Accessory Navicular: Excerpt from Book 2: Practical Biomechanics for the Podiatrist

The following is an excerpt from Chapter 6 of Book 2: Practical Biomechanics for the Podiatrist

https://store.bookbaby.com/book/practical-biomechanics-for-the-podiatrist1

Accessory Navicular Syndrome

 

CT scan image of an Accessory Navicular

 

     The accessory navicular is part of the navicular bone, a second ossification center, that never fuses with the main part of the bone. It starts to form around 8-9 years old and is fully formed no later than 16 years old. 10% of your patients will have them and 30% of those will have them on both sides. The prominence caused by this accessory bone has been called the second ankle bone, os tibiale externum, or os navicularis. When they begin to hurt, it is important to actively treat, as a percentage will need surgical removal. The pain can be from the the posterior tibial tendon attachment, from the junction of the accessory and main part (either syndesmosis, synchondrosis, or synostosis), from obvious shoe pressure like from a bunion deformity, or from symptoms arising from the arch collapse. One of the main reasons the medial arch stays strong is the incredible anchoring of the posterior tibial tendon first into the navicular and then spreading out plantarly across the midfoot. If you disrupt this in any way, by having a small amount of the posterior tibial tendon diverted into the accessory bone instead, the foot can strain to hold up the arch and pain ensues. A definite weak spot is created.

     To tie this into Chapter 3 and 4 on gait and biomechanical examinations, when a patient presents with accessory navicular syndrome,  the most important examinations to do in 10 minutes (or 20 minutes) are:

●       Signs of Excessive Pronation and Medial Column Overload

●       Medially Deviated STJ Axis

●       Functional Hallux Limitus

●       Posterior Tibial Strength

●       RCSP

●       AJ Dorsiflexion

 

Common Mechanical Changes for Accessory Navicular Conditions (with the common ones in RED)

1. Cam Walker with or without Crutches in the Immobilization Phase
2.  Inverted Orthotic Devices or another high medial support Orthotic Device (like the Mueller PTTD device)
3. Circumferential Taping with a Hole Cut Out for the Prominence
4. J Strap with Leukotape for Pronation Control
5. Progressive Posterior Tibial Strengthening Program
6. Metatarsal Doming and Single Leg Balancing
7. Strengthening of the 2 Long Flexors
8. 2 Positional Single Leg Heel Raises
9. Off Weighting of the Prominence (including shoe modifications)

 

     Cam Walker with or without Crutches in the Immobilization Phase may be your first treatment. Its mechanical function is in immobilization. If you suspect this problem, you need to err on the conservative side since the problem can lead to surgery if correctly or incorrectly treated. Any patient who first presents with a problem in my practice, that may need a surgical intervention, raises my red flags. You do not know how the injury is going to turn out. Usually looking at the prominence at first sight, before you take x- rays, you are going to know that you are dealing with an accessory navicular (or gorilloid navicular), and that some of these will require surgery. My goal is to get the patient to level 2 pain as quickly as possible on a consistent basis. If that requires a boot and time off work to drive the pain to 0-2, so be it. The goal is to create an environment that will allow them to heal. The crutches may be necessary initially as I experiment with tape, design an insert for the boot, or work on their inflammation. It is important to remember an EvenUp when you use a Cam Walker.

 

Here an EvenUp slips over the side not being immobilized to level the hips some

 

Practical Biomechanics Question #302: 3 patients present with accessory navicular pain with 3 different scenarios. Match the pain with the Phase of Rehabilitation.

1. Pain walking each step
2. Pain only when attempting to run
3. Pain only at 3 miles into running

 

     Inverted Orthotic Devices or another high medial support Orthotic Device (like the Mueller TPD Foot Orthosis) is crucial quickly to stabilize that medial column. Their mechanical function is in reducing pronatory forces on the injured tissue. I am not an advocate of pre-fabricated orthotic devices for children who present with this problem regularly. If a growing child needs an orthotic device, I feel it should be designed for them as exactly as possible. Since most patients who present with significant problems from accessory navicular are juveniles, I discuss with the parents why we have to protect them, even if surgery is needed. I discuss that the presence of this problem will be a weak spot their entire lives and custom support is so crucial. In my book entitled “The Inverted Orthotic Technique” I discuss how this is prescribed.

