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Sunday, March 18, 2018

Posterior Tibial Tendon Dysfunction with Accessory Navicular: Email Advice

Hi Dr. Blake,

I wanted your advice on my situation. I have been diagnosed with posterior tibial tendon dysfunction - stage II and accessory navicular syndrome. My doctor suggests the following surgical procedures: removal of accessory navicular, FDL tendon transfer and evans flatfoot. I had a recent MRI which showed some wearing of the tendon including a 1 cm tear. 
Dr. Blake's comment: As long as you are in Stage II, where there is no rigid deformity, you can undergo conservative treatment. So, if your arch looks close to normal non-weight bearing, you would be considered stage II, even in the presence of a tear. The tear needs to be treated with removable boot typically for 3 months, then ankle foot orthotics, then foot orthotics with posterior tibial taping or bracing. This should be done at the same time you are strengthening the posterior tibial, anterior tibial, achilles, arch, peroneus longus, and external hip rotators. This is a delicate matter and sometimes it is the inexperience of the health care provider in conservative management that leads to failure. You must find someone that can attempt to rehab this. 

I have been researching these conditions and come across studies which show that wearing an AFO with physical therapy can resolve PTTD. However, it is not clear to me if my accessory navicular or if my tendon tear would be an issue in the success of this protocol. 
Dr. Blake's comment: Definitely they are factors, but as long as your arch collapse is reducible when you are nonweight bearing, I would rehab. 

I would like to avoid surgery if possible but also do not want my PTTD to progress further.
Dr. Blake's comment: That is what is at stake. Surgery is very successful, but Stage II is fixable without surgery if it can be rehabbed. While it is being rehabbed, if the pain can not be controlled, and or the deformity of your arch gets worse, then you should sign up for surgery. I do not do this surgery, I have a wonderful podiatric surgeon as my partner, so I see the patients up to the point of surgery, and then 3 months after the surgery to finish the rehab. Whatever is done initially, if you eventually need surgery, then those same devices and skills can be used in the postoperative period. For example, the same AFO initially, can be used postoperatively until you get strong.  

Some more background: I am 41 years old and have been symptomatic for 4 years. Three years ago I wore a boot for 6 weeks and my symptoms seemed to resolve completely for one year. After that year I had some pain and limitations off and on but nothing that disrupted my life. I had not been wearing inserts until recently which I now realize was a mistake. Now I am in inserts and the air cast boot. 
Dr. Blake's comment: With or without surgery, orthotic devices can be vital, so I am glad you have a good pair. Begin strengthening, and stay in the air cast boot until you have your custom AFO made. Typically they start with a rigid model, and then as you improve, go to a hinged version for more mobility. Good luck!!

Thank you for your advice!

Useful review article: 

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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.