Navicular Pain: Email Advice

Hi there Dr. Blake!

Searching around the internet I came across your blog and I'm hoping you can help me?

I have been suffering from pain of the navicular bone and all around the navicular bone.  As you can see from the photos, it sticks waaay out, although X-rays have come back "normal"?? 

Dr Blake's comment: I did not receive the attachment with the photos, but an MRI should be done to look at the 3 dimensions of the injury. 

 The attacks began in August (it is now early Dec) and are becoming increasingly frequent.  These attacks begin as twinges in the medial area of my left foot, the area then burns and on occasion swells.  The attacks are leaving me hobbled and unable to weight-bear.  

This doesn't work for me as I am an active primary school teacher, I don't even have a chair at my desk, that's how little I sit!  I'm losing work time and this needs to be fixed.

Dr Blake's comment: The problem could be an accessory navicular, and also nerve pain from the back or ankle in the tarsal tunnel. Some patients just have a large navicular than interferes with the posterior tibial tendon and causes tendinitis.  Other than an MRI, you want to treat the area with taping, orthotics, and shoes for great support, and icing right now for 10-15 minutes three times a day for the inflammation. 

  I have seen a podiatrist and chiropodist who have said that my left leg is slightly longer than the right, which has caused my left foot to flatten and is tearing my posterior tibial tendon.  The attacks seem to come on out of nowhere, no rhyme nor reason which is what confuses me.  If I had such an issue, wouldn't the pain be constant? 

Dr Blake's comment: The neuropathic pain, arising from the nerves, typically behaves like this. The cause can be the pronation, which stretches the nerve as it comes around the ankle. Nerves hate to be stretched. Thus, trying to figure out the right amount of support, whether the nerve can take any compression from the tape, and if there is low back involvement. 

 And where did it come from all of a sudden?  I have orthotics coming in mid-December but am worried that they won't help the situation as I have been wearing drug store arch supports and supportive shoes and I still had an attack after a week or two.  I'm so worried I may not be able to exercise anymore!!  Please help!!!  What can I do to properly diagnose and fix this???  I'm hoping to get in to see an orthopaedic surgeon next. But that could take months!!!

Dr Blake's comment: I sure hope a custom device made for you will be better than store bought!! Did the doc who made them thus what was going on, what the role of the orthotics, if they can be adjusted, etc etc. Definitely keep me in the loop. Rich

Thank you in advance,

Navicular and Posterior Tibial Injury: Email Advice

Hi Dr. Blake: 

 I am a 64-year old woman.  Like many, I have a navicular bone on my right arch which is somehow intertwined with the neighboring tendon.  About 10 years ago, I somehow tweaked the tendon which resulted in a lot of pain.  I was relegated to a boot for 6 weeks and did not have any problems until about one year ago when it started acting up again. 

 It has been intermittent with months of pain free days but recently I had a foot massage and the well-meaning masseuse worked on my feet (much to my delight) only to awaken this pain yet again.  I have gone back into the boot but am not convinced that the boot is doing the best job.   I like being in my new balance tennis shoes with my orthotics because of the arch support from the orthotics which the boot does not have.  I looked on your website today and have also ordered the tape from supporthefoot.com to see if that will help.  There doesn’t seem to be any swelling and I have not had an MRI because the pain is so intermittent.  My concern is that I seem to get better and then fall back time and again… I would like to get this quieted down once and for all.  Any suggestions you can provide on the best course of action will be appreciated. 

Thank you.

Dr Blake's comment: You seem right now to be doing everything right in the short term, but addressing the overall strength of that tendon, and the surrounding tendons/muscles, could be crucial. I typically try to get patients 3 times stronger than you are now. You should also learn the leukotape version of posterior tibial taping. I have a video on that and also the main exercises. You should without pain gradually spend the next year getting stronger. The classic exercises are metatarsal doming, single leg balancing, 2 positional toe raises, and theraband posterior tibial and peroneus longus strengthening. Good luck!

https://youtu.be/AcSSyBfFocE

https://youtu.be/GY-mJjXmeIc



https://youtu.be/-4OB7wcYTJE



https://youtu.be/xjsYz_YFGyY



https://youtu.be/Wa3k5b9kNAM

Navicular Pain: Email Advice

Hello Dr Blake my name is Ron (name changed) and I live in Oregon. 

I have be diagnosed with Posterior Tibial Tendon Dysfunction. 

In 1988 I broke my Left ankle in a fall and and as a result I was left with a slight loss of dorsiflexion but not enough to keep me from running and riding my bicycle. I had a 20 year career of racing bicycles = Cyclocross which is riding and running without any problems. I have always known that I was limited in dorsiflexion but it was never a limitation for me.

In December of 2012 I bought a pair of shoes that have no built up heel so the thickness of the heel and fore foot are the same thickness.  They felt great and seemed to make my feet feel like they were getting stronger. At the same time I was skate skiing every weekend and began to develop a pain in my foot after skiing that would go away during the week and come back after skiing. 

This continued to develop into more pain centering on the navicular bone. 

My own theory was that the shoes without any heel height made my foot come into dorsiflexion sooner than if you were wearing a heel which pushed my foot into pronation. 

Dr Blake's comment: This was my exact thought when you mentioned the zero drop shoe. Not good if you have limited ankle dorsiflexion, and it is not merely an achilles flexibility problem. 

