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Sunday, December 9, 2018

Accessory Navicular: Email Advice

I read your website and enjoyed your informative responses to others who have
an accessory navicular syndrome.
I have been suffering from this from 9/8/18 and would greatly appreciate any input. 
I am also happy to travel from NYC to see you if that would be better.
I’m also happy to contribute to your website to keep it going as it is 
so informative— just let me know how to do so.

I am a weekend jogger, a 43-year-old female, fairly active. I ran into a hole in the ground
and all my weight went
to my right foot on 9/8/18.  I saw a foot orthopedic surgeon in my hospital who said I have a
large accessory navicular (X-ray confirmed) and recommended 3 weeks immediately
in a CAM boot which I did religiously.

After 3 weeks I weaned off for about 3 weeks into an orthotic and was feeling better. 
As a mother of a toddler, I had to drive her to class for about an hour
on that 3rd week and my symptoms worsened.

I contacted my orthopedic colleague who told me that more boot time or physical
therapy probably won't help.  I saw another foot orthopedic surgeon who immediately
started talking re the Kidner procedure. I’m a surgeon myself and was taken aback
about taking off a bone I’ve had all my life and retracting a tendon.
Dr. Blake's comment: Thank you for common sense. This is very common in orthopedic
/podiatry where you immediately lean to surgery and forget conservative care. 

So I saw a podiatrist who is quite nice and told me to go back into the boot and
start physical therapy.  I am also taping my foot.
This has been helping but when I saw him again he said I needed more time in the boot
for another 3 weeks.  He did not recommend a MRI as he felt that the treatment
would be the same regardless of whatever MRI result I have.
Dr. Blake's comment: If one doctor is talking about surgery, and there are patients with 
accessory navicular that need surgery, you have to have all the information at hand to 
make the right decisions. I would vote for an MRI to see what is going on. 

I was able to convince my orthopedic surgeon to get a MRI.  It showed:
1. No tear in the PTT
2. Mild to moderate PTT tendonosis most prominent at the navicular insertion 
    next to the accessory navicular
3. Marrow edema along the synchondrosis of accessory.
Dr. Blake's comment: So, what does this mean? The tendinosis means the tendon has been
straining for a long while and maybe this area was becoming a weak spot to you. 
The chronic part that will take the most work from you is the tendinosis. 
I will attach the posterior tibial tendon strengthening program video I like andthe taping you
should do for a while.

The bone edema is the acute part and that is going to take time since
that is very painful. You have to assume the worse that you broke the synchronosis
or synostosis bridge between the navicular and the accessory navicular. This is treated with 
3 months removable boot, 2 month minimum, to obtain the 0-2 pain level consistently.
Then you wean out of the boot into supportive shoes, good orthotics to support this area,
and use the taping. You ice for 10 minutes twice daily, and do contrasts baths in the
evening. You get an Exogen 5000 bone stim and treat this as a fracture, since it may. 
We will slowly wean into less supportive shoes, less supportive orthotics, less supportive
taping, but gradually as long as the 0-2 pain can be maintained. You gradually build up to 
2 sets of 25 level 6 theraband typically over the next 6 months. 