 

This shows the high medial column support from an Inverted Orthotic Device

Practical Biomechanics Question #303: How much inversion is placed into an Inverted cast to change the foot position one degree?

 

     Circumferential Taping with a Hole Cut Out for the Prominence is typically made from kinesio tape or RockTape perhaps 12-14 inches long and 2 inches wide. Its mechanical function is in light immobilization and support of the injured tissue. Before the tape is placed on the foot, and even without the backing removed, about 1 inch from the start a one inch diamond is cut in its center. The backing is then removed. The one inch diamond cut is placed over the medial prominence as the tape is applied gently over the dorsum of the foot from medial to lateral. When you get to the plantar surface of the foot, the tape is now pulled with “some force” from lateral to medial and up back to its origin and a little further usually slightly more distal (not an exact overlap so it grabs more skin). This type of tape needs to be rubbed in for a minute to activate the glue. You have to play with the tension implied by “some force.” The patient can learn this skill and the tape typically lasts 3-4 days.

 

Leukotape J Strap to create supination moments placed on with the foot slightly inverted and the Coverall protects the skin

 

     J Strap with Leukotape for Pronation Control is the most powerful way of taping for posterior tibial problems, including accessory navicular issues. Its mechanical function is in reducing pronatory moments across the injury and slightly immobilizing. Leukotape is by far the strongest tape I use. It is so strong, it has to have a layer of material called “Coverall” applied to the skin first. No Leukotape should ever touch the skin. Leukotape and Coverall are typically sold together with the Leukotape slightly narrower. Both types of tape of course are applied with the same pattern and it is called a “J Strap”. Occasionally, I tell patients to use 2 layers of Coverall overlapped by 50% to make a wider base to place the Leukotape on with. The tape is started just under the lateral malleolus and brought down and under the heel with no tension, then the foot is slightly inverted to neutral subtalar joint, and the tape is brought up medially over the accessory navicular and up at least 18 inches up the leg. The longer up the leg, the more you are spreading the force to stabilize over a bigger area. Again, like the circumferential taping, this tape should last 3-4 days before being removed. You typically remove it at night, so that you can rest your skin, and re-apply in the morning. It can be used in all of the Phases of Rehabilitation, with some of my recovered patients still using it for long backpacking trips months later.

 

Practical Biomechanics Question #304: Explain why some immobilization of the ankle is needed at times for an accessory navicular problem.

 

Resistance Bands exercise to isolate the posterior tibial tendon with inversion and ankle plantar flexed

 

     Progressive Posterior Tibial Strengthening Program is part of the Re-Strengthening Phase of this injury and vital to its success. Its mechanical function is to strengthen the posterior tibial fibers attaching into the navicular stabilizing the area. Chapter 11 (Book 3) will go through the aspects of strengthening for injuries, so I will just make three points here I want to highlight. First, the goal with all accessory navicular patients, is to progress them to 2 sets 25 repetitions at Level 6 resistance band. This can take months to accomplish so the health care provider has to be clear with the patient that even if they do not hurt, if they remain technically weak, that they can break down again. Second, the posterior tibial nerve which runs right next to the posterior tibial tendon, can make the exercises hurt. I always tell a patient if an exercise hurts they could be hurting themselves. This does not seem to include many patients strengthening their posterior tibial tendon. So, you have to have them do the exercise, and if there is no problem within the first 2 days, have them continue. For that reason, I have them strengthening the posterior tibial tendon every other day initially to check their response. And third, if you rely on anyone else to show your exercises, always check at the first visit. The posterior tibial tendon is strengthened with the ankle plantar flexed (pointed) and the foot inverted (abducted). Over half the time when I check the patient is not doing the exercise correctly.

 

Practical Biomechanics Question #305: What tendon are you strengthening if the foot is inverting against resistance, but the ankle is in neutral to dorsiflexed?

 

     Metatarsal Doming and Single Leg Balancing have both been described multiple times, including the last section on Cuboid Syndrome. Their mechanical function is to stabilize the injured area with muscle strength increases. Typically, with accessory navicular patients, metatarsal doming can be started immediately to keep the foot intrinsics in tone. The Single Leg Balancing is quite jerky and added at the end of the Re-Strengthening Phase or early in the Return to Activity Phase. You typically want the patient at Level 4 or 5 of the resistance bands before starting single leg balancing to ensure that they are strong enough.

