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Thursday, July 2, 2015

Accessory Navicular and Tarsal Tunnel: Email Advice

Accessory Navicular Problems: Further info from the initial blog post

Dr. Blake,

I am a 31-year old professional who currently works in an office in Massachusetts. Last year, however, I spent 9 months in Spain teaching English. I had no car and found myself doing lots of walking. I also gained about 15 pounds in the first couple of months there. I noticed after three months of walking in ballet flat style shoes a burning sensation in my right ankle. Long story short, here we are a year and a half later and I still have the pain. I weigh about 125 and am 5'2".
Dr Blake's comment: Tentative diagnosis is Tarsal Tunnel Syndrome. This is neuropathic pain, and needs to be treated with a nerve emphasis, some mechanical changes, and some anti-inflammatory measures.

I have seen a total of four doctors so far. I have done PT, tried custom orthotics (which I lost during my move back), tried a walking boot for 6 weeks, been on a couple strong NSAIDs, modified my activities, and tried ice and heat therapy at home on a sporadic basis.
Dr Blake's comment: This problem is helped with the mechanical support of the orthotic devices, especially if there is some varus wedge at the heel. Also, nerves love heat not ice, motion not lack of motion, no massage, and gentle stretching (like neural gliding). 

The orthotics caused more foot pain in other areas, so I am not sure they were made properly for my condition. The PT was done in Spain a year ago and consisted of 45 minutes of heat therapy, electric wave therapy, and massage every day for three weeks.

Six weeks in the boot this past winter was creating problems in my left knee and hip. They never gave me a leveler for the other side, but I did wear a high shoe which seemed okay.

Please help with your opinion! My current doctor who is an orthopedic surgeon and prescribed the boot is of the persuasion that PT and orthotics will not help the edema he sees on the MRI in my bones. I personally want to try a new PT routine and new orthotics before I resort to surgery, but that means I will have to move on to a new doctor yet again. Two doctors were in Spain and the other was here in the U.S. (podiatrist with a horrible bedside manner who said paying $400 for orthotics from his office was the only option).

I am so frustrated and feel like I have tried everything but I also think the timing and quality of the things I have tried could be reassessed and tried again. What do you think?
I don't want surgery if possible. It is my right foot and it will make me unable to drive.

Dr Blake's comment: Without a history of a fall or collision causing major injury, the need for surgery is typically small. Yes, starting again sounds the best. The bone edema could be residual for a stress fracture that has healed or is still healing, and the inflammation from the bone injury putting pressure on the nerves leading to the burning. Burning is classic nerve pain. You need to create your pain free environment however while you search out a new doctor. Typically sports medicine doctors, not necessarily podiatrists or orthopedists, are the best. If 6 months has passed from the first MRI, get another to assess the amount of healing. You may not feel any better until the bone edema is all healed. It is a reflection of bone trauma. Go back into the boot part of the day if you can not find another environment to keep the foot happy. See if warm water soaking works better than contrast bathes. If your skin can tolerate some massage, order NeuroEze online and massage 3 times per day, at least above and below the sore areas. Also do neural gliding 3 times per day, as long as it is comfortable. If warmth or contrast does not help, stay with ice packs. You can experiment with placing the ice pack over the area, or above it. Send me other info on what you have found works and does not work. Are you better in heels vs flats, barefoot vs shoes, etc? How long can you walk without limping? Send a photo of your foot with your finger pointing to the exact area. Hope this starts the forward progress. What exact diagnoses have you been given? Rich

Hi Dr. Blake,

Thank you so much for responding. I will do my best to answer your questions.
I have an accessory navicular in both feet (see photo of right foot with me pointing to general area of pain). I only realized they existed recently, because they never caused me any pain before, and I only present symptoms in the right foot. The pain changes places; sometimes it is under the arch, and other times there is a shooting pain up the post tibial tendon. Some days it feels like a rubber band about to snap with too much pressure, and other days it's that burning I described. I also have flat feet.
Dr Blake's comment: That definitely sounds more like an accessory navicular problem. Since it involves the posterior tibial tendon in the tarsal tunnel, you can get nerve pain or nerve symptoms being generated. 

It seems like switching shoes often helps. Barefoot is bad. I have spent more money on shoes in the past year than in my entire life! Dr. Scholl's inserts, MBT rocker bottom shoes (horrible for my condition), Clarks, sneakers, really expensive clogs, etc. The clogs (with a raised heel) are my favorite. However, I refuse to wear them in the summer as I still have some sense of fashion to maintain. I just bought some comfortable Clarks to get me through the summer that look like ballet flats but have a much better sole and support, with a wide toe. I'm also in love with Okabashi flip flops, and wear them around the house as much as possible.
Dr Blake's comment: If you can get comfortable, but stable orthotic devices, the design can be used in your sandals with a removable insole.

