analyses, though some clinical studies report higher rates in females.^[3] The condition itself is congenital, forming during fetal development and present at birth, but it often remains asymptomatic until later.^[7] Symptoms typically manifest during adolescence, particularly between the ages of 10 and 18, coinciding with periods of rapid skeletal growth and ossification of the navicular region.^[11] This timing aligns with the maturation of foot structures, where increased mechanical stress from activity and growth can exacerbate irritation at the accessory bone site. In contrast to the overall prevalence, which varies globally from 8% to 38%, demographic patterns highlight subgroup differences that influence clinical awareness.^[3] Ethnic variations in prevalence are notable, with the accessory navicular being most common in East Asian populations (38.4%) and least frequent in North American cohorts (8.0%).^[3] These differences suggest potential genetic or environmental factors tied to population ancestry. Additionally, familial patterns indicate a strong hereditary component, with heritability estimates reaching 0.88 after adjusting for age and sex, pointing to substantial genetic influence.^[26] In rare cases, inheritance follows an autosomal dominant pattern with incomplete penetrance, as observed in multi-generational pedigrees.^[27]

Clinical Presentation

Symptoms

The primary symptom of a symptomatic accessory navicular bone is pain located on the medial aspect of the foot at the navicular tuberosity, often described as a dull ache that intensifies during weight-bearing activities such as walking or running.^[2]^[28] This pain typically arises from mechanical irritation or inflammation at the site and impacts a minority of individuals with the condition, affecting daily walking.^[19] Swelling and tenderness frequently occur over the bony prominence, which patients may notice as a visible or palpable bump in the medial arch, sometimes accompanied by localized redness.^[2] These symptoms can lead to fatigue or persistent aching in the foot arch after prolonged standing, potentially resulting in a limp to alleviate discomfort.^[2]^[28] Symptoms often onset during puberty due to growth-related stresses or following trauma such as a sprain or overuse, presenting with intermittent exacerbations that worsen at the end of the day or with increased activity.^[2] This presentation may briefly involve irritation of the adjacent posterior tibial tendon, contributing to the overall medial foot discomfort.^[29]

Associated Conditions

The accessory navicular bone contributes to flexible flatfoot (pes planus) by disrupting the normal alignment of the medial longitudinal arch, leading to collapse and increased strain on the supporting structures of the foot.^[30] This association arises because the anomalous bone alters the insertion site of the posterior tibial tendon, which is crucial for maintaining arch integrity, often resulting in a hypermobile flatfoot deformity.^[31] Studies indicate that patients with pes planus and an accessory navicular are more prone to progressive arch collapse, particularly in type II variants where the bone is connected by a synchondrosis.^[32] A key comorbidity is posterior tibial tendon dysfunction (PTTD), where the accessory navicular interferes with the tendon's normal biomechanics, causing attenuation, tenosynovitis, or insufficiency.^[33] In severe cases, this dysfunction progresses to adult-acquired flatfoot deformity, characterized by hindfoot valgus and forefoot abduction due to unopposed eversion forces.^[34] Clinical evidence shows PTTD is evident in most symptomatic type II accessory navicular cases, with the anomalous bone exacerbating tendon strain during weightbearing activities.^[15] Altered biomechanics from the accessory navicular also increase the risk of stress fractures in the navicular or adjacent midfoot bones, as repetitive loading concentrates abnormal forces on the tarsal region.^[35] Additionally, it predisposes individuals to midfoot tendonitis, particularly involving the posterior tibial or flexor tendons, due to friction and irritation at the anomalous site.^[36] These secondary effects stem from the bone's position within the tendon's path, promoting chronic inflammation and microtrauma.^[28] Rarely, the accessory navicular co-occurs with other congenital foot anomalies, though these associations are not causally linked and typically represent independent developmental variations. In active individuals, these comorbidities may exacerbate biomechanical imbalances, leading to earlier onset of symptoms during high-impact activities.^[2]

Diagnosis

Physical Examination

The physical examination for accessory navicular bone begins with inspection and palpation of the medial aspect of the foot to identify any visible prominence or enlargement at the navicular tuberosity.^[7] Palpation typically reveals a firm, bony enlargement that is tender to direct pressure, particularly along the medial and plantar surfaces of the navicular, often correlating with a history of medial foot pain.^[7]^[37] This tenderness may extend along the course of the posterior tibial tendon insertion, indicating potential irritation or inflammation at the site.^[5] Observation of foot posture during weight-bearing stance is essential to evaluate arch height and hindfoot alignment. Patients may exhibit a flattened medial longitudinal arch (pes planus) or hindfoot valgus, which can contribute to stress on the accessory bone and associated structures.^[4] The navicular prominence should be differentiated from other bony landmarks, such as the talar head, by assessing subtalar joint motion while stabilizing the area with manual pressure.^[5] Functional tests assess the integrity of the posterior tibial tendon and provoke symptoms related to the accessory navicular. The single-leg heel rise test involves having the patient rise onto the toes of the affected foot while maintaining balance; weakness, inability to perform the rise, or pain during this maneuver suggests compromised posterior tibial tendon strength and arch support.^[5] Pain provocation maneuvers, such as applying direct pressure to the medial navicular prominence or performing resisted foot inversion (with the foot in plantarflexion), often reproduce localized pain at the site, confirming involvement of the accessory bone.^[38]^[39]