It took several months to figure out what was going on and now I have some orthotics which have helped quiet the pain in the navicular down some but not completely.  I have new shoes with heels that let my foot not have to go into dorsiflexion so quickly. I am able to ride my bike with stiff cycling shoes and a orthotic. 

I am Icing 2x a day and use my orthotics most of the time. Should I be doing the strengthening exercises daily?

Dr Blake's comment: First of all, all we are sure off is that you have arch pain. Pain at the navicular does not mean you have posterior tibial tendon problems. That being said, pain in any area should be treated with strengthening as much as possible. As you do foot strengthening as in the video below, see what muscles are weak and emphasize them. If it is the posterior tibial tendon, then that may point to PTTD. 

Will this tendon quiet down again now that I am not aggravating it?

Dr Blake's comment: Typically it will. But, you should ice 3 times a day for 10 minutes, gradually strengthen the area, wear supportive shoes/taping/orthotics as you increase activities, gradually stress it with a progression of activities from slight to more stressful on the area.

I would be willing to come see you if you think you can help me. 

Thanks for taking the time to read this. 

Accessory Navicular/Os Navicularis/Os Tibial Externum: Advice on Treatment

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Hi Dr. Blake,

I saw found your name through yelp, and I have been very impressed by your reviews. I wanted to get your opinion about surgical excision of an accessory navicular bone.
I'm a 27 year old male who is active with running and triathlons, and I'm also on my feet all day at work. I went in to my podiatrist with a complaint of pain at a bump on my medial arch that has been on and off for the past year. X-rays showed a rather large accessory navicular bone, and my podiatrist recommended removal of the bone and tacking down the posterior tibialis tendon to the true navicular. My pain level varies between 0 to 3 out of 10, and tends to flare up after running 3-4 miles or standing for 10+ hours. I have been forced to cut back on my running significantly as a result.

I was wondering what your experience and opinion is about surgical removal of an accessory navicular bone? Are there conservative measures that you feel may be successful? Or is surgery the best option?
Thank you, I appreciate you taking the time to read my email!

Jon

Dear Jon,

     Thanks for the email. The accessory navicular is also called "the second ankle bone", on the side of the foot as the arch, and rarely needs surgical excision. 10% of the adult population has it, and 30% of those have it on both sides. Being a very common weakness in the arch, and seeing thousands of patients with them, I have seen only a few go on to surgical excision. The posterior tibial tendon, the strongest tendon to support the arch and stop pronation, attaches into this side of the navicular. When you have an accessory navicular, you have a weakened arch by definition, but not one that is needs surgery that often. The source of the pain can be in the tendon, in the attachment of the accessory navicular into the navicular, and in the ligament underneath. The source of pain must be identified before you trade your pain with a surgical scar. A surgical scar has 10% chance of bothering you as much or more as your present symptoms. I am seeing on one hand, the gradual development of better surgical instrumention, and on the other hand, a problem with post operative care (less physical therapy being covered is a great concern particularly).

     With all that being said, let us start at the beginning. Golden Rule of Foot: Find Out What It Takes to Make The Patient Painfree, and then how to keep it that way. Before considering surgery, you should be on a very gradual progessive posterior tibial strengthening program. It is very reasonable to make your tendon 3 or 4 times stronger than it is now by exercises that isolate that tendon. In your honor, I will dedicate several posts over the next few weeks on this topic. Please see the links below on generalizations of strengthening. You will probably have to work with a good physical therapist to review all of the exercises and analyze where you are now and set up a reasonable plan. But, this is very do able.

    The next vital piece of the puzzle is anti-inflammatory. If you have pain, constant in nature, even at a 1 or 2 level, you should be doing a 10 minute ice pack twice daily to cool down the soreness, whether it hurts or not. Never run through pain (see the link below on Good Pain vs Bad Pain). If the soreness has been more up into the 3, 4, 5, 6 levels consistently, then you should use more activity modification, more icing, physical therapy, and perhaps medications. The program should be for 2 weeks longer than it takes to get the pain to 0 to 2 levels. Once you are at that level, you need to figure out how to keep it there. What does it takes?

    Normally while patients are dealing with strength and anti-inflammation measures, they are also working with biomechanics (arch support) and testing to discover the source of pain. The two standard tests are MRI and bone scan, but CT scan may have a place. The MRI is the best to see tendon or ligament damage (which may need surgery, but should be initally casted). The bone scan is best if you have a bone problem that may respond to removable cast and bone stimulator.  Oh, before I forget Jon, please copy a blow up photo of the accessary navicular (multiple views are encouraged) in the comment section or email to me, because it could give me more info.

     Getting the right orthotic devices can be hard (maximum support, but comfortable, is always a challenge), but it is vital to seeing first if surgery can be avoided, and second, helpful in the two years after surgery if needed that you have a weak arch. All the skills and understanding of principles you learn in this phase can be vital if surgery is indeed needed. Besides orthotic devices, arch taping (simple kinesio demonstrated in the photo above), power lacing (see link below), stable shoes, and training regimens, are all vital to keep you going.

     Jon, I hope this starts a journey of understanding so that if surgery is needed, you will have the best chance that it is successful.

  http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

http://www.drblakeshealingsole.com/2010/07/video-power-lacing-for-stability.html

  http://www.drblakeshealingsole.com/2010/06/quick-tip-9-begin-strengthening.html