Killer accessory navicular pain but torn peroneal tendons too :(

Hello-I have serious foot issues that have accumulated over the years with psoriatic arthritis. One foot has subluxing peroneal tendons, and the other has chronic peroneal tendon pain and severe accessory navicular pain-can't wear anything other than slippers because otherwise it rubs against the navicular (type 2). I'm scheduled to have peroneal tendons looked at bilaterally because physical therapy has failed, but I'm wondering if it's possible to have the accessory navicular removed at the same time as the peroneal tendon pain on the left...or is that two different surgeries? Really not excited bout the possibility of two separate surgeries so I figured I'd ask my surgeon if we can get it all taken care of at once...do you think that they'd be able to do that? Or is it too big of surgery to have done at once? I'm 25 and have had this foot pain for two years, so needless to say, it's really effecting my life! Especially since I've always been super athletic and can hardly do anything now :( Any thoughts? I'm so anxious to get moving again!

RESPONSE

Hi,

This would be a decision your surgeon would ultimately have to make since he or she is far more familiar with your case than me, but, in theory at least there is no reason why you could not have both peroneal tendon repair and removal of the accessory navicular done on the same foot, at the same time.

Since both of these procedures will require repair of tendons, more than likely your surgeon will want you in a cast and be non-weightbearing for a period of time and since you will not be walking on the foot, I see no reason not to have both procedures done at once.

I suppose the argument could me made that you might be able to salvage the peroneal tendon issue with conservative measures. I realize physical therapy has not worked out for you, but sometimes immobilization of a partially torn tendon will allow the tendon to heal.

The other issue with peroneal tendon pain is that in many cases the tendon is constantly being "jammed" in cases where a patient is excessively pronated or flat-footed. In these situations, there is excess jamming on the outside of the ankle which irritates the peroneal tendon and may or may not cause it to partially tear. The opposite happens on the inside of the ankle where there is a stretching of tissue including the tibialis posterior tendon which attaches into the navicular bone and "houses" the accessory navicular bone.

So, in many instances just by re-aligning the foot relative to the ankle with the use of an orthotic, you eliminate the jamming on the outside of the ankle as well as the stretching on the inside of the ankle. This in turn takes the strain off of both the peroneal tendons and the tibialis posterior tendon and many times will eliminate your pain. I am not saying this always happens, but it is certainly worth a try before you consent to surgery. If it does not help, you can always have the surgery.

Keep in mind that the stretching of the tibialis posterior tendon exacerbates the pain from the accessory navicular.

The caveat here is that if your accessory navicular is too large, with "too large" meaning that there is such a bulge on the inside of your foot there is a good chance that no matter what you do, you may still have issues with the accessory bone, unless it is removed surgically.

You do want to make sure you know why you are having issues with your peroneal tendons because if part of the problem is from excessive pronation resulting in irritation to the tendons, you could undergo the finest surgical correction in the history or peroneal tendon repair, only to end up with the same problem down the road, if the excessive pronation is not dealt with.

Hopefully, I have given you some food for thought and just make sure the biomechanics of your foot and ankle are fully analyzed so that you do not have to go through this all over again.

Marc Mitnick DPM
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