Imaging

Plain radiography serves as the initial imaging modality for evaluating suspected accessory navicular bone, typically using lateral oblique views to identify the ossicle and differentiate it from fractures through smooth cortication and lack of irregularity. Weight-bearing views are employed to assess the longitudinal arch and any associated flatfoot deformity, confirming the presence of type I (small oval ossicle within the tibialis posterior tendon), type II (separate ossicle with synchondrosis), or type III (fused prominent tuberosity) variants.^[40]^[41] Magnetic resonance imaging (MRI) provides comprehensive evaluation, particularly for soft tissue involvement, utilizing T1-weighted and T2-weighted fat-suppressed sequences to detect bone marrow edema in the ossicle or navicular bone, indicating symptomatic stress or osteonecrosis. It visualizes tendon inflammation, such as tibialis posterior tenosynovitis or tears, and assesses the integrity of the synchondrosis in type II variants, with edema patterns correlating to focal pain in affected individuals.^[42]^[41]^[40] Computed tomography (CT) provides detailed bony anatomy, especially useful in preoperative planning, by delineating the ossicle's size, shape, and fusion status while distinguishing it from acute fractures via well-corticated margins. Axial and sagittal reformats highlight the relationship between the accessory bone and the navicular, aiding in type classification and evaluation of any osseous irregularities.^[41]^[40] Ultrasound offers dynamic assessment of the tibialis posterior tendon gliding over the accessory navicular, particularly valuable in pediatric patients, by demonstrating soft tissue swelling, tendon pathology, or displacement during motion. High-resolution probes can confirm type II variants and detect associated inflammation without radiation exposure.^[40]

Treatment

Conservative Management

Conservative management serves as the primary treatment for symptomatic accessory navicular bone, focusing on symptom relief and functional improvement without invasive procedures.^[2] The RICE protocol—rest, ice, compression, and elevation—provides effective acute pain relief by reducing inflammation and swelling in the medial arch area.^[2] Rest involves avoiding activities that exacerbate pain, such as high-impact sports, while ice application for 20 minutes several times daily helps control local symptoms; compression with a wrap and elevation above heart level further minimize edema.^[2] Orthotic devices play a key role in offloading pressure from the accessory navicular and supporting the posterior tibial tendon. Arch supports or custom shoe inserts redistribute weight away from the medial foot, alleviating irritation at the navicular-tuberosity junction.^[4] These devices are often combined with wider, more accommodating footwear to prevent rubbing over the prominence.^[43] Physical therapy emphasizes targeted exercises to enhance foot stability and tendon function. Stretching routines focus on the posterior tibial tendon and calf muscles to improve flexibility, while strengthening exercises for the intrinsic foot muscles and ankle stabilizers promote better arch support and reduce recurrent strain.^[2] Balance and proprioception training may also be incorporated to aid overall recovery.^[37] Pharmacologic interventions typically include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to manage pain and inflammation associated with tendon irritation.^[4] These are used alongside other measures for short-term relief. For severe or persistent symptoms, immobilization with a short-leg cast or walking boot is employed for 4 to 6 weeks to allow tendon healing and reduce mechanical stress on the accessory bone.^[2] This is followed by gradual reintroduction of activity and supportive therapies.^[4]

Surgical Interventions

Surgical interventions for the accessory navicular bone are indicated in cases refractory to conservative management after approximately 6 months of treatment.^[38] The Kidner procedure, first described in 1933, involves excision of the accessory navicular ossicle and reattachment or advancement of the posterior tibial tendon to the navicular bone to restore tendon function and alleviate pain.^[38]^[44] This approach is particularly suited for Type II accessory naviculars, where the ossicle is connected by a synchondrosis, as it addresses tendon insertion abnormalities.^[38] For Type I accessory naviculars, which consist of a small ossicle embedded within the posterior tibial tendon, or non-fused Type II cases with minimal tendon involvement, simple excision of the ossicle without tendon repair is often sufficient to relieve symptoms.^[38]^[44] In Type III accessory naviculars, characterized by fusion of the ossicle to the navicular forming a prominent cornuate shape, surgical options include resection of the bony prominence (naviculoplasty) to reduce impingement.^[38] Postoperative care typically involves immobilization in a cast or boot with non-weight-bearing for 4-6 weeks, followed by protected weight-bearing and physical therapy to restore range of motion and strength.^[38]^[45] Success rates for these procedures range from 85% to 95%, with most patients reporting significant pain relief and improved function.^[44]^[46]

