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Friday, January 4, 2019

Accessory Navicular: Email Advice

Dear Dr Blake,

My daughter was diagnosed with accessory Navicular syndrome in August of 2018. She is a competitive dancer and started complaining of pain in her foot in January of 2018. Initially I thought it was just pain of dancing as she had not hurt herself. We used some wraps, massage, and creams and kept dancing.
Dr. Blake's comment: The accessory navicular is an extra bone in the arch that begins forming around 8-9 years old and is fully formed by 16, probably even earlier. The posterior tibial tendon, the strongest arch muscle, attaches into it instead of where it should to support the arch. It has to work harder to support the arch and symptoms can develop. Because patients with accessory navicular have arch stabilization problems with the tendon, they typically develop flatfeet. 10% of patients have accessory naviculars and 30% of those it is on both sides. In doing the math, 3% of patients may bilateral accessory naviculars. There attachment to the normal bone (navicular) can be strong or weak, and it is the weak ones that get symptoms. It is typically an arch sprain scenario treated with the proper phases of rehabilitation: Immobilization, Re-Strengthening, and Return to Activity. It typically responds well to treatment, so it is troublesome when they do not and we need to find out if the rehab was just done improperly, or if there is a reason surgery is needed to remove the bone. It can take good investigation.

In May it became pretty painful so we went to our regular doctor who suggested some physical therapy. We continued through end of competition season in July and did try outs and then went back to the regular doctor- she did an x ray and noted she seemed to have an accessory navicular bone. At the time only one foot was hurting her. Her left foot.

We were sent to specialist who initially tried her with inserts.
Dr. Blake's comment: This is one part of the Immobilization Phase. You are trying to get the pain level consistently to 0-2. Common treatments in the Immobilization Phase are: Removable boots (also called cam walkers), Posterior Tibial Dysfunction Brace from Aircast, Posterior Tibial taping either circumferential or up the leg in a J Strap design, Orthotics with strong medial arch support, activity modification, etc.

After three weeks, we went back and he adjusted her inserts and tried limits n dance (so no ballet which was more painful).
Dr. Blake's comment: This was good so the Immobilization Phase was being treated by orthotic devices and activity modification, but the Re-strengthening program should begin soon. Were you getting the pain down to 0-2? The use of Anti-Inflammatory measures are normal during the Immobilization Phase, to limit the actual amount of immobilization, by icing 3 times a day to calm the symptoms. I like to begin strengthening asap so typically posterior tibial strengthening begins now, along with single leg balancing, metatarsal doming, peroneus longus strengthening, and gastrocnemius and soleus work with double and single heel raises. Everyday she is in pain, you typically lose 1% of strength, and you only gain back 1/4 to 1/2% back a day. Begin now.

After 3 weeks we went back. She still had pain, so he made her sit out of dance for three weeks, icing and ibuprofen. 

She still had pain so he booted her. She was booted initially for three weeks (no activity) other than walking to class.
Dr. Blake's comment: So, now the Immobilization Phase has boot, orthotics, activity modification and some anti-inflammatory measures.

She still had pain so he kept her booted and had her start physical therapy a mix of land a water therapy. She got ill and could not return for an additional 5 weeks so her boot was on for a total of 8 weeks. She had physical therapy during those 5 weeks. He took her out of her boot. Her right foot felt better although with much walking she still had some pain. Her right foot had begun to bother her.
Dr. Blake's comment: So, the boot was on the left side, and now the right side was a problem also. I think I get it. The accessory navicular is a biomechanical issue. This means that without an actual injury, which she did not have, the pain comes from a tissue overload during overuse. The accessory navicular is a weak spot of her arch that got irritated. You can make it less of a weak spot by strengthening (by gradually building up to 2 sets of 25 Level 6 theraband). While you do that, you have to relie on a slow progression of activity, taping, orthotics, and anti-inflammatory.  

We did additional physical therapy (it is December at this point) and he did xrays on both feet. he indicated that she also had accessory navicular on her right foot but it was less pronounced. 

I requested an MRI even though he said he normally did one just if surgery was being considered. I was unable to go to the visit after the MRI but we had done a lot of walking around the day before and her right foot was really bothering her. Up to this point she had started back to one class in dance and we decided to limit her competitive dances and the amount of dance for next year (she normally dances 15 hours a week).
Dr. Blake's comment: So, learn the posterior tibial taping for class, both J Strap and Circumferential. She should stay in the boot for the worse side, alternating sides as needed, while she dances. You should be taping and orthotic devises in the boot. Let me know what the MRI showed. She should get one on the right side also.
     At this point, it is also important to know what pain level she has in every environment: getting up first steps, in the boot, in the orthotics, when she is taped, how the brace feels, in class, after class. Since some of these athletes need surgery, and if you are trying to prevent that scenario, we need to do everything right.

At the visit my husband indicated her continued pain (more on the left foot than the right) and the doctor said that her tendon looked pretty good... that her accessory navicular was worse on the left side and that next steps were to go back to dance and see if she could tolerate the pain. If she could not, it sounded like surgery would be our next option. I am concerned that it feels like he has given up and it seems like our options are having pain when doing the activity she loves the most or surgery.
Dr. Blake's comment: This is the first part of your email that makes no sense. It sometimes is generated by the patient saying that dance is her whole life and she/he must do it. The doctor who is trying to be compassionate then gives in since it is not life threatening and allows the athlete to go back to the sport. But, to cover themselves, they throw in something about surgery in the conversation. Overall, it is not smart medicine. It is a bad decision to dance over a 0-2 pain level. I know some kids that really can not tell the difference between 2 and 5, only know 0 and 10. For those kids, you have to make sure that they do not limp in their sport. You have to have the coach watching carefully, they can not participate again until the symptoms have calmed back down. You also need to watch and see how inflamed the activity gets it. Typically, these are hard jobs. Try to get your daughter to understand and verbalize the entire pain scale from 0-10 and what each number means.
     It is trying to maintain the 0-2 pain level that we perfect the orthotic support, that we figure out the right way of taping, that we find out how much to ice, rest, etc.

I am concerned if we go back to dance that her pain problems will come back. I am concerned we have not done enough to address her issues.
Dr. Blake's comment: To dance at all, she needs to be able to walk with her injury taped for 30 minutes keeping the pain between 0-2. In dance, there are so many motions, she first has to find the one that do and don't bother her. She can test those motions every other week, but not daily. I always feel a dancer should dance as part of her rehab, but not if it elicits the pain over 2 or causes her to limp to avoid. Like my sport of basketball, dance has some much you can do and not hurt, that she should be able to be on a program that will not hurt her, enable her to workout, and continue to allow the injury to heal.

My daughter does have very flat feet.  She does continue to use her inserts which she loves. Her inserts don't really work in her dance shoes.
Dr. Blake's comment: Some version of hapad medial longitudinal arch pads should help in the dance shoes along with taping.

Any suggestions on what to do next are appreciated. We live in the Dallas area and I am considering trying to get a referral to a different specialist for a second opinion. The first specialist is not necessarily a childrens specialist.
Dr. Blake's comment:Yes, see if the schools in Dallas have a foot specialist they recommend highly.

Any suggestions on what to try next or help on where to go would be greatly appreciated.

Dr. Blake's comment: I sure hope this helps some. Have her listen to her body, get used to 0-2 pain levels, get good at taping and icing.

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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.