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Sunday, January 7, 2018

Accessory Navicular post Ankle Sprain: Email Advice

I'm a female 37 y/o. I have a question about treatment for a recurrent problem with left accessory navicular after a sprain to ankle in April '17. 
Dr. Blake's comment: When you have a typical inversion sprain where your foot rolls to the outside, you should have all your pain on the outside. When someone has an inversion sprain and has some inside pain (medial side of the foot of the arch side or big toe side), you have to investigate. This is a Golden Rule: There should never be inside pain after rolling your foot to the outside. If there is inside pain, you must consider that something else has been injured in the sprain. That you possibly have more than one injury at the same time. 

 Seen two orthos and they want to keep in brace/orthotics, off feet if in pain and if worsens back to boot then consider cortisone injections, last resort surgery.   Podiatrist made orthotics. 
Dr. Blake's comment: This is a bad area to have cortisone shots since it can weaken the tendon attachment causing further problems. Stick with PT, icing, contrast bathing, diclofenac gel, etc to reduce the inflammation at the attachment site. 

Last time hurt was 12 yrs ago playing soccer was put in a hard cast then air stirrup, crutches. and PT, no break. No surgery. Was back to activities faster but took a year to get back to playing soccer. 
Dr. Blake's comment: This is definitely a weak spot if it took more than a couple of days to recover. One year tells me it is vulnerable, but you got better. Hooray!!

 This time April 6th, 2017! tripped walking and inverse ankle roll but made my body fall on left (opposite side as I was initially falling)due to injury in right wrist and wanting to protect. No fracture on MRI/X-ray just soft tissue rupture w/some edema. Was put in camper boot for 8 wks and out of work couldn't walk w/o pain. 
Dr. Blake's comment: It is a significant injury if you can not walk on it. If the edema was in the bone, we have a long injury ahead of us. 

Started PT and got out of the boot in a week and learned to walk again w/o brace. PT focus on being able to walk again, balance on board, desensitizing foot due to being in the boot so long w/setbacks. PT did physical manipulation work which was the only thing helping me but PT stopped after 10 visits due to insur.
Dr. Blake's comment: So, the typically 8 weeks of boot/cam walker is fine. You know you are doing okay, if the transition from boot to no boot is done with maintaining your 0-2 pain level. I assume it was. But, an injury to the posterior tibial attachment with or without the accessory navicular should be progressed from boot to custom orthotic and posterior tibial taping ideally. Slowly wean off the taping. I have attached my video to this taping.

 Now it's 2 mths w/no PT and almost 7 mths later since the injury. Orthopedic surgeons want to do surgery now and remove the bone. I’ve been wearing custom orthotics since sometime in July w/ASICS cumulus. Tried to return to work Sept 15  (on feet as hospital social worker log up to 3-4 miles a day on feet) but it was too painful, had pain getting up from a chair, ended up limping barely able to walk, swelled up, back out of work.
Dr. Blake's comment: Always need to know how to get you to that 0-2 pain level. When you went back to work, were you at 0-2. Were you walking fine without a brace, but with orthotics? Can you go back to work with a removable boot and EvenUp (on the other side)? At least you could wear the boot the 2nd half of the day. Do your orthotic devices need improvement? Can the above tape help you? Can you get an AFO for work to be able to rest the pull of the posterior tibial tendon, but still wear a shoe? The surgeon could be right of course, but you need to have all these things before you try to recover some accessory navicular surgery. You have a lot to do before surgery is to be done or considered. 

 Finally saw 6 mths wait-to-see sports medicine doctor at HSS Sept 21 and he prescribed me anti-inflammatory, PT, stationary bike, and rest for 6 wks, didn’t think ready for surgery that pathology does not merit the pain I’m reporting.Rested and iced swelling stopped and pain decreased so for back to walking with sitting breaks up to 2.5 miles. 

Went back to same PT for re-evaluation last wk finally once insur allowed and referred to acupuncturist says extra accessory navicular bone is jammed and other stuff around is locked and would help to consider trauma related to few times I hurt it and address either on my own or with a Therapist.  Wtg to find out if insur. Will approve more PT or not. Saw acupuncturist today first time at the same facility and did cold laser since I was scared to start with needles. She thinks I need both and to address trauma. My goal is to resume all normal activities (job on feet all day) and get back to being able to do recreational sports/activities (hiking, soccer, tennis). I want to avoid surgery. I’ve been reading your blog so thanks for the info. and support when it can seem so isolating. I greatly appreciate any feedback. Thx

Dr. Blake's comment:
Since I had not answered the original email for 2 months, I asked her for any additional information. 

