Special Report on Accessory Navicular Syndrome

What is the Accessory Navicular? The accessory navicular (os navicularum or os tibiale externum) is an extra bone or piece of cartilage located on the inner side of the foot just above the arch. It is incorporated within the posterior tibial tendon, which attaches in this area. An accessory navicular is congenital (present at birth). It is not part of normal bone structure and therefore is not present in most people. What is Accessory Navicular Syndrome? People who have an accessory navicular often are unaware of the condition if it causes no problems. However, some people with this extra bone develop a painful condition known as accessory navicular syndrome when the bone and/or posterior tibial tendon are aggravated. This can result from any of the following: • Trauma, as in a foot or ankle sprain • Chronic irritation from shoes or other footwear rubbing against the extra bone • Excessive activity or overuse Many people with accessory navicular syndrome also have flat feet (fallen arches). Having a flat foot puts more strain on the posterior tibial tendon, which can produce inflammation or irritation of the accessory navicular. Signs and Symptoms of Accessory Navicular Syndrome Adolescence is a common time for the symptoms to first appear. This is a time when bones are maturing and cartilage is developing into bone. Sometimes, however, the symptoms do not occur until adulthood. The signs and symptoms of accessory navicular syndrome include: • A visible bony prominence on the midfoot (the inner side of the foot, just above the arch) • Redness and swelling of the bony prominence • Vague pain or throbbing in the midfoot and arch, usually occurring during or after periods of activity Diagnosis To diagnose accessory navicular syndrome, the foot and ankle surgeon will ask about symptoms and examine the foot, looking for skin irritation or swelling. The doctor may press on the bony prominence to assess the area for discomfort. Foot structure, muscle strength, joint motion, and the way the patient walks may also be evaluated. X-rays are usually ordered to confirm the diagnosis. If there is ongoing pain or inflammation, an MRI or other advanced imaging tests may be used to further evaluate the condition. Treatment: Non-Surgical Approaches The goal of non-surgical treatment for accessory navicular syndrome is to relieve the symptoms. The following may be used: • Immobilization. Placing the foot in a cast or removable walking boot allows the affected area to rest and decreases the inflammation. • Ice. To reduce swelling, a bag of ice covered with a thin towel is applied to the affected area. Do not put ice directly on the skin. • Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed. In some cases, oral or injected steroid medications may be used in combination with immobilization to reduce pain and inflammation. • Physical therapy. Physical therapy may be prescribed, including exercises and treatments to strengthen the muscles and decrease inflammation. The exercises may also help prevent recurrence of the symptoms. • Orthotic devices. Custom orthotic devices that fit into the shoe provide support for the arch, and may play a role in preventing future symptoms. Even after successful treatment, the symptoms of accessory navicular syndrome sometimes reappear. When this happens, non-surgical approaches are usually repeated. When Is Surgery Needed? If non-surgical treatment fails to relieve the symptoms of accessory navicular syndrome, surgery may be appropriate. Surgery may involve removing the accessory bone, reshaping the area, and repairing the posterior tibial tendon to improve its function. This extra bone is not needed for normal foot function. Committed to your health, Dr. Craig Conti Sarasota Foot Care Center www.sarasotafootcarecenter.com

Special Report on “Fallen Arches” Otherwise Known as Posterior Tibial Tendon Dysfunction

What is Posterior Tibial Tendon Dysfunction (PTTD)? Seemingly overnight, one or both of your arches have flattened. You don’t remember your foot looking like this in the past. What has happened? What is going on? You probably have a condition called posterior tibial tendon dysfunction (PTTD) commonly called “fallen arches.” PTTD is an inflammation and/or overstretching of the posterior tibial tendon in the foot. An important function of the posterior tibial tendon is to help support the arch. But in PTTD, the tendon's ability to perform that job is impaired, often resulting in a flattening of the foot. The posterior tibial tendon is a fibrous cord that extends from a muscle in the leg. It descends the leg and runs along the inside of the ankle, down the side of the foot, and into the arch. This tendon serves as one of the major supporting structures of the foot and helps the foot to function while walking. PTTD is often called "adult-acquired flatfoot" or “fallen arches” because it is the most common type of flatfoot developed during adulthood. Although this condition typically occurs in only one foot, some people may develop it in both feet. PTTD is usually progressive, which means it will keep getting worse -- especially if it isn't treated early. Symptoms of PTTD The symptoms of PTTD may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. As the condition progresses, the symptoms will change: • When PTTD initially develops, typically there is pain on the inside of the foot and ankle (along the course of the tendon). In addition, the area may be red, warm, and swollen. • Later, as the arch begins to flatten, there may still be pain on the inside of the foot and ankle. But at this point, the foot and toes begin to turn outward and the ankle rolls inward. • As PTTD becomes more advanced, the arch flattens even more and the pain often shifts to the outside of the foot, below the ankle. The tendon has deteriorated considerably and arthritis often develops in the foot. In more severe cases, arthritis may also develop in the ankle. What Causes PTTD? Overuse of the posterior tibial tendon is frequently the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs. Non-Surgical Treatment Approaches Because of the progressive nature of PTTD, it's best to see your foot and ankle surgeon as soon as possible. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested. In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities. In many cases of PTTD, treatment can begin with non-surgical approaches that may include: • Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle stirrup brace or a custom orthotic device that fits into the shoe. • Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weight bearing for a while. • Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization. • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. • Shoe modifications. Your foot and ankle surgeon may advise you on changes to make with your shoes and may provide special inserts designed to improve arch support. When is Surgery Needed? In cases of PTTD that have progressed substantially or have failed to improve with non-surgical treatment, surgery may be required. For some advanced cases, surgery may be the only option. Surgical treatment may include repairing the tendon, realigning the bones of the foot, or both. Your foot and ankle surgeon will determine the best approach for your specific case. Committed to your health, Dr. Craig Conti Sarasota Foot Care Center www.sarasotafootcarecenter.com