If I could ask your opinion on the following:
1. As of next week, I will be in the CAM boot for 10 weeks.  
    How long do I need to be in the boot?  It actually hurts now being in it.
    Dr. Blake's comment:
It is hard to know if you have a delicate fracture across the
    synchondrosis needing more immobilization. What helps is the understanding that 
    if you can maintain a 0-2 pain level, you are pretty safe in whatever your 
    environment. Learn the taping, max the support from shoes and orthotics, and you
    should be able to wean out of the boot. Remember you need to wean out, typically
    2-6 weeks, based on maintaining the 0-2 pain level. 
2. Do I need surgery?
    Dr. Blake's comment: Typically it takes almost a year if the doctor is really trying to 
    avoid surgery by using rehabilitation to know if you need surgery. It is not wait and see
    but trying to figure out how to drive the pain to 0-2 but be completely active. First you
    want to figure out what it takes to keep pain down and walk 30 minutes daily and see 
    where to go from there. Did it take orthotics, shoes, taping, PT, AFOs, etc? Do you
    have to wear a boot occasionally due to flares?
3. Can I ever run if I do not have surgery?
    Dr. Blake's comment: Yes, that is why you have the surgery, so that there is no long term 
    disability. However, it is the same reason to avoid surgery, since a surgical complication, 
    less than 10%, could give you some long term disability. The surgery is very successful, 
    but the post operative course is a bell shaped curve for healing, and you could be in the
    slow group. This is surgery to the arch, arch supports will be a permanent addition to 
    your running accessories to rest this area. A surgical area in orthopedics tends to be a 
    weak spot to some degree going forward.  
4. Do custom orthotics matter?  I had some moldings done w an pedorthist in NYC. 
    Dr. Blake's comment: Depends on their knowledge with your injury, and what works.
    Based on your unique biomechanics, there is probably seven or eight orthotic cast
    corrections to choose from, not counting the modifications that are possible to the 
    device itself. It does not have to be perfect by any means, just thoughtful for you. 
5. What percentage of adults (not adolescents) who present to your practice 
    w accessory navicular syndrome need surgery?
    Dr. Blake's comment: Not common, and I am sure some are lost to followup, but I always 
    have a surgical opinion as we try to work this through. 10% that need surgery even 
    feels high to me. The surgery is normally because the tendon is more the problem I think. 
    Repairing a diseased posterior tibial tendon is part of the removal process of the 
    accessory bone. I think we know at 6 months if someone is going to avoid surgery. 
    And all the skills we learned trying to avoid the surgery in the first place: good shoes, 
    good orthotics, how to tape, how to get strong, how to get rid of inflammation, etc, will
    help in a post operative course. I know the last 10 patients I saw with this, none 
    needed surgery, but at some point in the ups and downs, they all would have had
    surgery if I had given up. 
6. How long does it take normally for symptoms to improve?  6 months?  1 year?
    Dr. Blake's comment: Phase I of Rehabilitation: Immobilization (where you are at). Here 
    the pain should be reduced to 0-2 by immobilization, fitting for orthotic devices, getting 
    stable shoes, avoiding barefoot, learning to tape, etc. In Phase II, Re-Strengthening, 
    you are progressiving through the stages of strengthening exercises, but still 
    maintaining 0-2 pain, so tape, orthotics, shoes, occasional boot are needed. Phase III
    Return to Activity you still maintain 0-2 while you start a Walk/Run Program, and
    other sport specific drills, continuing to tape, ice, bone stim, strengthen, etc. Therefore, 
    the symptoms should be low by the time the main immobilization is done, and 
    treatment is based on maintaining that as activity returns to normal. A poor 
    rehabilitation plan will not get you through, but I hope I have given you some idea of how
    to do it successfully. Sorry, but no guarantees in life. I would approach this as a rehab 
    program, not as "I hope I can avoid surgery program." The next time to think about
    surgery is 4 months from now to check how you are doing. Now your job is to begin
    to put the ducks in a row and maintain 0-2. 

Any help would be appreciated and again if you prefer to examine me
I am happy to travel to SF.  I was actually studying at the USF
in the early 2000s and
enjoyed living in the Sunset area.
Dr. Blake's comment: I grew up in the Sunset on 38th Avenue. Happy
to see you if it seems appropriate at some time this next year. Hope this has been 
helpful. Rich

Thank you very much.

Best regards,

Thursday, December 6, 2018

Stim Router for Nerve Pain: Recent Patient with wonderful results

     Every now and again I am exposed to new technologies that may help many of my patients. This information on Stim Router came from a patient who was kicked in ultimate frisbee on the inside of his lower leg injuring the posterior tibial nerve. This gave him pain in the leg, ankle, and foot (especially the arch). He eventually had a complicated tarsal tunnel surgery at the ankle (although the injury to the nerve was 5 inches above the ankle. When that surgery did not work, he was referred for the stim router technology. They run a wire from one side of your leg under the skin so that it sits on top of the injured nerve. Then they attach a sensor on the outside of your skin that can be turned on and off to stimulate the injured nerve to stop the pain. Fascinating. The links to the technique and individual doctor my patient used at Stanford are below. 

The video below is one version of the technique.

Discussion from a patient who just had the procedure.

Monday, December 3, 2018

Problems post Big Toe Joint Fusion: Email Advice

Dear Dr. Blake,

I was referred to you by Stephen Pribut (podiatrist in the Washington, DC. area).  He said you may be able to respond to my questions by email and offer suggestions for a course of action.

I am writing to request your opinion on the problems I am having with the fusion of my left big toe.  I know this is not an examination but I believe you can address a couple of specific questions I have described below.