 

Single Leg Balancing with Light Touch on Door Frame

 

     Strengthening of the 2 Long Flexors is basically to help the posterior tibial tendon in its ankle plantarflexion and inversion functions, and probably some with arch support. Its mechanical function is to strengthen agonist muscles to the posterior tibial tendon. The posterior tibial tendon, along with the 2 long flexors, run alongside each other under the laciniate ligament under the medial malleolus. They have shared functions, so our strengthening should take some strain off the medial tissues. The classic toe curl exercise, where you build up to 100 curls of the toes as you grab the towel and pull it backwards, is a perfect way to strengthen the two tendons.

 

This is a common gym version where a Bosu Ball is used to balance on single and double legged. The toe flexors can be activated as you lean forward and try to maintain your balance.

 

     2 Positional Single Leg Heel Raises is one of the most powerful exercises you can prescribe and an important monitor of the success of a patient. Their mechanical function is to strengthen the foot and ankle taking stress off the injured area. The ability to do 25 straight knee (gastrocnemius) single heel raises and 12 bent knee (soleus) single heel raises is an indicator of the health of the tissue. However, it is more for the Return to Activity Phase, or later aspects of the Re-Strengthening Phase of Rehabilitation. When the patient presents with accessory navicular syndrome, the testing of whether they can perform a Single heel raise on that side is crucial. It has to be painless. As soon as your heel lifts from the ground, in the next ¼ of an inch of heel rise, the posterior tibial tendon will pull hard on the navicular to assist that heel raise. It is an important overall exercise as the gastrocnemius and soleus supinate the subtalar joint strongly, but it is also an important exercise to sense the strength or frailty of the accessory navicular complex with the posterior tibial tendon.

 

Practical Biomechanics Question #306: What muscles/tendons will help a weak achilles tendon to lift the heel off the ground (any of these structures can be injured because of this)?

 

     Off Weighting of the Prominence (including shoe modifications) is of course really common in ice skaters when they make custom boots and downhill skiers. Its mechanical function is to off weight the sore area. From the age the accessory navicular completely forms, they can become shoe fit nightmares or at least projects. Besides the shoe fitters tasks, on a daily basis the patient may need the use of some ¼ inch adhesive felt to off weight the prominence. The two common ways are 1) a one inch square piece above or proximal to the prominence, and 2) an “upside down smile” making a tent around it, but as close to it except plantarly. This usually is only needed for shoes which seem to bother it. I tell my patients, like my bunion patients, if they remove the shoe at night and the tissue is red at all, the habit of protecting it in those shoes should begin.

 

Here a double layer of ¼ inch adhesive felt is applied proximally in the shoe to off weight the sore point.

Top 10 Treatments for Accessory Navicular Syndrome

Accessory Navicular circled on the inside

of the arch just in front of the ankle

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 one of the stretch tapes (KT tape, Rocktape, or Kinesiotape) or Quick tape from supportthefoot.com tape or a classic low dye taping technique 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, Powerstep, or Pure Stride 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) and maintain this through the rehabilitation process.

10.  If the MRI shows bone reaction (edema), order a bone stimulator as soon as possible to start strengthening the bone.

Thank You Dr. Kevin Kirby!!

     This post is a thank you to a Rock Star, so to be noticed will probably never happen!! Dr. Kevin Kirby from the Sacramento area of California has greatly influenced my beloved profession and my beloved field of biomechanics. He has his beliefs, and stays true to those beliefs, a trait I completely admire. 

     So, let me explain why this overdue thank you in cyberspace is happening today. Today, I saw a typical patient needing my biomechanical help. At 17, and a runner, he had already had his left accessory navicular removed, and was trying to avoid the same surgery on the right side. This is a small extra bone that 10% of the population has, and only 3% have on both sides. Lucky him. It is both aggravated by pronation, and can cause pronation by weakening the arch. 

     One of my measures of a patients pronation is called the relaxed calcaneal stance position or RCSP for short. This measurement is ideally vertical (standing straight up) or a few degrees in varus. For my patient he stood 6 degrees everted RCSP, so very pronated, and this matched his pronatory gait and pronatory symptoms. 