Special Report on Orthotics

First of all, what are orthotics? Orthotics are custom made devices that fit inside your shoes and improve the function of your feet and ankles. You can think of them as “glasses for your feet.” Just like a pair of glasses causes your eyes to function in the proper way, a pair of orthotics improves the function of your feet and ankles. It also decreases pressure on the bones and skin of the foot, decreases pain and aligns the joints of the foot, ankle and knee.

What aren’t orthotics? Orthotics are not soft, gel or foam things that you can bend with your fingers. For an orthotic to work it must put your foot into a position that your foot does not want to go. During walking, all your weight is on one foot at a time. Imagine all of your weight on a soft, gel or foam device. It will flatten to nothing and will not improve the function of your foot.

Are orthotics comfortable? Absolutely, when they are made properly you don’t even feel them in your shoes. The only way that a pair of orthotics will be strong enough to work and yet comfortable enough that you will actually wear them, is to have them custom molded exactly to your foot.

But what about the ones you can get at the drug store from “the machine” or from the “foot store?” Collectively, the doctors of Sarasota Foot Care Center have been practicing medicine for well over 65 years. Not only do we know how to get you the true orthotic you need, but we will be there to help you down the road if anything happens and adjustments are needed. Try that with the “machine” or the “foot store.”

But aren’t they expensive? Expensive is when you pay good money for something and get no results. We don’t care if the so-called orthotics you can get at the shoe store only cost $60 dollars, they won’t help you. So is $60 dollars for a worthless pad a good deal? I don’t think so.

A pair of custom orthotics will last for about 3-5 years. It will improve your foot function and decrease your pain. Is that worth two installments of $225? How much does your heel hurt? How much would you pay to get out of the bed in the morning without that stabbing, shooting pain? How much would you pay to be able to exercise and finally lose those pounds you need to?

In these very sensitive economic times we completely understand priorities. If the decision is food or orthotics…that is a very simple decision. Another question you have to ask yourself is if you can afford not to get orthotics? Can you afford to miss more work because of your foot pain? Can you afford to take 6 weeks off because of a possibly avoidable surgery? There is not one golfer we know that would not pay that cost to shave a few strokes off of their game. How much easier would tennis be without the pain in the ball of your foot?

What foot conditions do orthotics treat? Orthotics treat a large group of conditions that all stem from the movement of the muscles and bones of the foot. These conditions include, but are not limited to: heel pain, heel spurs, flat feet, “fallen arches,” bunions, neuromas (pinched nerve in the foot), painful corns and calluses under the ball of the foot, sore feet and ankles, tendonitis and joint pain.

What will happen if I need orthotics but I don’t get them, can I do permanent damage to myself? Yes you can. Flat feet are genetic and are usually noticed early in life. If untreated, the excess pressure and abnormal wear and tear on the joints can lead to severe arthritic conditions and loss of function. Heel pain is ultimately a problem with alignment and no amount of stretching or cortisone shots will cure the problem with out addressing the underlying alignment issues. In fact, all the conditions that are treated with orthotics have a major alignment component to them. Leaving this alignment uncorrected only leads to further pain and loss of function. It is critical to correct the root cause of these conditions and the root cause is the deranged alignment. Orthotics are the only thing that can correct this alignment problem.

Will I have to get bigger shoes to fit the orthotics? No, you should not need a larger size to fit your orthotics. Most athletic shoes have a removable foot bed that will create the room needed to fit the orthotics. The same goes for most lace-up loafers or boots. In fact, there are some sandals that have a removable foot bed and work with orthotics as well. There are, of course some shoes that will not work with orthotics. High heels and flip-flops come to mind immediately. Have no fear. If you wear the orthotics when you are most active, occasional flip-flops and high heels are acceptable.

If you have been experiencing pain or soreness in your foot, what are you waiting for? Biomechanical problems, which is to say bone, muscle and joint problems, do not just heal themselves. You would never expect your vision to miraculously improve and you should not ask for miracles with your feet either. If your feet have been hurting you, or you have been watching someone you care about suffer with foot pain, stop waiting and get the pair of orthotics you need, today.


Committed to your health,

Dr. Craig Conti
Sarasota Foot Care Center
www.sarasotafootcarecenter.com