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Friday, March 1, 2013

Accessory Navicular: Email Advice

Dr. Blake, I've read through most of your accessory navicular related blog and am wondering if you know any like-minded podiatrists in Seattle that have dealt successfully with non-surgical solutions.
Dr Blake's comment: Just heard a great lecture by Dr Mark Reeves from the Seattle area.

 My ortho has taken me through the boot, orthotics (custom and non), air casts, limited activity, etc. with little to no improvement and is now indicated surgery is my only option.

 He's not been willing to consider any kind of strengthening, physical therapy in this mix and I have yet to find a physical therapist that has said experience.
Dr Blake's comment: When you are dealing with the accessory navicular, you need to strengthen both the intrinsics and the posterior tibial tendon itself. 

 I will note that the pressure of all of the orthotics and motion limiting efforts, including a simple neoprene ankle brace for night-time which, apart from driving, is when I experience the worst pain, all cause MORE pain.
Dr Blake's comment: Even if intellectually a treatment sounds good, if it increases pain, it must be modified or abandoned. You must be in an orthotic that gives you great support but does not put pressure on the sore area. Most orthotic makers, and labs, know how to design what they call "sweet spots" in the orthotic device. Have the prescribing doctor talk to the lab that made them. This is so crucial to success, and even post op if you end up having surgery. 

 If not immediately then at least within hours or days. The only shoes I can wear that don't cause pain are flat with little to no pressure on my arch (ideally none) or heels which put so much weight not the ball of my foot that my arch gets a break.

 My doctor has completed x-rays and MRIs and indicates that, while the accessory navicular area is "extremely irritated" there are no other issue of concern and gave me permission to take six months to try whatever I wanted (with no specific recommendations from him as he believes strengthening is not helpful) before getting the surgery.
Dr Blake's comment: In an ideal world, a surgeon teams up with a non-surgeon to successfully deal with these injuries. 

 Another side note, my ortho effectively diagnosed me with a leg discrepancy just under a year ago. I've had this since I was at least 13 and it had started to cause me low back issues. He recommended lifts which I now employ in my shoes (under the heel) at great relief to my low back. The accessory navicular "flare up", the first one I've had, occurred within three months after correcting the leg discrepancy. I was feeling much better and had increased my running activity (though I was a regular runner prior the better alignment seemed to help my endurance) which seems to have stressed the accessory navicular. While my ortho claims it was unrelated to my leg discrepancy fix I find it hard to believe a change it my hip alignment is not somehow precipitating to my flare-up.
Dr Blake's comment: If you read my blog posts on Short Leg Syndrome, you will understand I am not a big proponent of heel lifts to treat Short Leg Syndrome. For some, they increase lower extremity instabilities (like wearing a heel on one side). To be safe, I would switch to a full length lift on the short side. 

 While the benefit of the lifts is overall better low back health, should I forget the lift for a crucial period of time (as I did this week when I went to spin class--currently my only exercise along with limited yoga--forgot put my lift in my shoe and pulled my low back) I will easily re-injure my low back. I am desperately in need to support with my overall alignment, appropriate strengthening and prevention that will hopefully keep me out of the operating room and off the couch. Any suggestions? Sincerely appreciate your input,
Dr Blake's comment: So, where do you go from here? It is important to take it one month at a time. Over the next month, do the following: I hope this helps you. Dr Rich Blake

  1. Gradually begin both intrinsic and posterior tibial strengthening, pain free. 
  2. Get the Aircast Airlift PTTD Brace
  3. Research how to get a supportive orthotic that does not put pressure on sore spot.
  4. Ice Pack the sore area 3 times per day for 10-15 minutes
  5. Try to create a pain free environment with shoes, inserts, braces, activity modification, etc
  6. Change your lift to full length from a heel lift 
  7. Use Kinesiotape arch taping with the sore area cut out so the hole in the tape lines up with the sore area. 
  8. Check out Dr Reeves for an opinion. 

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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.