     The technique I use for this is called the Inverted Orthotic Technique. It is a highly corrected orthotic device, which I felt important for the need to let the patient run and attempt to avoid right foot surgery. These are both moderate to severe implied needs for maximal correction on my part.

The technique is based on a 5 to 1 orthotic correction to foot change. Therefore if I correct the foot 5 degrees I get 1 degree of foot change. 

     So, what happened? I gave the patient with 6 degrees everted RCSP a 30 degree Inverted Orthotic Device and the feet changed to 4 degrees everted. I realized I was a little wide with the heel cup so I lost a degree or so, but this is common when you are initially trying to grab the foot that the foot does not respond how you want it. 

     So, at last visit with the patient, I gave him the 30 degrees of correction with a 2 degree foot change, and ordered a new orthotic at no cost to the patient. I was committed to helping. I added a 3 mm medial Kirby to the existing mold (which normally gives me 2-3 degrees of change when added to the Inverted Technique). I called the dad a week later just to see how he was doing and he said that the new orthotic (that I was unhappy with) was far superior to his previous orthotics and he was really enjoying running in them painfree. 

   Today, I dispensed the 30 degree Inverted with 3 mm Kirby and his heels stood straight up and down at vertical RCSP. This was then reflexed in his gait walking and running. At times it is the Kirby Skive that makes the most difference, and at times the Inverted Orthotic that makes the most change. So, we are inseparable (since I invented and the trustee of the Inverted Technique) and I thank you Dr. Kirby. This is how Dr. Kirby works in the shadows in my office daily, and why his technique has been vital now for over 30 years. 

Thank you Dr. Kirby for always being there for me!!

Accessory Navicular: Email Advice

Dr. Blake,

I happened upon your blog and found some very useful information about Accessory Navicular.  I have a unique case according to my podiatrist and wanted to share and get your opinion. 

I am a 40 year old teacher.  I only discovered anything about accessory navicular around 3 years ago.  I have always had intense pain tolerance and can remember in college after waiting tables I would curl my feet and walk on just the outside heels and toes to relieve the pain. 

I have Accessory Navicular in both feet.  It was never discovered as a child or young adult.  I played athletics and did pointe ballet for many years.  The problem increased as I got older until the pain was constant and it did not matter what I did to alleviate the pain , stretching, ice, rest it was always there. 

3 years ago I made the decision to go to the podiatrist and they made this discovery I was quickly fitted with a Richie Orthotic on both feet.   It immediately changed my pain level.  Was it still painful yes but I could now walk again and for long distances and could stand for long amounts of time again, it was wonderful. 
Dr. Blake's comment: This is a ankle foot orthotic device. 

https://images.app.goo.gl/r57MThgpfPFF96Mj6

Recently I have had a change in pain in association with the Accessory Navicular on both feet.  It has come back and it is intense.  It seems as though my Richie braces while still providing some support are now not doing all it was doing even 6 months ago. 

I have been told I am a candidate for the surgery but it puts me out for quite a while and with having this condition in both feet the concern is favoring the non surgery foot and intensifying the already agitated condition.  

Do you have any suggestions?
Dr. Blake's comment: Sometimes you just have to rest the area for a while to get it to calm down again, while you are gradually strengthening the posterior tibial tendon. Flareups should not be construed as reasons to do surgery. See the videos below on a gradual posterior tibial strengthening program (6 months) and the taping technique (also 6 months). Icing 3 times a day to decrease the overall inflammation for 10 minutes a session. Below the knee boot for 4 hours per day to rest the area per foot, alternating back and forth. You have to have a EvenUp on the other side to balance. You should know if this is starting to calm it down over the next month while you continue to be the teacher of the year!!. I hope this helps you start going in the right direction. Rich

https://youtu.be/AcSSyBfFocE



https://youtu.be/w3FXx4OFqec




Thank you for your time and consideration

Sincerely,

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.


https://www.bing.com/search?q=dance+schools+dallas+tx&src=IE-SearchBox&FORM=IENAD2

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

Thanks!
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.
Rich

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. 
https://youtu.be/AcSSyBfFocE


https://youtu.be/w3FXx4OFqec


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,

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: 

https://www.hss.edu/conditions_posterior-tibial-tendon-insufficiency-overview.asp

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. 
https://youtu.be/AcSSyBfFocE

 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. 

https://youtu.be/w3FXx4OFqec

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.