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Friday, June 6, 2014

Posterior Tibial Tendinitis with Accessory Navicular: Email Advice

Dear Dr. Blake,
     I have been following your site for a few months now and I am blown away by your kindness and generosity in answering the questions of strangers. It is an amazing blessing that you are giving to others and the sense of hope I have received from some of your entries is enormous.  I also read that you recently lost some people who are close to you and I wanted you to know that I'll be keeping you and your family in my prayers.  I was touched by the video you posted on June 1st and will certainly forward it to others.
Although I'm in Boston and can't come to CA to see you, I would be happy to pay you for email advice, so just let me know what your policy is. I would also be happy to send payment along with copies of x-rays, MRIs, etc. if you think it is necessary. I spent a few days writing and editing this to keep it concise and "calm" so I don't come off as a crazy patient! Although we distance runners ARE a bit crazy :) 
Dr Blake's comment: I can not thank you enough for your kind words. I have never charged for this service, but hope it is worth more than what you pay. I have to deal with crazy runners all the time, and because I am a crazy basketball player/athlete, we tend to get along just fine. I am needing time to review another patient's scans that she sent (sorry Sue, but I am slowly getting to yours), so I may not be able to review for a while. You can definitely send.  

     I am a 26 year old female runner - I absolutely love running half and full marathons, and this fall ran a full marathon that made my dream come true- qualifying for the 2015 Boston marathon. I have had no foot pain in my past 10 years of running about 35-40 miles a week, every week, except for some mild pain when I was about 16  which led me to get custom orthotics (they have been great for over a decade with zero signs of pain! BUT I've been wearing the same running orthotics for over a decade). Through my career I've had some minor problems that always resolved quickly with PT and cross-training (knee, hip), but never anything in my foot. I did once have a really bad sprain in my right ankle (not my currently affected side) that took over 6 months to heal. I do over-pronate and have somewhat low arches, but I'm certainly not flat-footed. I am petite at 5'2" and 103 lbs. (so I don't think I have much extra mass that is causing problems). 

     Mid-April while training for another marathon, I started getting some tightness/soreness in my left inner arch. I did a lot of icing, took days off of running here and there, but continued to train. I successfully ran my 20 mile training run on April 18th with some tightness, but not really pain. On April 25th, I took a short 4 miler and had a moment of sharp pain near my navicular, and limped the last 1/4 mile home. I put myself on a running hiatus for a full week. On the 8th day, I decided to "test" running again to determine if I needed to call off the marathon and cancel my travel and hotel. I successfully ran 10 miles with zero pain. However, that night my foot was stiff and sore.  Since then, I have not run a single mile - 40 days so far. Obviously I chose to sit out the marathon.  I wanted to be very cautious and not make my recovery any longer than it needed to be which is why I stopped running completely.

     The pain in mid April- early May was initially  at the accessory navicular, although I didn't know what that was at the time. I could produce pain when I pressed anywhere on it, with stiffness more generally around the arch. Further down in the email I'll give an update on where the pain is now. At no point did I have severe pain - I don't think it ever went beyond a 3 on the 1-10 scale. 

      I have iced in an ice bucket 2-3 times a day all 40 of those days that I have not run, and I have been cross-training with zero pain (bike, elliptical, etc.). Like many athletes,  I tend to run through A LOT of pain (including a stress fracture once!), but something in my heart and mind told me to STOP when it came to this particular injury. My heart is broken without running, although I'm trying to keep it in perspective. Lots of prayer!!  It has been emotional but I am grateful that I can at least cross-train but I'm living in fear of "will this ever heal?"

     I am a researcher by training, so of course I got onto PubMed and downloaded every medical journal article I could find. I diagnosed myself (haha) with an accessory navicular and posterior tibial tendonitis. 

     I saw a general sports doctor at Prominent Boston Hospital #1 in early May (omitting name out of respect for the doctor/hospital) who was largely dismissive of my injury and seemed totally un-sympathetic, but he told me my self-diagnosis was totally correct after looking at the x-rays (PTT and accessory navicular). He tested my feet and said my foot muscles were super weak so PT would be helpful. I had to basically get on my knees to BEG him for an MRI, because I knew I couldn't sleep until I got it. I had been making myself sick with worry.  He was frustrated with me but finally prescribed one (I was in tears at that point).

     I then saw a foot and ankle surgeon at Prominent Boston Hospital #2 yesterday, June 4th, 2014, who was kind, sympathetic, and seemed encouraging. He thought that it might be time for new orthotics since I've run in mine for so long, and having ones with a medial post would help with my overpronation, rather than only supporting the arch with a wedge. He prescribed PT and said we could meet again in 6 weeks to see how things were and re-evaluate if surgery is really necessary. The idea of surgery plus 6-8+ weeks in a cast, plus all that rehab, totally terrifies me, especially given that I'm not in severe pain.
Dr Blake's comment: The chance of you needing surgery is probably 2%. 