Hi Dr. Blake,

Thanks for your reply. Happy New Year.
The update is I did receive 5 more PT sessions after insurance reversal of denial with the last PT session on 12/12/17 and the insurance denied any further PT treatment. I had a total of about 20 sessions of PT. 
Dr. Blake's comment: Did you make some progress? Are they working on the overall strength of the area? I have attached my video on posterior tibial strengthening which must be done or you will still break down. This is you probably do on your own, but definitely, lay an ice pack for 10 minutes 3 times a day, and learn to tape for sure.

My sports MD prescribed me Diclofenac on 11/15/17 due to what my PT told the sports MD; 1. Lateral cuboid does not plantar flex, 2) lateral cuneiform does not plantar flex, 3) distal fibula does not translate. 
Dr. Blake's comment: These can be all left over from the inversion sprain that the PT should be able to rectify. 
The doctor's notes from this session 11/15/17 are attached for your review. 
Dr. Blake's comment: His comments were pretty unremarkable. If one side of your foot is not working, the other side will work abnormally. It seems normal after and sprain and boot and rest that you need some PT to mobilize the lateral column. I am worried that I see no mention of re-strengthening the posterior tibial tendon, or any other part of the foot and ankle, and no mention of how supportive the orthotics are, and whether taping would be helpful. It is all a bit superficial. 

My last appointment with sports MD was 12/13/17 and the plan was to return to work on 12/18/17 light duty at x 4 hours per day but my employer (being a hospital) does not offer light duty and referred me to the Office of Reasonable Accommodations. I am waiting for the paperwork to be submitted by my sports MD to my employer to see if I get approved for an accommodation although I'm not sure how they can accommodate me when the issue is being on my feet for extended period of time. Otherwise, I'm going to have to resign for medical reasons. 
Dr. Blake's comment: Can you work with a boot on? I do not see why not? Or perhaps an AFO that stabilizes you, but can fit in a shoe, or just the tape the video shows may be all you need or a combination of things. Many of my patients, so they can get back to work, have them all: boot, AFO, custom orthotic devices, taping, and posterior tibial dysfunction Ankle Brace called Aircast Airlift PTTD Brace. Some days or hours you need more restriction, and some days less. 

My next appt. with sports MD is scheduled on 1/30/18. He seemed to think I should try for a full year of PT and alternative treatments before I consider surgery.
Dr. Blake's comment: Sounds about right, since you have all the above mentioned stuff to perhaps try.  

It will be one year on April 6, 2018 from the date of injury and mid-June 2018 since PT started. 
Dr. Blake's comment: Like many patients, for many reasons, it is just hard to find the right things that work sometimes. I am assuming you did not know the joints are still jammed up, any info on AFOs, PTTD Braces, taping, and how to make your orthotics better.

I continue to use orthotics, go on the bike 20-30 min on level 3 (Keiser M3), to do alphabet with left foot, calf raises each foot, stand on each foot for 30 sec while holding other foot up., while seated stepping down with ball of left foot on piece of foam without moving legs. I attend weekly acupuncture but will likely cut back to biweekly due to insurance/OOP fees. 

I have difficulty doing the calf raises more on my right foot. 
Dr. Blake's comment: After doing the posterior tibial exercises for a week, you should know where you are on the right foot and where you are on the left foot. That can be really revealing. You start from the beginning with each side, making sure you can easily progress through an active range of motion, then with gravity, then isometrics, then level I theraband, and so on. The therapists will have the theraband, or else you can buy them. 

I had stopped doing the towel, marble, side lunges, heel cord stretch, and ball roll underfoot, amongst other exercises.  
Dr. Blake's comment: Why? Were they sore? Were they easy? Did you not know which were important? 

My PTs said I could come back once a month out of pocket for a mechanization session and just do the exercises at home the rest of the time. 

The PTs said the issue is my foot keeps reverting to an unnatural resting position after the mechanization as if my foot was still in the boot. She suggested physiological calming and to pay less attention to my foot as  I'm no longer panicking worried I'm causing further damage when I have pain after being on my feet for a while but the pain still happens. 
Dr. Blake's comment: I guess that means you stiffen up your foot. It probably fatigues out. That is why in the middle of the day if you feel this, and can throw in a brace, boot, AFO, you can essentially rest it for a couple of hours. Then you can remove the brace, etc. 

