The os trigonum and os peroneum are accessory ossicles (extra bones) in the ankle/foot that are present at birth (congenital) in some people.  Most of the time, these extra bones go unnoticed.  They may be identified on x-rays, but are often asymptomatic and do not need to be addressed.  However, as a result of overuse or an injury, these bones and the surrounding tissue and/or joints may become inflamed and painful.  The terms Os Trigonum Syndrome and Os Peroneum Syndrome are used to describe the painful symptoms.

The os trigonum can form behind the ankle bone (talus) during adolescence when it does not fuse with the rest of the ankle bone leaving a small extra bone.  This bone can get pinched between the talus and calcaneus (heel bone) with repeated downward pointing of the foot/toes during sports activity (eg – soccer).  Ballet dancers can develop a “nutcracker injury” due to spending frequent and prolonged time on their toes which can crunch the os trigonum causing inflammation in the area. 

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The os peroneum is an accessory bone that is located in the peroneus longus tendon which passes over the lateral aspect of the foot.  About 1 in 5 people have this extra bone.  This bone and the surrounding tendon can become inflamed with repetitive activity such as running and jumping or with an acute injury like an ankle sprain. 

Signs and symptoms of both these syndromes include:  swelling in the back of the ankle (os trigonum) or lateral foot (os peroneum), tenderness in the area, pain with pushing off the foot/toes when walking, and weakness.  X-rays or other imaging can confirm the presence of these accessory bones. 

Conservative treatment of these syndromes involve the following:

•             Rest – avoiding aggravating activities such as running, jumping, dancing, etc.

•             Immobilization – a walking boot may be prescribed to limited motion of the ankle/foot

•             NSAIDs and cold packs – to reduce pain and inflammation

•             Physical Therapy – to restore normal flexibility/mobility, increase strength/stability and assist with return to ADLs and recreation/sports

If symptoms persist, then steroid injections may be used.  Surgical intervention may be required to remove the os trigonum or os peroneum.  Following surgery, physical therapy can be prescribed to regain ROM, strength, balance/stability, endurance, and to facilitate return to prior level of function.

If you have questions or would like to learn more about this topic, contact the therapy professionals at ProActive Physical Therapy and Sports Medicine for help.

For Accessory Navicular Syndrome Exercises, Visit One of Our San Diego Area Clinics

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by Jayson Caalaman PT, DPT

Do you work from home and spend long hours at a desk? Sitting for extended periods can result in forward or slumped posture as you maintain a repetitive reach toward your keyboard. Try these simple exercises to open up your chest and spine! No equipment is needed.

Seated Chin Tucks

Sit with an upright posture and create a double chin with your neck – sinking your head in, rather than tilting your head backward. You should feel a slight pull in the back of your head.

What is the purpose of Seated Chin Tucks?

The purpose of this exercise is to strengthen your deep neck flexor muscles which often get weakened with prolonged forward head posture.

Scapular Retraction

What are common causes of neck pain?

With increase laptop use, long commutes and overall an increase in activities that require us to sit and a majority of time sitting in poor postures, tightness in our necks has become a common physical limitation. These limitations can affect anyone driving a car trying to look to change lanes, a tennis player hitting their shots, a golfer trying to get into a better backswing, a baseball player trying to see a pitch coming as the are batting, a football receiver or defense back trying to find the ball as they are running down the field, a basketball or lacrosse player trying to play better defense keeping track of the opposing players, etc.

What is interesting is that out of all 7 levels of the neck, half of your neck rotation occurs at one level. The motion in the joint between your first vertebrae (C1) and second vertebrae (C2) makes up about 45 degrees of the total rotation of your neck. This joint is commonly tight after traumas to the neck including whiplash injuries, falls and even with the stiff neck that you wake up with one morning that never goes away.

If the C1C2 joint is not moving, then the neck rotation motion has to come from either the skull on C1 or motion between C2-C7 which are not built to rotate more than about 45 degrees or half way. With the Greater (running more up the back of your head) and Lesser (more on the side of your head above you rear) Occipital Nerve coming off the C2 nerve root and running through the muscles at the base of your neck, these nerves become irritated producing many of the headaches that people associate to their neck tightness.

Many people, including athletes do not really understand how limited their neck motion is, especially when most people are able to compensate with other joint motion or movements. Unfortunately these compensations can lead to breakdown in other joints (C4, C5, C6, C7) and limitations in athletic skills leading to poor performance. Try the following test to see what your neck motion is:

How do I know what is causing my neck pain?