     At the same time, I so desperately want to be a "real athlete" again, and if the surgery afforded me that, I would do it. He definitely had limited experience with patients with this problem (he was in his fellowship in foot/ankle surgery, but I found him to be patient, understanding, and deeply caring) but his supervising surgeon had plenty and he would talk to him about it. He looked at my MRI and x-ray and said he didn't see much that was concerning, except for a tiny bit of fluid around the PTT. He was expecting to see much more irritation around the accessory navicular, but it didn't look bad at all.
Dr Blake's comment: This is a good sign. When the accessory navicular is a problem, there is more fluid around and/or in it. Hopefully, you have posterior tibial tendinitis mainly. 

     When I got home yesterday evening, my MRI report was finally in my mailbox- would have been helpful if I had it before I saw the surgeon! Maybe I'm reading into it too much, but the report from the radiologist seemed worse than what the surgeon told me today (he didn't think things looked too bad).
Imaging results: X-rays of foot and ankle showed accessory navicular. MRI report for the ankle said:
1. 11 mm multiloculated ganglion cyst between the spring ligament and talus
2. Mild tenosynovitis along mid to distal aspect of posterior tibialis tendon, with mild tenodonitis at its insertion on a type 2 os naviculare
3.  Mild degenerative changes along the articulation between the os naviculare and navicular bone
Dr Blake's comment: This mainly shows tendinitis. The treatment of tendinitis is very conservative--PT, orthotic devices, anti-inflammatory, taping, and strengthening. The ganglion cyst and degenerative changes make this interesting. 

     Other text on the report on foot and ankle: "normal alignment, joint spaces are preserved, no fracture is appreciated. The anterior ankle tendons are intact with normal signal intensity. Mild tenosynovitis along the mid to distal aspect of the posterior tibialis tendon. The tendon is normal in morphology and signal intensity, except at its attachment to a type 2 os navicularis where there is mild tendonosis. Normal fat signal seen within the sinus tarsi. The anterior and posterior talofibular ligaments are in tact. The anterior talofibular, posterior talofibular, and calcaneofibular ligaments are in tact, the deltoid ligament is intact. Deep to the spring ligament and overlying the talus there is a multiloculated ganglion that measures up to 11 X 6 mm in the axial plane. The subtalar joint is unremarkable. The articular cartilage throughout the midfoot is intact. The marrow signal is normal. There is no talar dome osteochondral defect. There is no acute dislocation, marrow edema, erosion, or cortical thickening. The flexor and extensor tendons about the foot are  intact, with normal signal intesity. No intermetatarsal bursitis is appreciated. No significant subcutaneous edema."
Dr Blake's comment: No significant change here. The ganglion is interesting if it is involved with your pain. 

     I'm thinking I might mail this report to the surgeon I saw yesterday so he can review it with the supervising physician (chief of foot and ankle surgery at the biggest Boston hospital) before my follow-up in 6 weeks. He reviewed the MRI and said nothing about the ganglion cyst, which I am in a complete panic attack about. I don't even know what this cyst is, but I assume it is horrible, terrible news. I'm avoiding googling it out of fear. 
Dr Blake's comment: Ganglion cysts arise from herniations of the ligaments from a joint. Sometimes they need to be removed. We always try injecting them and draining if possible. Some of them cause pain, most do not. 

     My pain these days: At no point since the initial onset of pain, up to today, have I been in incredible pain, thank God. I almost feel embarrassed that this has caused me so much distress, but I've been in very little pain this entire time. I can walk to and from work (about a mile each way), go about my daily activities, etc. with little or no pain. Cross training has been fine- no pain or stiffness during or after whatsoever.  The reason I have not run a single mile in 40 days is primarily because when I wake up in the morning, I have pain/stiffness in my foot for a few minutes. As an athlete, I take this as my body's message of "something is damaged," so I don't want to risk it. The  surgeon I saw yesterday said I could try some light running (but I refuse out of fear until I get my new orthotics). 
Dr Blake's comment: You are showing great wisdom at your young age. Definitely, this is an arch problem, and perfecting the orthotics first makes sense. Learn how to do some version of arch taping. I have the kinesio version and the low dye versions on my blog. These should be done with the orthotics for several months until your running is back up to normal. 

     The pain/stiffness upon waking is sort of difficult to localize and feels "deep" in my foot, but generally in the area of the navicular. Sometimes when I am sitting at my desk at work or get up after sitting for a while, there will be some stiffness in the arch, and there is often tenderness in the area of the PTT near the ankle  but more of an annoyance, not serious pain. As I mentioned, originally (in April/early May) I could produce pain on the accessory navicular when pressing it. Now, it is quite difficult for me to produce pain on the accessory navicular, and it almost never hurts. But the mild PTT tenderness, and particularly the tightness/pain in my arch upon waking, makes me worry. I am quite sure that if I went running, I'd spend the evening with a very stiff and sore foot. Right now, I mainly am limping during my first 3 or so  minutes out of bed, plus occasionally rubbing/flexing my foot during the day to test for stiffness/soreness. I'd say my pain on waking up in the morning is about a 3, the rest of the day I'm at a 0 or 1. Given this relatively low level of pain, it seems crazy to risk going through a major surgery. Honestly, if I were not a runner, I probably would not have even seen a doctor for this. But as an athlete, it consumes most of my thoughts, and makes me lose sleep! 
Dr Blake's comment: I have seen too many surgeries by great docs go wrong to say something but any thought of surgery  (if needed) should be 2 years from now. This means you do everything possible to avoid surgery. Again, the ganglion is a little unusual, and could be removed with minimal problem if we could prove it was your problem. Ganglion cyst are injected with cortisone all the time, but if placed too close to the posterior tibial tendon, could cause a rupture. If these things were easy a monkey could design a treatment plan. 

