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Navicular Stress Fracture

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Other Names

  • Navicular stress fracture
  • Mueller-Weiss syndrome
  • Tarsal Navicular Stress Fracture

Background

History

  • Navicular stress fractures first described by Towne in 1970[1]

Epidemiology

  • Most frequently injured tarsal bone (need citation)
  • Represents up to 1/3 of all stress fractures[2]
  • 98.5% occur in athletes[3]
  • Rugby
    • Account for only 8% of foot injuries, 22% of player absence with average return to play of 188 days[4]

Pathophysiology

  • General
    • See: Stress Fractures (Main)
    • Stress injury seen in running and track and field athletes
    • Navicular is susceptible due to middle 1/3 is relatively avascular
    • Diagnosis is typically delayed 4-7 months from onset of foot pain[5]
  • Mueller-Weiss syndrome
    • Spontaneous Navicular AVN
    • Rare disease
    • Seen in middle aged adults with chronic midfoot pain

Etiology

  • Chronic overuse injury
    • Repetitive foot strikes in weight bearing exercise or running
    • Inadequate rest and recovery time
    • Navicular bone subjected to repetitive and continuous overload
    • Resulting in microfractures and generating a so-called weak spot in the foot architecture
    • True cortical breaks can eventually occur

Pathoanatomy

  • Navicular
    • 'Keystone' of the arch of the foot[6]
    • Articulates with the Cuneiforms (distal), Talus (proximal), and Cuboid (lateral)
    • Particularly susceptible due to middle 1/3 is relatively avascular

Risk Factors

  • General
    • Male > Female[7]
  • Sports
    • Running
    • Track and field (account for 59% of all navicular stress fractures)[2]
    • Basketball[8]
  • Intrinsic
    • History of stress fracture
    • Poor foot and ankle biomechanics[7]
  • Extrinsic

Differential Diagnosis


Clinical Features

  • History
    • Overuse injuries should have a history consistent with stress fracture
    • Symptoms may persist for up to 6 months before pursuing evaluation
    • Onset of pain is insidious, initially during activity only, eventually even at rest
    • Eventually limits sports participation, activities of daily living[9]
    • Worse with certain activities such as sprinting, pushing off, jumping
    • Patient will endorse pain, swelling over the midfoot
    • Trouble weight bearing
  • Physical Exam: Physical Exam Foot
    • Swelling may be noted over dorsomedial midfoot
    • Tenderness to navicular, especially at the "N" spot
      • Described as nickel-sized area in the center of the proximal dorsal navicular
      • Positive in 81% of patients[10]
    • Tarsal adduction, abduction may be painful
    • Stand on toes or single leg hop may be painful[11]
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Initial imaging modality of choice
    • Only 33% sensitive for navicular stress fracture[12]
    • Lateral, oblique views provide best detail (need citation)
  • Accessory navicular bone
    • May be seen and can present as a fracture
    • May also be confused as a tuberosity fracture
    • Compare to other foot as needed

CT

  • Findings
    • Incomplete fracture in central 1/3 of bone
    • Fracture line extends obliquely from dorsolateral to plantarmedial[13]
    • Can see dorsal notching up to 10 years after healed stress fracture

MRI

  • Utility
    • Imaging modality of choice
    • Most sensitive for identifying stress fractures[14]
  • Findings
    • T2 hyperintensity over fracture site indicating bone edema

Bone Scan

  • Triple Phase
    • 100% sensitive with high PPD for navicular stress fractures (need citation)
  • Downside
    • Lack anatomic resolution
    • Not specific

Classification

Saxena Classification Based on Location of Fracture

  • Type I: Dorsal cortex[15]
  • Type II: Extension into the body
  • Type III: Extension from dorsal to plantar cortex

Management

Nonoperative

  • Indications
    • Nondisplaced fractures
  • General
    • Management is somewhat controversial
    • Nonoperative management revolves around immobilization and protected weight bearing
  • Immobilization, non weight bearing for 6-8 weeks
    • Torg eg al found 100% healing rate without complication[10]
      • In the same cohort, patients in walking cast, 78% could not return to sport
    • Khan et al had similar findings comparing non weight bearing to walking cast[12]
  • Bone Stimulator
    • Some studies have shown benefit in distal radius, tibia fractures compared to placebo
    • Beck et al: RCT failed to show benefit for MTSS except in severe cases[16]
    • Does not seem to pose harm, may provide benefit
  • Shock Wave Therapy
    • Multiple studies demonstrating use in treatment of fracture nonunions[17][18]
    • Utility in stress fractures has not yet been proven
    • Overall, fast and safe
  • Vitamin D
    • Well supported in the literature in the setting of stress fractures
    • Can also be used to reduce stress fractures in high risk populations
    • Consensus opinion is that it aids in fracture healing[19]
  • Teriparatide
    • Recombinant human parathyroid hormone
    • Used primarily in osteoporosis, has some evidence for use in fractures and nonunion[20]
    • One small study among premenopausal women with lower extremity stress fractures showed improved bone formation markers, MRI[21]

Operative

  • Indications
    • Displaced navicular stress fractures
    • Nondisplaced complete fractures with sclerotic changes
    • Comminuted fractures
    • Athletes who fail conservative management
    • Athletes who cannot tolerate a prolonged recovery course
  • Technique
    • Open reduction, internal fixation
  • Bone Marrow Aspirate Concentrate (BMAC)
    • