What You Should Know About Navicular Stress Fractures

John R. Fowler, MD, John P. Gaughan, PhD, Barry P. Boden, MD, and Joseph S. Torg, MD

What The Studies Reveal About Cast Immobilization

The proper treatment of navicular stress fractures has been a recent topic of debate. Historically, conservative treatment in a non-weightbearing cast has been the treatment of choice.1,3,8,11 More recently, authors have described open reduction and internal fixation (ORIF) for navicular stress fractures.7,8,12-14

   Torg and colleagues retrospectively reviewed 21 cases of navicular stress fracture and demonstrated that these stress fractures heal well with conservative treatment.11 Since routine radiographs failed to show the fracture, the interval between the onset of symptoms and diagnosis ranged from less than one month to 38 months (a mean of seven months).11 Conservative treatment in this series consisted of non-weightbearing cast immobilization for six to eight weeks, which was followed by gradual weightbearing in a boot for two to six weeks until patients were pain free.

   Several authors have confirmed the efficacy of this treatment protocol.5,12,15 Even in patients who have failed treatment in a weightbearing cast, the use of a non-weightbearing cast treatment compares favorably with surgical treatment.12

   Khan and colleagues studied 86 patients with navicular stress fractures and found that initial non-weightbearing cast immobilization for at least six weeks facilitated a return to sports in 19 of 22 patients (86 percent).12 In contrast, of those who initially continued weightbearing with limited activity, only 9 of 34 patients (26 percent) returned to sports. For patients who failed initial treatment, six of 7 patients (86 percent) treated with subsequent non-weightbearing cast immobilization achieved a successful outcome compared to 11 of 15 patients (73 percent) who underwent surgical treatment.

   There is strong evidence supporting the effectiveness of proper conservative management for both partial and non-displaced complete stress fractures of the tarsal navicular.

   Case series or reports from Ostlie, Alfred, Murray, Towne, Goergen, Ariyoshi, Miller and Ting all reported a 100 percent success rate when utilizing at least six weeks of non-weightbearing management.1,16-22 The data also strongly reaffirms that weightbearing rest or limited activity as a conservative treatment often leads to an unsuccessful outcome including: delayed union or nonunion, re-fracture, fracture progression or recurrence of symptoms.1,5,11,12,15,23,24

Weighing Surgical Versus Conservative Management

However, it appears that current management of this injury more frequently utilizes surgical intervention both as a first-line treatment or following failed treatment with conservative weightbearing management due to pressure on both the athlete and the physician to have the athlete return more quickly to competition.5,15

   In a retrospective review in 2000, Saxena and colleagues studied 22 patients who sustained navicular stress fractures during athletic activity.26 For the nine patients who underwent ORIF, the average return to activity was 3.1 months. For the 13 patients treated with conservative care, the average return to activity was 4.3 months. The authors suggested that surgical intervention will decrease the amount of time for an athlete to return to his or her activity level prior to injury.

   However, the most recently reported data by Saxena and colleagues in 2006 demonstrated no significant difference between surgical and conservative management for navicular stress fractures when it came to return to activity.27 According to the prospective study, patients with type 1 navicular stress fractures received non-operative treatment while patients with type 2 and type 3 injuries received ORIF. The return to activity for patients with type 1 injuries was 3.8 months whereas the return to activity for patients with type 2 fractures and type 3 fractures was 3.7 months and 4.2 months respectively.

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