Stress fractures of the tarsal navicular
Section snippets
Anatomy and pathophysiology
The midfoot performs an important function as a rigid connection between the hindfoot and forefoot. The unique geometry and strong ligamentous support provide an extremely rigid and stable construct that forms the medial longitudinal and transverse arch of the foot. The oval-shaped navicular articulates distally with the three cuneiforms, proximally with the head of the talus, and forms the medial column of the foot. The distal articular surface is convex; three separate articular facets
Case presentation
A 28-year-old professional American football player presented in spring training to the training room with a 2-week history of right foot pain. The patient stated that the injury began as a vague discomfort after practices that steadily developed into pain during practices. He was seen by the athletic trainer; after radiographs proved negative Fig. 3, Fig. 4 he was diagnosed with anterior tibial tendinitis, started therapeutic modalities, and continued to practice. When his pain did not improve
Presentation
Patients often present with ill-defined complaints of foot soreness or cramping. Navicular stress fractures results from repetitive cyclical loading on the forefoot which is common in athletes; these injuries are uncommon in the general population. This injury is most common in explosive push-off or change of direction sports, such as track and field, football, rugby, and basketball [3], [6], [12], [17], [18]. Individuals who are involved in low-intensity cyclical activities, such as distance
Radiographic evaluation
The delay in diagnosis often can be attributed to the initial plain radiographs. In 1983, Pavlov et al [13]found that in a retrospective review of positive bone scans, plain radiographs identified only 9 of 23 stress fractures. Prospectively, only 5 of the 23 stress fractures were identified. Also, all of the fractures were complete; none of the incomplete fractures was identified retrospectively. Khan et al [3], in a 1994 review of the literature, found that 24% of incomplete fractures and 81%
Treatment
Navicular stress fractures have been separated into displaced and nondisplaced and complete and partial fracture patterns. After the navicular stress fracture has been imaged appropriately, treatment options must be discussed with the patient. Because most injuries occur in the dedicated athlete, prolonged conservative treatment options may be unsatisfactory.
Conservative treatment is the most appropriate course to take in most patients who have nondisplaced complete and partial fracture
Surgical technique
The surgical technique for a complete or displaced fracture consists of a longitudinal incision on the dorsum of the foot overlying the navicular. The neurovascular structures are identified and retracted medially and the extensor tendons are taken laterally. The fracture may be difficult to identify; the use of image intensification, as well as palpation of the dorsal cortical surface with a Kirshner wire or knife blade, can aid in the search. Often, the talonavicular joint capsule must be
Rehabilitation
Postoperative management should consist of immobilization in a nonweight-bearing cast for 4 to 6 weeks. The length of time required may vary depending on the severity of the original fracture. Protected weight bearing is begun with a cast for individuals who had displacement or complete sclerotic fracture lines. Patients who had incomplete fractures can use a walker boot to weight bear and begin running and swimming activity as well as physical therapy to initiate motion. The absence of pain
Complications
Delayed union or nonunion are the most serious complications of tarsal navicular stress fractures. This diagnosis is made by complaints of continued pain with activity and is confirmed by a CT scan. Patients who had not undergone operative intervention are advised to proceed with operative intervention. Operative intervention involves the usual risks of infection, neurovascular injury, and nonunion or delayed union. With the difficulty of union in the navicular, the authors generally use bone
Summary
Tarsal navicular stress fractures present a difficult diagnostic and treatment dilemma for the orthopedic physician of an active individual. Patients often complain of diffuse, poorly-defined symptoms and have a paucity of physical findings. Initial diagnostic evaluation often fails to recognize navicular stress fractures which results in delayed diagnosis and treatment. A bone scan is sensitive in detecting this entity and the clinician should use this examination in any patient who is
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2016, Orthopedic Clinics of North AmericaCitation Excerpt :However, if tenderness persists then a walker boot is used with low-impact activity allowed for an additional 6 to 8 weeks. If no improvement is realized within 3 to 4 months of the initiation of treatment, then some investigators have recommended a repeat CT scan be obtained.58 Note that CT scan is only useful in assessing for progression of fracture lines and development of sclerosis of the cancellous margins indicating nonunion.
Graduated Loading Program
2016, Pathology and Intervention in Musculoskeletal Rehabilitation