Prognosis

Outcomes

Conservative management of symptomatic accessory navicular bone achieves pain relief in approximately 69% of pediatric cases, with 28% experiencing complete resolution and 41% partial relief sufficient to avoid surgery, typically within 8 months.^[43] Surgical interventions yield high success rates, with simple excision resulting in excellent outcomes in 80% of patients, moderate in 18%, and overall satisfaction ranging from 85% to 95% across procedures, accompanied by restored foot function and low recurrence rates.^[44]^[47] Success is influenced by early intervention to prevent chronicity and by navicular type, with Type II cases more commonly symptomatic due to their cartilaginous connection and thus often requiring excision.^[44]^[48] Patients generally return to full activities, including sports, within 3 to 6 months post-surgery, with 94% resuming pre-injury levels.^[49]

Complications

If left untreated, symptomatic accessory navicular bone can contribute to chronic posterior tibial tendon dysfunction (PTTD), a progressive condition that weakens the tendon's ability to support the foot's arch.^[4] This may lead to flatfoot deformity, including adult-acquired rigid flatfoot in advanced stages, due to ongoing irritation and altered biomechanics at the tendon's insertion site.^[50]^[51] Surgical management, such as the Kidner procedure involving excision and tendon relocation, carries risks including wound infection in low rates (reported in isolated cases across systematic reviews) and scarring or wound irritation as minor complications.^[44] Tendon weakening or degeneration of the posterior tibial tendon can occur post-relocation, potentially leading to insufficiency if healing is impaired.^[45] Over-resection of the navicular prominence may increase tendon tension.^[52] Conservative approaches, including orthotics, may cause skin irritation over the prominence due to pressure from ill-fitting devices or persistent rubbing against footwear.^[53] In adolescents, delayed symptom resolution can occur during growth phases, prolonging reliance on immobilization.^[37] Rare long-term issues include persistent pain and the need for revision surgery, depending on procedure type and foot alignment.^[44] These complications are more frequent in type III accessory navicular or cases with delayed intervention.^[45]

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Jul 1, 2022 · Type I is a small round ossicle that is embedded within the posterior tibial tendon [3]. Type II is a triangular-shaped ossicle connected to ...
[44]
Revision Surgery for Recurrent Pain after Excision of the Accessory ...
May 8, 2017 · Postoperative Care. Postoperatively, all patients were immobilized in a short leg non-weight-bearing cast for 6 weeks. For the first 3 weeks ...
[45]
[PDF] Accessory navicular surgery - Royal Berkshire Hospital
Accessory navicular surgery, April 2025. 2. What are the success rates and risks? The surgery has a success rate of about 90% (9 out of every 10) in taking ...Missing: types | Show results with:types
[46]
Operative Outcomes for Accessory Navicular in Adolescents - PubMed
Surgery eliminated pain in 91% of patients and can be safely performed in athletes with high rate of return to their previous athletic performance. (Journal of ...
[47]
Risk Factors for Persistent Pain Requiring Surgical Treatment in ...
May 1, 2022 · Younger age at symptom onset and type IIB were the risk factors for persistent pain requiring surgical treatment in adult symptomatic accessory navicular.
[48]
SURGICAL OUTCOMES OF ACCESSORY NAVICULAR IN ... - NIH
Jul 14, 2021 · Surgery eliminated pain in 76% of patients and allowed 94% of patients to return to sport. Residual pain in 4 patients was correlated with a pre ...
[49]
MR Imaging of Disorders of the Posterior Tibialis Tendon | AJR
The presence of either an accessory navicular or a cornuate navicular is a risk factor for posterior tibialis tendon tears. However, most people with an ...<|separator|>
[50]
Progressive flatfoot deformity accompanied with avulsion and ...
Pisani described that the presence of an accessory navicular bone is suspected to be a possible pathogenic cause of degenerative changes in the spring ligament.
[51]
Effects of customized orthoses on foot morphology and pressure in ...
May 17, 2025 · Custom orthoses serve as an effective conservative treatment for accessory navicular syndrome, offering several key benefits: Personalized ...
[52]
Operative Management for Symptomatic Accessory Navicular
Sep 25, 2025 · The complication rate in the Kidner cohort was 11%, while the arthrodesis cohort demonstrated the highest complication rate (25%) and failure ...Missing: success | Show results with:success