What You Should Know About Navicular Stress Fractures

Author(s): 
John R. Fowler, MD, John P. Gaughan, PhD, Barry P. Boden, MD, and Joseph S. Torg, MD

   In support of this view, Burne and colleagues found the clinical outcome of alternative therapies inferior to that which is reported for cast immobilization.5 These authors found “limited evidence to support surgical intervention as a first line of management” and suggested that the large variance in different surgical approaches “may reflect a lack of consistently satisfactory outcomes.”

Reviewing The Findings From A Recent Meta-Analysis

A recent meta-analysis by Torg identified 313 tarsal navicular stress fractures in 23 reports in the peer-reviewed literature.7 Seventy of the 73 fracture patients (96 percent) initially treated with non-weightbearing cast immobilization for six weeks had a successful outcome with return to activity in an average of 4.9 months. Seventeen of the 22 patients (77 percent) treated with non-weightbearing cast immobilization for less than six weeks had a successful outcome with return to activity in an average of 3.7 months. Only 41 of the 92 (44.5 percent) patients initially treated with weightbearing rest and/or cast immobilization experienced a successful outcome with return to activity in an average of 5.7 months. Fifty-four of 66 patients (82 percent) with initial surgical treatment had a successful outcome with return to activity in an average of 5.2 months.

   Comparing the modes of treatment, the authors found no statistically significant difference between non-weightbearing conservative treatment and surgical intervention.7 Patients treated with non-weightbearing conservative therapy experienced more successful outcomes (96 percent versus 44 percent) than patients treated with weightbearing conservative therapy. There was no statistically significant difference between non-weightbearing conservative management and surgical fixation regarding successful outcome or the time to return to activity.

   Torg and colleagues further analyzed and compared the effectiveness of non-weightbearing treatment with surgical intervention as secondary treatment modalities following failed weightbearing management.7 Although this particular analysis had limited value because of the small numbers, there was no statistically significant difference between the treatment methods.

Case Study: Treating A Football Player Who Has Exacerbated Foot Pain When Making Cuts

A 16-year-old high football player received a referral to our office from his athletic trainer. The patient had pain in his left foot that had been present for three weeks but denied any trauma to the foot. The wide receiver said his pain was exacerbated when making cuts or coming out of his route.

   Upon performing the physical examination, we noted no swelling or erythema over the dorsum of the foot. However, he did have point tenderness over the central aspect of the navicular. Hopping on the affected foot reproduced his pain.

   Plain radiographs were unremarkable. We subsequently obtained a technetium labeled bone scan, which demonstrated increased uptake in the left midfoot. A MRI demonstrated a stress reaction within the central third of the left navicular.

   The patient wore a short leg cast and was non-weightbearing for six weeks. After cast removal, the patient wore a walking boot for an additional two weeks. He resumed jogging eight weeks after the initiation of his treatment and was able to return to football later in the same season with complete resolution of his symptoms. The patient remained pain free at the most recent follow-up visit.

In Conclusion

The recent literature suggests that patients with navicular stress fractures are undergoing surgery or they are receiving conservative weightbearing management as a first-line treatment option with the expectation that they will return to their activity more quickly.5,26,27 Although surgical treatment seems increasingly common, it remains largely underreported in the literature.

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