The MRI was done in January 2015 and we are now in May. My condition has not changed symptomatically since December 2013. My orthopedist believes that physical therapy will inflame the edema more, or be useless. He is also not a fan of orthotics, which I tend to agree with, because from what I've read online, they don't make your feet work hard enough and allow them to lazily conform to a mold. Some doctors believe they create dependency. What is your view on this?
Dr Blake's comment: I love orthotics for this problem. I believe you only need to do 2-3 minutes a day of strengthening to make up for any weakness from the bracing effect. And strengthening the posterior tibial tendon should be part of your program. You must understand, since you are still trying to get into a pain free environment for most activities, you are still technically in the Immobilization/Anti-Inflammatory Phase of Rehabilitation, so any assistive aid is very appropriate now (especially when some are suggesting surgery).

So you think I should try using the boot again even though it didn't cure the condition in 6 weeks, just for comfort, while I search for a sports medicine doctor? The boot does cause problems in the left hip and knee if I wear it too long, but I will certainly do anything to get better! I will also mention that I am developing a bunionette on the right foot from compensating, as well as from wearing winter boots with a tapered toe. Not too happy about this!
Dr Blake's comment: See the video on Tailor's Bunion care.

I am currently taking Meloxicam and it doesn't seem to be helping after a month. I was on Indomethacin for a few weeks, and while I believe it did help reduce inflammation temporarily, the side effects were awful. You are correct in stating the foot likes heat better than ice.
Dr Blake's comment: At this stage you have both inflammatory pain and nerve pain. And they can trade off on a daily or weekly basis what gives you the current symptoms. Try to see if you can distinguish the various types of pain, and what treatments help them. 

My life has changed completely and I cannot play tennis, do Zumba classes, or walk long distances anymore. It has affected my social life and career as I must ask co-workers, family and friends to coordinate activity around my pain. Sometimes I push myself when I'm alone because I need to get things done (cleaning, vacuuming, etc). but I suffer the following two days recovering.
Dr Blake's comment: This is why I would err on getting and learning all forms of immobilization: various taping, different orthotic designs, Aircast PTTD brace, removable boots, AFOs, shoes, and power lacing. Read the posts on posterior tibial tendon dysfunction to see all these avenues like the one below.

The reason I have hope for recovery is that I have had a couple sporadic days with absolutely no pain. I did not change anything activity-wise, so I have no idea what alleviated the symptoms. I hope I am being reasonable by avoiding surgery. I am very anxious about it, but I also don't want to avoid it forever if it's really the best option. It seems that the body can heal itself in many cases given the right conditions, and want to exhaust all options before going under the knife, being out of work, collecting disability, etc. I am a very active person and while I have rested the foot a great deal, I won't pretend it's been easy to slow down.
I'd like to lose 10 lbs. because I think being a little lighter will alleviate some pressure, but I am not even overweight and don't want to have to maintain a low weight my entire life just for this reason (I.e., what if I get pregnant someday)? I think the weight is a contributing factor, not a root cause. I am having a hard time losing weight with the condition, ironically.
Thank you again for your time, Dr. Blake. I sincerely appreciate it!

Dr Blake's comment: Good luck. Here is my typical checklist for accessory navicular issues (with tendinitis and tarsal tunnel symptoms just part of the overal syndrome).

The top 10 treatments for accessory navicular syndrome:

1.  An MRI is very important to discover what the source of pain actually is: stress fracture, joint inflammation, or tendinitis. There is a joint between the navicular and its accessory bone.
2. Use Kinesio Taping or tape or classic low dye taping techniques intially 24/7 and then for extended activities.
3.  Ice pack the sore area 10-15 minutes 3 times daily.
4.  Go into a removable boot (such as an Anklizer) for 2-3 months if needed to calm the foot down.
5.  Strengthen the posterior tibial tendon starting initially with active range of motion like ankle circles.
6.  Check out the Aircast Airlift PTTD brace to see if it is helpful for you and can get you out of the boot faster.
7.  Custom foot orthotics are a must for a 2 year period. They must produce a good force against the navicular, but it may take time finding the right orthotic guy/gal.
8.  You can use Sole OTC orthotic devices with medial longitudinal Hapads initially until a good protective orthotic device is made.
9.  Create a pain free environment as soon as possible (level 0-2).
10.  If the MRI shows bone reaction (edema), order a bone stimulator as soon as possible to start strengthening the bone.

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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.