In May 2017 I had my left big toe fused due to hallux rigidus.  Once I started trying to walk, I felt significant pain underneath the last joint of the big toe.  There is no pain at the MTP joint.  For the last 18 months, I have been trying to determine the cause of the pain with no success.  The surgeon says the fusion is okay. 

In June 2018, I got 2nd opinions.  I was told either the angle of the toe was fused too low or the hardware was to blame.  I didn't want to redo the fusion so I had the hardware removed.  This did not solve the problem.
Dr. Blake's comment: This is not uncommon, but a pesty complication where the big toe is not fused high enough so the end of the toe becomes the low point when pushing off and takes all your body weight. You can rebreak and refuse or design orthotics to off weight the point to distribute the force. Most choose the orthotic or padding option. 

I came across the chapter attached discussing complications of the fusion.  My symptoms mirror exactly the situation where the toe was fused too plantarflexed or too low.  If you look at the upper of the HOKA rocker shoe I've been wearing, it is evident that my midfoot to the 5th toe is bending over to the outside.  Then, as I walk, I pronate and roll over the foot to the inside trying to avoid the end of the toe.  I have a large callous on the side of the toe as a result.  I have tried but now realize I can not really feel the ball of my foot/MTP joint touch the ground.  So, when I toe off, all the force is on the end of the toe.  It looks like the xray shown in the chapter - Figure 2A and 2B, p117.

I would appreciate your comments on 2 items:

1. I had a gait analysis on November 19, 2018.  The graph is in the attachment while other data is copied below.  I believe the graph/image supports an over plantarflexion of the left big toe.  I know this is not a formal examination but please can you tell me what you see from the graph/image? Dr. Blake's comment: Yes, that is how it looks.  
I would note my right foot looks more normal to me even though I had some scar tissue excised on the 2nd and 3rd toes just 2 weeks ago.  It is little stiff but no pain like I experience with every step with my left foot.

2.  Noting the pronation of my left ankle, the physical therapist believes that might be a cause.  I have always had some pronation but I have never had pain under my toe until this fusion.  I believe the pronation is now exaggerated because the midfoot is rolling to the outside which it never did before.  So the ankle has to roll farther to the inside to get me over the toes.
The pt suggests a medial wedge.  I think this may make the midfoot problem worse.  What do you think?
Dr. Blake's comment: Yes, a medial wedge will just throw you out and mess everything up from more constant supination. Typically it is a balancing act of some lateral support so not to supinate at all, and some off weight-bearing padding on a full-length orthotic device to take pressure away from the point of pressure in the gait image. 

He taped the inside of my calf/heel as a test and that caused pain just below the knee on the inside.
All the modifications to shoes, orthotics, etc. to avoid the big toe only make foot mechanics worse, not better, in my opinion.
Dr. Blake's comment: You are on the right track. You need stability with weight spread out on the big toe, just not on the sore spot. After a fusion, the benefit is to have this stable big toe joint that is not painful and can accept all this weight. At least by theory. So, you want a stable orthotic that loads 90% of the big toe, not off weights the big toe. 

I would be most grateful for your opinion on these 2 matters.  It is looking like I will need to get the fusion redone.  I want to make that decision with the benefit of all the information I can obtain.  It is difficult when there will be opposing views.  My goal is to return to downhill skiing and hiking if I can.  Three years ago I was playing tennis too.  Now, I can't go for a walk because of the pain in the foot and related hip and lower back issues.
Thanking you in advance for your help, Good Luck!!

Dr. Blake's comment: 

I am just back from Hong Kong, visiting my son and his family so my response will be influenced by jet lag to some degree. First of all, thank you and Stephen for contacting me. The graph looks like the pressure from standing only with you having a high arch. Is it true,  and are there other graphs? Typically these problems do not need another surgery, so I am so sorry the hardware was removed. If the big toe was placed too far plantarflexed, and you can not bend the joint, you have to get orthotics that stabilize both sides of your foot and get Hoka shoes that roll. Typically you can build up the orthotic device under the big toe joint and the base of the hallux to even the pressure through that area. Most podiatrists can accomplish that. You can test that theory by getting 1/8th-inch adhesive felt from and place something like a cluffy wedge on your foot (explained in my blog). The area on the toe that is hot should not have any covering. Please take this info and ask me other questions. Rich