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 sideof 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.

Cavus Foot (High Arches)

What is Cavus Foot?

Cavus foot is a condition in which the foot has a very high arch. Because of this high arch, an excessive amount of weight is placed on the ball and heel of the foot when walking or standing. Cavus foot can lead to a variety of signs and symptoms, such as pain and instability. It can develop at any age, and can occur in one or both feet.

Causes

Cavus foot is often caused by a neurologic disorder or other medical condition such as cerebral palsy, Charcot-Marie-Tooth disease, spina bifida, polio, muscular dystrophy, or stroke. In other cases of cavus foot, the high arch may represent an inherited structural abnormality. An accurate diagnosis is important because the underlying cause of cavus foot largely determines its future course. If the high arch is due to a neurologic disorder or other medical condition, it is likely to progressively worsen. On the other hand, cases of cavus foot that do not result from neurologic disorders usually do not change in appearance.

Symptoms

The arch of a cavus foot will appear high even when standing. In addition, one or more of the following symptoms may be present:

• Hammertoes (bent toes) or claw toes (toes clenched like a fist)

• Calluses on the ball, side, or heel of the foot

• Pain when standing or walking

• An unstable foot due to the heel tilting inward, which can lead to ankle sprains

Some people with cavus foot may also experience foot drop, a weakness of the muscles in the foot and ankle that results in dragging the foot when taking a step. Foot drop is usually a sign of an underlying neurologic condition.

Diagnosis

Diagnosis of cavus foot includes a review of the patient’s family history. The foot and ankle surgeon examines the foot, looking for a high arch and possible calluses, hammertoes, and claw toes. The foot is tested for muscle strength, and the patient’s walking pattern and coordination are observed. If a neurologic condition appears to be present, the entire limb may be examined. The surgeon may also study the pattern of wear on the patient’s shoes. X-rays are sometimes ordered to further assess the condition. In addition, the surgeon may refer the patient to a neurologist for a complete neurologic evaluation.

Non-Surgical Treatment

Non-surgical treatment of cavus foot may include one or more of the following options:

• Orthotic devices. Custom orthotic devices that fit into the shoe can be beneficial because they provide stability and cushioning to the foot.

• Shoe modifications. High-topped shoes support the ankle, and shoes with heels a little wider on the bottom add stability.

• Bracing. The surgeon may recommend a brace to help keep the foot and ankle stable. Bracing is also useful in managing foot drop.

When is Surgery Needed?

If non-surgical treatment fails to adequately relieve pain and improve stability, surgery may be needed to decrease pain, increase stability, and compensate for weakness in the foot. The surgeon will choose the best surgical procedure or combination of procedures based on the patient’s individual case. In some cases where an underlying neurologic problem exists, surgery may be needed again in the future due to the progression of the disorder.

Deep Vein Thrombosis

What is Deep Vein Thrombosis?

The blood supply of the leg is transported by arteries and veins. The arteries carry blood from the heart to the limbs; veins carry blood back to the heart. The leg contains superficial veins, which are close to the surface, and deep veins, which lie much deeper in the leg. Deep vein thrombosis (DVT) is a condition in which a blood clot (a blockage) forms in a deep vein. While these clots most commonly occur in the veins of the leg (the calf or thigh), they can also develop in other parts of the body.  DVT can be very dangerous and is considered a medical emergency. If the clot (also known as a thrombus) breaks loose and travels through the bloodstream, it can lodge in the lung. This blockage in the lung, called a pulmonary embolism, can make it difficult to breathe and may even cause death. Blood clots in the thigh are more likely to cause a pulmonary embolism than those in the calf.

Causes of DVT

Many factors can contribute to the formation of a DVT. The more risk factors a person has, the greater their risk of having a DVT. However, even people without these risk factors can form a DVT.

            Risk Factors for DVT:

• Previous DVT
• Varicose veins
• Blood clotting disorders
• Family history of DVT or blood-clotting disorders
• Heart disease
• Chronic swelling of the legs
• Obesity
• Inflammatory bowel disease
• Cancer
• Dehydration
• Sepsis
• Hormone replacement therapy
• Birth control pills containing estrogen
• Pregnancy or recent childbirth
• Age over 40 years old
• Immobility (through inactivity or from wearing a cast)
• Recent surgery
• Trauma (an injury)
• Smoking

Signs and Symptoms of DVT in the Leg

Some people with DVT in the leg have either no warning signs at all or very vague symptoms. If any of the following warning signs or symptoms are present, it is important to see a doctor for evaluation:

• Swelling in the leg

• Pain in the calf or thigh

• Warmth and redness of the leg

Diagnosis

DVT can be difficult to diagnose, especially if the patient has no symptoms. Diagnosis is also challenging because of the similarities between symptoms of DVT and those of other conditions such as a pulled muscle, an infection, a clot in a superficial vein (thrombophlebitis), a fracture, and arthritis. If DVT is suspected, the doctor will immediately send the patient to a vascular laboratory or a hospital for testing, which may include a blood test, Doppler ultrasound,Treatment of DVT

If tests indicate a clot is present, the doctor will make a recommendation regarding treatment. Depending on the location of the clot, the patient may need hospitalization.

Medical or surgical care will be managed by a team of physicians which may include a primary care physician, internist, vascular (blood vessel) surgeon, or hematologist (blood disease specialist).

Treatment may include:

• Medication. A blood-thinning medication is usually prescribed to help prevent additional clots from forming.

• Compression stockings. Wearing fitted hosiery decreases pain and swelling.

• Surgery. A surgical procedure performed by a vascular specialist may be required.