     I am scheduled to get casted for new Orthotics (the first appointment I could get for casting the orthotics is July 14, ugh!) and I will have my first PT session on June 16th (also the soonest I could get in).
So my question is... in your experience, do you really think there is a possibility of ridding myself of my PTT/accessory navicular pain with continuing rest, ice, and PT, even if 40 days off of running hasn't healed it?
Dr Blake's comment: Yes, orthotics with more support, a great strengthening program, icing, taping, activity modification, gradually increase running every other day with new orthotics (the new orthos should be more supportive and comfortable in the area of the accessory navicular), should all help. 

     Do tendons just sometimes take this long to heal? My concern is that if my accessory navicular is causing my PTT pain, how will I ever resolve it if I don't get the accessory navicular OUT of my foot? I guess I need to hear that other athletes out there in the world struggled with this for MONTHS but eventually returned to sport without surgery but plenty of PT and patience. The other part of me thinks "I had this bone for 26 years with NO pain, so what's to say I can't go back to being pain-free even if the bone is still in my foot?"  I dread a lifetime of just wondering when I'll need to have major surgery on this, and long for the days just a couple of months ago when I could easily run 40 miles a week, wear flip flops, go hiking, etc., without giving a single though to my feet. It seems like this came out of nowhere. I have been a serious runner for so long, with basically no change in what I was doing.  Do you think this very surprising finding of the ganglion cyst is related (a cause or a result?) of the navicular/PTT issues? Am I totally doomed?
Dr Blake's comment: 3% of the population have accessory naviculars. Our sports clinic which is geared more towards rehabilitation, does one of these removals every 2-3 years. Probably on 1% of the patients presenting like you. So, I feel comfortable that your chance of needing surgery for the accessory navicular over the next 40 years, with high level sports is probably around 2% at most. That being said, the ganglion cyst is more likely a cause of problems and needs long discussions with your docs. We really do not know where you are, so after you get the new orthos, and after you need that they give great support, along with taping, begin running every day with your foot taped, while you start PT. It sounds like it will take until September to get a great feel of where you are going with this. Keep me in the loop. 

     Second, is it bad that I'm still doing the ice baths, 40 days later? Should I also be doing heat baths of some sort on it? I just want to make sure there isn't the possibility that I'm over-icing, if that is a thing!
Dr Blake's comment: Definitely I would have you ice pack 10 minutes only 2 times a day, especially after exercise, and do one session of contrast bathing each evening. 

     Third, although I'm sure the Physical Therapist I'm going to see will be fine (I live in Boston with good access to medical professionals), my assumption is that PTT and accessory navicular issues are rare. I doubt they will know much about a ganglion cyst in the spring ligament.  Is there any information I should bring him/her about which specific areas I need to be strengthening? I don't want to make it worse with PT! Are there additional types of therapy, massage, medication I should be trying?
Dr Blake's comment: The ganglion is something for you and your doc to work on, and to decide if it is related to your pain. There is nothing that the PT does for this. The PT should painlessly strengthening the posterior tibial tendon in particular, the rest of your foot and ankle tendons in general, and work on your core strength, cardio, cross training. They will also do anti-inflammatory modalities. Definitely run while you have PT to get an honest feel of how you are doing no matter what they say to do. 

     I am totally dedicated to staying away from running as long as I need to in order to get through this without surgery (though praying I will be able to run the Boston Marathon in 10.5 months!) but you can be honest with me if you think surgery is going to be the only true option to "fix" me.
Dr Blake's comment: It is actually unfortunate that you have any running goals ahead of you. They sometimes get in the way to common sense. I am hopeful with the taping, PT, new orthotics, and return to running goes smoothly. We will see if there are any glitches over the next few months. Keep me in the loop. Rich

     The one blessing in this is that it has helped me re-evaluate my focus on faith, family, friends instead of just running, and it has encouraged me to cross-train and strength-train more (which I almost never did). I am an obedient PT patient and will follow my PT orders religiously. I want to come out of this healthy and strong, able to enjoy my feet and where they take me well into my nineties.
Thank you SO much for your kindness, I am praying for hope and perspective on this since it has been very tough to keep the tears back during the past 40 days.

Sybil (name changed)
Boston, MA - Age 26

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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.