Test #1 – Sitting with your left shoulder towards a mirror. Turn your head to the left, keeping your chin level. People with limit neck rotation will bend their head backwards trying to gain more motion. Does your chin move over your left shoulder or at least over the far end of your collar bone? Now turn around and turn your head to the right, compare the amount of motion. It may help to have someone else note how much true rotation motion you have. Check to see if you are sitting in a good posture, if not correct your posture and repeat the test. You will notice more neck rotation while in a good posture.

Now perform Test #2 – Standing straight in front of a mirror with your hands placed on your chest, try to rotate your shoulders right and left without moving your head at all. (On a side note, your pelvis should not be moving either)

If you found that you have enough neck motion or mobility but that you could not able to move your shoulders without moving your head, you are having problems with stability or disassociation, which will be discussed in a future article.

A skilled physical therapist should be able to evaluate for a true neck mobility or stability dysfunction, treat and educate you on more specific exercises to maintain the required neck range of motion necessary to have full function in your neck thus reducing your headaches and/or enhancing your athletic performance.

For Help With Neck Pain or a Consultaion, Visit One of Our Clinics

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Tennis Ball Relief

Do you ever feel like you have a knot in your muscles? Do the muscles in the back of your head, neck, and shoulders just feel really tight? How about at the bottom surface of your foot? If you suffer from chronic myofascial tightness, chances are good that using a tennis ball to self-massage the injured area can bring great relief.

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Both words are spelled correctly but tendinitis tends to be the more preferred term used in medical literature. More importantly, what is upper extremity tendinitis? The suffix “itis” means inflammation and the term tendinitis should be reserved for tendon injuries that involve larger-scale acute injuries accompanied by inflammation.(1) Risk factors include repetition, awkward postures, direct pressure, high force and prolonged static positioning.(2)

Symptoms of Tendonitis/Tendinitis

Symptoms can appear suddenly or develop over a period of time. The most common and insidious symptom is pain. It can sharp or dull, aching or burning and radiate up or down the upper extremity. Occasionally you can hear popping or see a bump. Other symptoms include stiffness, swelling and weakness. Signs can be more specific for certain types of tendinitis, such as difficulty gripping a pot with the arm straight with tennis elbow, or turning a key in the ignition with thumb tendinitis.

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What is Myofascial Decompression (MFD)?

AKA “cupping,” MFD is an ancient technique used to improve angiogenesis to taut tissues.¹ It lifts skin and muscle through negative pressure which causes blood to collect in the selected area to oxygenate and improve myofascial mobility.¹

Thumb Pain: Does it Have to do With My Phone?

It comes at no surprise that Americans like their smartphones and use them daily. In 2019, the average American adult (18 years and over) spends 3 hours and 43 minutes on their phone per day (Wurmser, 2019). Use of smartphones lead to repetitive motions with scrolling of the thumb. As one may suspect, or may have experienced themselves, increased complaints of thumb pain have been reported. There is even a new term in the medical field, “texting thumb,” also known as gamer’s thumb. Houston Methodist Health (2019) describes texting thumb as occurring from repetitive use, where the inflamed tendons rub against a narrow tunnel, causing pain. 

As more people are working from home, increased complaints of tightness and soreness are brought up in the clinic. Many recognize that their computer setup at home is just not the same as at the office. Though we may not be inclined to go out and buy new chairs, desks, and computer screens immediately, there are things we can do to help reduce discomfort while working at home. 

Knee pain is commonly seen in the physical therapy clinic, especially anterior knee pain. This syndrome is typically explained as pain below the kneecap, in the front of the knee, which is felt during knee flexion movements, such as squatting or descending stairs. PFPS is due to poor patellar tracking during knee flexion and extension movements.

Blood Flow Restriction (BFR) training is a modality used to briefly occlude arterial and venous blood flow. The blood flow is occluded by a tourniquet cuff set at a specific percentage pressure relative to the individual’s total limb occlusion. BFR has shown to enhance muscle strength, endurance, hypertrophy, and can even serve as a pain analgesic. As a clinician, I use BFR most with my post-op patients, specifically ACL repairs. In the early stages of rehab for an ACL repair, the patient is under load restrictions for bodyweight exercises. BFR is a great way to enhance the muscle strength needed to progress in this rehab process. The idea is to perform exercises at 20-30% of the 1-rep max, but with the occlusion, the body is challenged by the submaximal loads. Muscle strength and hypertrophy can be enhanced in the early stages of rehab thus optimizing the progression to the next phase of exercise, typically without the post-operative knee brace.