Accessory Navicular Excision and Continual Pain: Why?

Surgery date: 1/9/17

Accessory navicular excision with reattachment of post tib tendon w/suture 

Current diagnosis: Stage II PTTD

Please understand I am still regaining strength since surgery so not all the weakness is due to bad tendon. Prior to excision I had painful tendinitis but full calf and tendon strength in the foot.

Video of Ability to do Heel Raises

Front View Amount of Pronation

Back View Amount of Pronation

Dr Blake's comment: This patient is really struggling post op accessory navicular removal. I had her send me a video (not sure it is working for you guys) of her ability to do single leg heel raise. She could do this just fine. The standing barefoot pronated positions are fairly equal (the right had the surgery), so nothing seems amiss that I can find. The post tib tendon is Stage 2, which is still considered one that can be successfully treated with orthotics, taping, PT, icing, strengthening and achilles stretching. She has to find out what can be improved/modified in these areas. 

Here is more from the patient (out of order because I am out in left field sometimes):

Dr. Blake,

I want to send you a copy of the MRI but I am not sure where to have it sent to.

Dr Blake's comment: Dr Richard Blake, 900 Hyde Street, San Francisco, CA, 94109.

If I could get a cheap flight my husband and I would consider flying out to see you for an appointment.  Let me know if this would be possible and how far you are booked out.

Dr Blake's comment: Only a week, but since we need ample time to perhaps make an orthotic, could you fly Thurs, seeing me in the afternoon, and again see me on Monday. 

My surgeon told me if I could come up with a situation using OTC orthotics and materials (wedges, etc.) that works for me, I could take that to a podiatrist and tell them exactly how to make the orthotics.  That's easier said than done as I don't have all the materials I would want to use to accomplish what I have in my mind.  I know I want an orthotic with a low arch that is tipped at an angle to combat the pronation, and I want the pressure points to be soft/gel.

Dr Blake's comment: So, at least start with the varus wedge from Altra. 

https://www.altrarunning.com/women/womens-stability-wedge?c3ch=PLA&c3nid=A2275-1-A&c3api=7940,109107172001,&utm_source=GoogleShopping&utm_medium=cpc&utm_campaign=AltraBrand

My husband will take some better pictures ASAP and send them to you.  The surgeon has told me I am in stage II of Post Tibial Tendon Dysfunction.  He recommends 1) gastroc release surgery and then if that doesn't work 2) flatfoot reconstruction: tendon transfer and calcaneal osteotomy.  He said the second surgery is a 6-month PROJECT and from what I read online it sounds like I would never be able to do high-impact sports again and would lose foot function.  Well, I guess that wouldn't be much different than my lifestyle now but it makes you wonder if it's worth it?  Considering the stiffness I have in my foot after the accessory navicular was removed I am very leery of any additional negative effects of more surgery.

Dr Blake's comment: You may well be a candidate for these, but definitely try alot of things first. I am glad I may have the opportunity to see you and assess your achilles tightness/flexibility, posterior tibial strength, etc. Nothing you sent from the photos above look bad enough to warrant anything but perhaps a posterior tibial tendon exploration. Ideally you could get an independent review from another surgeon here to get their perspective. Surgeons love to cut, and you never tell one surgeon what another one said, but they can differ alot in their approaches. 

I am really thinking it would be wise to wait at least 6 more months to see how I do before committing to another surgery.  I asked surgeon if I could try new medicines or another cortisone injection.  He said we could try Celebrex and an ultrasound-guided cortisone injection NEAR the tendon where he sees inflammation, but not IN the tendon itself.

Dr Blake's comment: I hate any thought of cortisone near a tendon, even with guided ultrasound. I would think it is resonable to put local anesthetic without cortisone into the tendon sheath to find out if it is the tendon that hurts. You are numb for 5 hours, so you have to be very careful. 

What do you think of all this?  

I am so frustrated and in so much pain and I feel like I have very few options and many years of pain ahead of me whether I opt for the surgery or not.  I know it's not a doctor's place to comment on personal life choices but my husband and I are looking at moving in the next year or so and starting a family...I can't imagine doing all that with the level of pain I have.

Dr Blake's comment: No guarantees, but you should be fine. Gastroc releases are done in extremely tight achilles that are flattening your arches, and flatfoot reconstructions in flatfeet that need to be reconstructed. I do not see any of the flatfoot. The amount of pronation should be helped by orthotics, taping, and gradually strengthening your foot. Someone would have to evaluate the achilles and see if it is tight and by how much, and can it be stretched out. I have alot of normal people take up yoga and get the achilles really stretched out without trying too hard. 

http://www.drblakeshealingsole.com/2013/10/achilles-tendon-flexibility-measurement.html

I personally do NOT think the gastroc release will work and the physical therapists told me do not get this surgery.  They see patients in recovery and it sounds like they think it's not very helpful.

The tendon feels diseased.  It's the tendon that needs to be scraped or reconstructed or removed or injected or something.  It's felt this way for 3.5 years now.

