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Sunday, December 9, 2018

Accessory Navicular: Email Advice

I read your website and enjoyed your informative responses to others who have
an accessory navicular syndrome.
I have been suffering from this from 9/8/18 and would greatly appreciate any input. 
I am also happy to travel from NYC to see you if that would be better.
I’m also happy to contribute to your website to keep it going as it is 
so informative— just let me know how to do so.

I am a weekend jogger, a 43-year-old female, fairly active. I ran into a hole in the ground
and all my weight went
to my right foot on 9/8/18.  I saw a foot orthopedic surgeon in my hospital who said I have a
large accessory navicular (X-ray confirmed) and recommended 3 weeks immediately
in a CAM boot which I did religiously.

After 3 weeks I weaned off for about 3 weeks into an orthotic and was feeling better. 
As a mother of a toddler, I had to drive her to class for about an hour
on that 3rd week and my symptoms worsened.

I contacted my orthopedic colleague who told me that more boot time or physical
therapy probably won't help.  I saw another foot orthopedic surgeon who immediately
started talking re the Kidner procedure. I’m a surgeon myself and was taken aback
about taking off a bone I’ve had all my life and retracting a tendon.
Dr. Blake's comment: Thank you for common sense. This is very common in orthopedic
/podiatry where you immediately lean to surgery and forget conservative care. 

So I saw a podiatrist who is quite nice and told me to go back into the boot and
start physical therapy.  I am also taping my foot.
This has been helping but when I saw him again he said I needed more time in the boot
for another 3 weeks.  He did not recommend a MRI as he felt that the treatment
would be the same regardless of whatever MRI result I have.
Dr. Blake's comment: If one doctor is talking about surgery, and there are patients with 
accessory navicular that need surgery, you have to have all the information at hand to 
make the right decisions. I would vote for an MRI to see what is going on. 

I was able to convince my orthopedic surgeon to get a MRI.  It showed:
1. No tear in the PTT
2. Mild to moderate PTT tendonosis most prominent at the navicular insertion 
    next to the accessory navicular
3. Marrow edema along the synchondrosis of accessory.
Dr. Blake's comment: So, what does this mean? The tendinosis means the tendon has been
straining for a long while and maybe this area was becoming a weak spot to you. 
The chronic part that will take the most work from you is the tendinosis. 
I will attach the posterior tibial tendon strengthening program video I like andthe taping you
should do for a while.

The bone edema is the acute part and that is going to take time since
that is very painful. You have to assume the worse that you broke the synchronosis
or synostosis bridge between the navicular and the accessory navicular. This is treated with 
3 months removable boot, 2 month minimum, to obtain the 0-2 pain level consistently.
Then you wean out of the boot into supportive shoes, good orthotics to support this area,
and use the taping. You ice for 10 minutes twice daily, and do contrasts baths in the
evening. You get an Exogen 5000 bone stim and treat this as a fracture, since it may. 
We will slowly wean into less supportive shoes, less supportive orthotics, less supportive
taping, but gradually as long as the 0-2 pain can be maintained. You gradually build up to 
2 sets of 25 level 6 theraband typically over the next 6 months. 

If I could ask your opinion on the following:
1. As of next week, I will be in the CAM boot for 10 weeks.  
    How long do I need to be in the boot?  It actually hurts now being in it.
    Dr. Blake's comment:
It is hard to know if you have a delicate fracture across the
    synchondrosis needing more immobilization. What helps is the understanding that 
    if you can maintain a 0-2 pain level, you are pretty safe in whatever your 
    environment. Learn the taping, max the support from shoes and orthotics, and you
    should be able to wean out of the boot. Remember you need to wean out, typically
    2-6 weeks, based on maintaining the 0-2 pain level. 
2. Do I need surgery?
    Dr. Blake's comment: Typically it takes almost a year if the doctor is really trying to 
    avoid surgery by using rehabilitation to know if you need surgery. It is not wait and see
    but trying to figure out how to drive the pain to 0-2 but be completely active. First you
    want to figure out what it takes to keep pain down and walk 30 minutes daily and see 
    where to go from there. Did it take orthotics, shoes, taping, PT, AFOs, etc? Do you
    have to wear a boot occasionally due to flares?
3. Can I ever run if I do not have surgery?
    Dr. Blake's comment: Yes, that is why you have the surgery, so that there is no long term 
    disability. However, it is the same reason to avoid surgery, since a surgical complication, 
    less than 10%, could give you some long term disability. The surgery is very successful, 
    but the post operative course is a bell shaped curve for healing, and you could be in the
    slow group. This is surgery to the arch, arch supports will be a permanent addition to 
    your running accessories to rest this area. A surgical area in orthopedics tends to be a 
    weak spot to some degree going forward.  
4. Do custom orthotics matter?  I had some moldings done w an pedorthist in NYC. 
    Dr. Blake's comment: Depends on their knowledge with your injury, and what works.
    Based on your unique biomechanics, there is probably seven or eight orthotic cast
    corrections to choose from, not counting the modifications that are possible to the 
    device itself. It does not have to be perfect by any means, just thoughtful for you. 
5. What percentage of adults (not adolescents) who present to your practice 
    w accessory navicular syndrome need surgery?
    Dr. Blake's comment: Not common, and I am sure some are lost to followup, but I always 
    have a surgical opinion as we try to work this through. 10% that need surgery even 
    feels high to me. The surgery is normally because the tendon is more the problem I think. 
    Repairing a diseased posterior tibial tendon is part of the removal process of the 
    accessory bone. I think we know at 6 months if someone is going to avoid surgery. 
    And all the skills we learned trying to avoid the surgery in the first place: good shoes, 
    good orthotics, how to tape, how to get strong, how to get rid of inflammation, etc, will
    help in a post operative course. I know the last 10 patients I saw with this, none 
    needed surgery, but at some point in the ups and downs, they all would have had
    surgery if I had given up. 
6. How long does it take normally for symptoms to improve?  6 months?  1 year?
    Dr. Blake's comment: Phase I of Rehabilitation: Immobilization (where you are at). Here 
    the pain should be reduced to 0-2 by immobilization, fitting for orthotic devices, getting 
    stable shoes, avoiding barefoot, learning to tape, etc. In Phase II, Re-Strengthening, 
    you are progressiving through the stages of strengthening exercises, but still 
    maintaining 0-2 pain, so tape, orthotics, shoes, occasional boot are needed. Phase III
    Return to Activity you still maintain 0-2 while you start a Walk/Run Program, and
    other sport specific drills, continuing to tape, ice, bone stim, strengthen, etc. Therefore, 
    the symptoms should be low by the time the main immobilization is done, and 
    treatment is based on maintaining that as activity returns to normal. A poor 
    rehabilitation plan will not get you through, but I hope I have given you some idea of how
    to do it successfully. Sorry, but no guarantees in life. I would approach this as a rehab 
    program, not as "I hope I can avoid surgery program." The next time to think about
    surgery is 4 months from now to check how you are doing. Now your job is to begin
    to put the ducks in a row and maintain 0-2. 

Any help would be appreciated and again if you prefer to examine me
I am happy to travel to SF.  I was actually studying at the USF
in the early 2000s and
enjoyed living in the Sunset area.
Dr. Blake's comment: I grew up in the Sunset on 38th Avenue. Happy
to see you if it seems appropriate at some time this next year. Hope this has been 
helpful. Rich

Thank you very much.

Best regards,

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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.