Although the mechanization can be quite painful at times she has been able to get my foot to release or whatever the word is and was even able to set up an obstacle course and I dribbled a soccer ball after in the same session without pain but a week or so later the foot reverts.
Dr. Blake's comment: That can be only a strength issue since you are definitely improving, but your orthotic devices and the amount of strength you have cannot maintain supporting you. But, that is definitely the best news you have told me and makes the possibility of surgery less and less. Get really strong, better orthotic devices if possible, and you may lick this. 

My balance has improved and ability to pivot and step up and step down. At close to 2 miles I get pain from walking. Riding the subway is difficult and painful when holding onto the bar when the movement of the train is pushing against my body and I'm trying to maintain my balance. The cold weather has been very painful for my foot so I double layer my socks. 
Dr. Blake's comment: The 2 miles is the fatigue of the tissue setting in. Taping alone, even before you are stronger, should raise that bar. It is sort of fun playing with different taping, different braces, different orthotic modifications, and have the patient report back how that helped or did not help.  

I'm hopeful I will be able to return to full activities including day hiking and hopefully pick up soccer. My acupuncturist thinks I'm making some progress with acupuncture, cold laser, and tens. She suggested to ice for 10 min when in acute pain after being on feet a lot then follow with heat. 
Dr. Blake's comment: At least, if the pain is located at the navicular, ice pack for 10 minutes 3 times a day, whether you hurt or not at the time, should reduce some inflammation significantly after 75 to 100 times, so get started. 

Any input would be helpful at this point as I'm unsure if this is even a reasonable time frame to heal and I need to just trust my body to heal and do the exercises. 

I really do not want to do surgery as it is unclear to me how this would resolve the problem at this point and appears might create other complications and challenges I would rather avoid.
Dr. Blake's comment: I can find nothing that seems like it needs an operation at this point, so follow the advice above, and from the sports doc, and PTs. Ask them to perform a good foot, ankle, and leg strength test on both sides and see what it shows. Tell them I want particularly the differences in the anterior tibial, posterior tibial, peroneus longus, and peroneus brevis. Thanks and Good Luck. Rich

Thank you for your time.

More info from the patient:
Hi Rich,

My apologies for not using or inaccurately using proper terminology and omitting info. you asked for.

Just to clarify, I rolled my left ankle inward but stopped my body from falling that way and made myself fall outside due to avoid the risk of falling on right wrist.

 Also, I did the transition from boot to ASO brace, to taping to just orthotics as per Ortho in about 3wks. At first, I was wearing an old NB shoe that was too over stabilizing + the ASO due to it being able to fit the brace and was closer in height to cam walker boot. When I got my orthotics I also got the ASICS cumulus sometime in June or July. I preface this to say I could not use crutches due to the wrist and had to use a cane on the left side which I got a week after injury. BTW I’ve both ASO and aircast braces got after was put in a boot (initially using a flimsy store wrap right after injury referred by the pharmacist) but haven’t used ASO or air cast since the Summer. 

I’m beginning to think didn’t get clear enough instructions from providers as no one has mentioned returning to brace or taping and only suggestion was gradually increasing time on feet.

One Ortho said might’ve to go back to boot but that was in August but I didn’t go back to him or other Ortho who seem to just want me to go for surgery. Podiatrist made me orthotics but haven’t been back I didn’t get a good impression he could do anything else.

 From what I’ve been informed by providers all along is that the range of motion has not been an issue. 

I’ve been doing some of the strengthening exercises for posterior tibial tendon as you suggested in video and walking backward on a treadmill then w/o treadmill, and toe raises on a weight machine at PT.  

Ar home I continue to do the exercises instructed by PT; alphabet, heel raises, stand one leg, the ankle dorsi/plantar, eversión and inversión exercises. 

I stopped standing calf stretch, resistance bands, side lunges, marble, towel, ice baths bc I wasn’t told to continue last time I asked but will check again this week to get a full list of what should do now.

Perhaps, I wasn’t clear but PT had been working on to get the left foot to mirror right foot at rest and not have my foot overextend to the outside when doing the eversión exercise. 

As far as a timetable, I had my PT cut off again but in Dec. last they thought that I would be ready by June. My acupuncturist thinks I’ll be ready by April-most optimistic of all.

I’ll update you when I get rest of info you asked for about strength tests hopefully at next appt.

BTW do you have any NYC recommendations for doctors who treat this issue?
Dr. Blake's comment: You can see Dr. Joseph D'Amico at the New York College of Podiatry. 

Thanks so much for your help. The videos are great for reference. 

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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.