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Saturday, April 16, 2016

Accessory Navicular Syndrome: Email Advice

Hi Dr. Blake,

I have been reading your blog religiously in light of my increasing foot problems. Your blog is a huge source of trustworthy information and education for anyone suffering from foot problems. Thank you for the time and care you have put into this blog because it is truly rare to find quality, trustworthy information out there regarding some of the more obscure foot problems you write about.

I am writing because I have bilateral accessory navicular syndrome, with my left foot giving me the majority of the pain. I am a 24 y.o. female who has recently moved to NYC (relevant detail).

I was diagnosed with ANS in 3rd grade when a kid threw a frisbee right at my foot in gym class, which caused my left foot to roll. I limped around all day after that, and experienced pain in my arch for the first time. I went to see the podiatrist, and he told me I had ANS and prescribed custom orthotics. He also put me in a small boot and soft cast for about 2 weeks. He mentioned surgery was a possibility if my pain persisted. I continued to wear my orthotics for a very long time without any additional incidents of pain. I did notice that if I walked more than usual, my left foot would be a little sore, but the pain would alleviate with rest.
Dr Blake's comment: This is the typical response in a young child with beginnings of problems related to the accessory navicular. The doc immobilizes, then gives orthotic devices, and everything seems fine for a while. The type of orthotic device may not be supportive enough in the long run, plus needs to be redone with a shoe size change of 1 to 2 sizes. This is a pain for parents. The common problem I see here is that posterior tibial strengthening is not done at this young age, and that could prevent future problems. 

https://youtu.be/QP3Ud4d39dc

Unfortunately, when I left home for college, I got the idea that I no longer needed my orthotics. I met a running coach at a tennis shoe store who encouraged me to leave my orthotics behind to “train” my foot to properly hold itself. I naively listened to him. I became more active during college and started doing things such as running and yoga. Unfortunately, my left foot started giving me more problems during this time, and I was wearing unsupportive shoes often, such as flats and flat sneakers. If I ran/walked more than usual, my foot would ache the next day but it would always recover with rest. I thought that this coming and going of foot-aches and pain was just my “new normal”. But in general, I did not have pain.
Dr Blake's comment: This why there was a war with podiatrists and minimalists unfortunately. Some feet, like those with inherited weakness such as accessory navicular, ligamentous laxity, tarsal coalitions, flexible high arches, plantar flexed first metatarsals with exposed sesamoids, etc etc, should have a strengthening program but with protection. 

Last year I went on a trip to SF, and the combination of wearing new chunky heels, walking up and down the inclines of SF, and overall just A LOT of walking, my feet just gave out. Not only did I experience arch pain, but I also experienced pain at the ball and heel of my foot. Bearing weight on my foot was just terrible. It took me a WEEK of wearing supportive tennis shoes (no orthotics), elevation, and icing it for my foot to feel better.

After that incident, I have just not recovered fully. 6 months ago, I moved to NY and now walk more often than I did in TX. The pain has become chronic and dehabilitating. I went to my old podiatrist and he prescribed new custom orthotics and put me in a soft cast and Cam walker boot for 2 weeks and Cam walker with ace bandage for the following 2 weeks. When he took an Xray of my left foot, he said that I actually have 2 small extra bones instead 1. He also gave me PT exercises to do. However once I was out of the Cam walker and I started walking <1 actually="" again="" allows="" and="" as="" back="" because="" but="" cam="" did="" do="" doing="" exercises="" flare="" getting="" groceries.="" help="" i="" increasing="" independently="" insurance="" into="" issues.="" it="" me="" mile="" much="" myself="" not="" of="" pain="" pt="" put="" recovery="" simple="" slower="" span="" supervision="" the="" them="" things="" time.="" to="" up="" walk="" walker="" was="" with="" without="" would="">
Dr Blake's comment: Without insurance problems, here is where an MRI is crucial to see where the problem lies. Is there inflammation in the accessory bones, posterior tibial tendon, or navicular itself. You can also have a fluroscopic exam  to see how much movement there is between the accessory bones and navicular. If the MRI points to an inflammation/sprain problem, the cam walker, plus orthotics, plus taping can be helpful. If the bone is involved, perhaps a bone stimulator for 6 months while you keep the pain level between 0-2. Also, PRP injections for a sprain, or prolotherapy injections, are showing good promise.

I went to see podiatrist #2. He was very confident in recommending a cortisone shot, with the idea that he would give me 2. He gave me the shot right above my AN bone, and I reacted terribly. I could barely walk home from the subway and the pain was present for 1.5 weeks. I could not bare weight on it at all or wear the Cam walker because I had a bruise where the doctor injected the shot. I took Diclofenac Sodium for an NSAID but it did not really help with pain.
Dr Blake's comment: I am not sure what injection was given, but long acting cortisone shots can not be given around tendon insertions. I hope when the dust settles you are fine.
My doctor podiatrist failed to tell me any possible side effects before administering the shot, and I was completely blindsided. I felt worse than I did before getting the shot. This doctor says he doesn’t know what to tell me. I really want to avoid surgery. He says I can try doing 7-8 sessions MLS of laser treatment or PRP (Platelet rich plasma) injections. Have you heard of those treatments? He tells me that he cannot tell me the success rate that he’s had with these treatments since my situation is unique. He has also prescribed PT but I have yet to find a physical therapist yet.
Dr Blake's comment: Right now without your MRI to elucidate the origin of pain, it is hard to advise you. Laser is being used alot, and I know there are different ones, but I can not tell you if it would help. Sorry. Are you icing twice daily, and doing contrast bathes each evening, and perfecting posterior tib taping? 

https://youtu.be/e1JAewWT9Fc

I haven’t had an MRI yet, but he said he could justify ordering one if I wanted. Money is tight for me at the moment. I am trying to evaluate if it is worth getting an MRI. I don’t know if there is tendon or ligament damage or bone edema, etc.
Dr Blake's comment: Get the MRI, self pay is normally around $400-$500, and they may have installment plans. I am sure the doc wants one, but is trying to be cost containing for you, but the money is worth it at this point. 