Complications of DVT

An early and extremely serious complication of DVT is a pulmonary embolism. A pulmonary embolism develops if the clot breaks loose and travels to the lung. Symptoms of a pulmonary embolism include:

• Shortness of breath

• Chest pain

• Coughing up blood

• A feeling of impending doom

A long-term consequence of DVT is damage to the vein from the clot. This damage often results in persistent swelling, pain and discoloration of the leg.

Preventive Measures

For those who have risk factors for DVT, these strategies may reduce the likelihood of developing a blood clot:

• Take blood-thinning medication, if prescribed.

• Reduce risk factors that can be changed. For example, stop smoking and lose excess weight.

• During periods of prolonged immobility, such as on long trips:

– Exercise legs every 2 to 3 hours to get the blood flowing back to the heart. Walk up and down the aisle of a plane or train, rotate ankles while sitting, and take regular breaks on road trips.

– Stay hydrated by drinking plenty of fluids; avoid alcohol and caffeine.

– Consider wearing compression stockings.

Rheumatoid Arthritis in the Foot and Ankle

What is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a disease in which certain cells of the immune system malfunction and attack healthy joints. RA causes inflammation in the lining (synovium) of joints, most often the joints of the hands and feet. The signs of inflammation can include pain, swelling, redness, and a feeling of warmth around affected joints. In some patients, chronic inflammation results in damage to the cartilage and bones in the joint. Serious damage can lead to permanent joint destruction, deformity, and disability.

When joints become inflamed due to RA, the synovium thickens and produces an excess of joint fluid. This overabundance of fluid, along with inflammatory chemicals released by the immune system, causes swelling and damage to the joint’s cartilage and bones.

Symptoms Affecting the Foot and Ankle

Foot problems caused by RA commonly occur in the forefoot (the ball of the foot, near the toes), although RA can also affect other areas of the foot and ankle. The most common signs and symptoms of RA-related foot problems, in addition to the abnormal appearance of deformities, are pain, swelling, joint stiffness, and difficulty walking. Deformities and conditions associated with RA may include:

• Rheumatoid nodules (lumps), which cause pain when they rub against shoes or, if they appear on the bottom of the foot, pain when walking

• Dislocated toe joints

• Hammertoes

• Bunions

• Heel Pain

• Achilles tendon pain

• Flatfoot

• Ankle pain

Diagnosis

RA is diagnosed on the basis of a clinical examination as well as blood tests. To further evaluate the patient’s foot and ankle problems, the surgeon may order x-rays and/or other imaging tests.

Treatment by the Foot and Ankle Surgeon

While treatment of RA focuses on the medication prescribed by a patient’s primary doctor or rheumatologist, the foot and ankle surgeon will develop a treatment plan aimed at relieving the pain of RA-related foot problems. The plan may include one or more of the following options:

• Orthotic devices. The surgeon often fits the patient with custom orthotic devices to provide cushioning for rheumatoid nodules, minimize pain when walking, and give needed support to improve the foot’s mechanics.

• Accommodative shoes. These are used to relieve pressure and pain and assist with walking.

• Aspiration of fluid. When inflammation flares up in a joint, the surgeon may aspirate (draw out) fluid to reduce the swelling and pain.

• Steroid injections. Injections of anti-inflammatory medication may be applied directly to an inflamed joint or to a rheumatoid nodule.

When is Surgery Needed?

When RA produces pain and deformity in the foot that is not relieved through other treatments, surgery may be required. The foot and ankle surgeon will select the procedure best suited to the patient’s condition and lifestyle.

SOFT TISSUE BIOPSY

What is a Soft Tissue Biopsy?

A soft tissue biopsy is the removal and microscopic examination of a small sample of soft tissue for diagnostic purposes. “Soft tissue” includes the skin, fat, muscle, and tendons that surround, connect, or support other tissues or organs. Soft tissue biopsies require little time or involvement from the patient. They enable the foot and ankle surgeon to reach an accurate diagnosis and determine the best treatment for the specific condition.

Conditions Identified by Soft Tissue Biopsies

A wide variety of medical conditions can be identified through a soft tissue biopsy. Some people think the word “biopsy” means that cancer is always suspected, but this is not true. In fact, premalignant or malignant conditions account for only a small percentage of the diagnoses made from soft tissue biopsies.

A few examples of conditions assessed through soft tissue biopsies include:

• Freckles (macules)

• Benign pigmented, or colored, spots (moles or nevus)

• Fungal or bacterial infections

• Rashes (such as eczema or dermatitis)

• Lesions related to a disease affecting the entire body (such as diabetes)

• Nodular conditions (such as a ganglion cyst, lipoma, or fibroma)

• Toenail conditions (onychomycosis, psoriasis)

• Wart-like growths on the skin (benign keratoses)

• Premalignant conditions (actinic and seborrheic keratoses)

• Malignant conditions (skin cancer)

What Does the Biopsy Involve?

A biopsy involves removal of a small piece of tissue, and takes just a few minutes. The procedure performed will depend on the tissue to be sampled. After numbing the area, the surgeon performs one of the following:

• Shave biopsy. A thin piece of tissue is shaved off.

• Punch biopsy. A small, round instrument removes a tiny core of tissue. Stitches may be needed.

• Incisional or excisional biopsy. A piece, or the entire lesion, is removed. Stitches are often needed.

Once the sample is obtained, the surgeon sends it to a clinical laboratory so that the condition can be identified. The specimen will be examined by a pathologist who specializes in evaluating soft tissue biopsies.

After the Biopsy

Patients should follow the instructions provided by the surgeon for care of the biopsy site. If the area has stitches, an appointment will be scheduled for their removal. It usually takes several days for the lab results to arrive at the surgeon’s office. If the patient has not heard about the results after 10 days, the surgeon’s office should be contacted. Biopsy results, as well as additional treatment that may be required, will then be discussed.