Dr Blake's comment: You know your body the best then the little time any doctor spends with you. Keep It Simple Stupid is a good mantra for a humble health care provider. We are stupid if we make it too complex when it does not need to be. I can not remember the last MRI on the tendon and what it looked like. Also, please see if the radiology department can do a diagnostic tenography of the posterior tibial tendon, but no cortisone injected. I hope this helps. I' m trying. 

http://emedicine.medscape.com/article/386322-overview#a2

Post Op Accessory Navicular and Posterior Tibial Tendon Surgeries

Dear Dr Blake,

http://www.drblakeshealingsole.com/2015/01/accessory-navicular-general-treatment.html

I came across your website and hopefully you can help with some advice.

I am 44, male and had a operation in December 16.  I had an excision of accessory navicular on left foot with reattachment of of tibialis posterior tendon. I was suffering from inflammation and pain on the tendon for many years and got worse ever after having custom orthotics (two pairs).  (being overweight not helping).  I used to play a variety of sports – badminton, tennis and cricket and hoping to resume soon.  I did play tennis for 1hr at moderate pace last week and did not suffer any issues.

Dr Blake's comment: Functional orthotics are actually designed to make the posterior tibial tendon work better, so that is a problem we sometimes face when we are trying to support and prevent the tendon from being over-stretched. Post-op hopefully they will work better for you. 

I have done all the rehab, physio and still do some physio now when time allows.  I only get mild pain now but want to make sure I have full recovery.

Dr Blake's comment: Hopefully you are using level 6 theraband 2 sets of 25. I will send you the link below. 

The problem is that I have quite large (size 11 US) and wide, flat feet and find wearing insoles very difficult as they invariably do not fit my feet.  I have been wearing the attached in my work shoes (3/4 length, full length don't fit) and seem to work fine, although I can’t wear too thick socks.  I was advised by my physio that I should wear some sort of low arch insoles which would help.

Dr Blake's comment: Could you go back to the custom ones? They should work, although I know you are a bit leery of them. Taught to the doc who made them. Your photos show fairly wimpy orthos for a big guy. 

Do you have any recommendations for insoles that would fit my requirements as my current ones do not fit my trainers and more importantly I want to buy some trainers which I can wear during my sporting activities. (ideally will wear one pair for all, or running shoes)  Ideally I would like to wear trainers that have appropriate support without the insoles.  Any advice on trainers?

Dr Blake's comment: If you want to stay OTC go to Sole inserts since they have more support. Also, get the New Balance Cross Trainers about 1/2 size larger. They have good width selections. The New Balance 1260, 990, or 860 should be fine. But you want to pick the one that feels the most stable to you.  Hope this helps you. 

I hope you can help in this matter.

Many Thanks

PS You also do well taping for long activities for the next several months while you get your strength better. 

https://youtu.be/AcSSyBfFocE

Post Op from a Patient's Perspective

Hi Dr. Blake,

Today I am at exactly 6 weeks post-op for accessory navicular excision and partial post tibial tendon reattachment. My surgery was January 9th. My surgeon has cleared me to start driving, and he said I am allowed to walk without crutches or the walking boot if I want to, starting today. 

I am not ready to walk without boot/crutches yet, but I can drive short distances. I have been pretty careful/conservative with my healing, so despite being allowed to put weight on my foot in the boot the past several weeks, I have not done so frequently because it would sometimes hurt and cause swelling. I tend to worry, so I erred on the side of caution while carefully moving/stretching/building back some muscle non-weight-bearing.

I know some surgeons prohibit weight-bearing entirely the first 6 weeks. My surgeon takes the approach that it is better for me psychologically to be more mobile (which I appreciate) and he knows if I am in pain, I will stop. He has assured me that the tendon is very structurally sound and I can't do damage. It's just a matter of pain management. He only had to partially reattach the post-tibial tendon so it is probably more solid than an entire reattachment.

My Achilles' tendon is very stiff and my foot is weak. I have noticeable atrophy up to the lower thigh. I could have been using an exercise bike, but since I haven't had time to procure one yet, I've been doing light motion/pushing exercises on my roll about scooter. I'll be scheduling physical therapy today for the next few weeks.

I rarely need to ice because elevating my foot reduces the heat/swelling. I've been given some heavy duty compression stockings. I don't like them, but I should probably try to wear them when I start walking more.

I am currently able to limp with the boot only, or walk smoothly with one crutch on the opposite side of the boot. Yesterday I noticed when I did a lot of walking with one crutch I had pain/tenderness later. A good night's rest seems to reset me, and I always feel better in the mornings.

The incision looks great and is healing nicely. I decided on my own to use silicone strips to protect it and help it heal better.

I've never seen my leg like this. It's all bone and floppy fat! Even if someone didn't have surgery, I doubt they would be able to walk if they didn't use their leg for 6 weeks. 

One thing I would like to comment on is the issue of post-surgical depression, which had been a struggle. I usually beat the winter blues by going shopping and staying as active as possible in the winter. Spending the majority of the worst part of the winter on the couch is challenging. If someone has never had surgery they might not be prepared for the emotional and mental challenges of being weak, vulnerable, bored, etc. 

Plus, as I'm sure you're aware, other parts of your body become overworked after a surgery while trying to compensate. My "good" foot is aggravated, and every week I've pulled a different muscle somewhere in my body by mistake! I can't wait to get back into full body workouts! You see, the past 3 years I was more sedentary than I used to be. So I wasn't in the best shape pre-op. I would recommend to anyone undergoing foot surgery to do a lot of strengthening prior to the procedure so it's not such a big impact.

I'll keep you posted. Thanks for your support.