I would like to do PT and find someone experienced with this condition. Is there a case in which a patient with ANS/PTT should NOT attempt PT…. for example when should & should not a patient start doing PT? I just don’t know if my feet are ready to do PT.
Dr Blake's comment: The goals you are to use immobilization techniques (boot, orthotics, taping, Aircast Airlift PTTD brace), and anti-inflammatory measures (icing, contrasts, topical or oral anti-inflammatory, activity modification) to get the pain between 0-2 levels. If you can not do that, you use PT, laser, acupuncture, etc to bring the pain down. If not, you go into a permanent cast for 6 weeks to totally rest it. Once you are in that 0-2 range, physical therapy gradually strengthens, changes your gait, makes suggestions about orthotic modifications, does soft tissue and joint mobilization, makes sure your calf is not tight, etc. So, you typically use PT in the restrengthening phase of rehabilitation, but some need it in the immobilization phase also.

https://youtu.be/g0sD0gUbEMU

I don’t feel l pronate with my orthotics on, and my arch does not look collapsed/flat. I rest, ice, and elevate my feet. Epsom salt soaks help a little. Should I be using heat also? The pain is under my arch, and if I walk to much (especially in the CAM walker), my calves, glutes, and leg get sore. If my foot starts hurting while I am walking, there is sometimes a shooting pain up my posterior tibial tendon. I tend to shift my weight more on my right foot now and it is beginning to hurt also. The outer right ankle sometimes aches while walking.
Dr Blake's comment: Always err with ice. Heat can be used to warm the tissue up before exercise. Please get an EvenUp for the other side when wearing the Cam Walker, if you are having problems keeping the hip heights level. You probably should be doing daily calf, hamstring, quad, and glut stretches. You should be wearing your orthos in the Cam Walker, and perhaps taping also. Even simple Kinesio taping for the arch as long as you surround the accessory navicular with the tape can be very helpful. If the pressure of the tape irritates, you can pre-cut a hole out for the bump before applying. 
https://youtu.be/NLfzvAJgyJ4

I am seeking your opinion because my current doctor seems to not have an opinion on my condition. After the disaster of the cortisone shot, he seems to not want the responsibility of making any recommendations. I really want to try as many conservative treatments as I can as I am very adverse to the idea of surgery. However, I don’t want to hurt myself by prolonging  this process.

I appreciate your time and knowledge so much. I can send you pictures of Xrays (might take time) or my foot if you suggest.

Thank you in advance for your help.
-SurgeryAdverse

Dr Blake's comment: I am happy to have you send a CD of the MRI when you get that. They can burn the xray images if done at the same place only. Sounds like you have alot to do before any surgery is anticipated. Glad the orthos have been done right. Good luck and I hope this helps some. My mailing address would be 900 Hyde Street, San Francisco, Ca, 94109.    Rich

Patient's Response:
Thank you so much for your quick reply! 

I hope to get an MRI soon- within the next month. I have a new job and will be getting new insurance so it will hopefully be more affordable. Thank you for encouraging me to get an MRI, your justifications make sense and will hopefully give me & doctors more insight on how to move forward.

I haven’t heard of a contrast bath yet but I will try that. I have tried taping but I’m not sure if I am doing it right. I have been watching your videos and others and will continue to try to perfect it. Sometimes the bottom of my foot feels cramped after I tape which I’m not sure is normal or not. I am icing a couple of times a day and elevating my feet.

Thank you again for your help. I will send you MRIs once I get them. It is so nice to get a second opinion.

Have a great weekend!

2 comments:

  1. Hi Dr. Blake,

    I have been having pain in my inner arch of my right foot for the last 2 years. I have seen a podiatrist and an orthopedic surgeon and they are both stumped about the cause of my pain. I have very high, flexible arches and I was born with an extra bone in both feet. I believe it's called accessory navicular bone. I have had xrays and an mri and the only guess could be that there might be either nerve entrapment or that extra bone is causing irritation to a tendon. You can not visibly see this extra bone in my foot. My feet don't always bother me during the day but if I roll over on my left side in my sleep the pain in my foot wakes me up immediately. Sometimes it throbs but it mostly feels like a hot knife stuck into my arch. I also have a small ganglion cyst about an inch above the accessory navicular bone. I have used custom orthotics in the past but they were made from really hard slick plastic and they made my foot slide into the toe of my shoe and it hurt my toes. I could have surgery with a very long recovery time but since the doctors don't know exactly why my foot hurts that may not solve the problem. I am just about at my wits end and don't know what to do. I would love it if you could give me your opinion!

    ReplyDelete
    Replies
    1. Susiebelle, this accessory navicular syndrome could not the cause of the pain, along with a syndrome called tarsal tunnel. Have that evaluated. What did the MRI show of the bone inflammation at the junction of the navicular to the accessory navicular bone. See a neurologist to evaluate for tarsal tunnel, but also give you advice about sleeping. They may give you a small dose of nerve relaxer, but it may calm that part down. The hot knife symptom is definitely nerve, but is it being triggered by the extra bone I do not know. See my and other videos on neural flossing, do three times a day, and see if it excites or calms, or neither. Buy Neuro-Eze a OTC nerve balm that desensitizes. I hope this helps. Rich

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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.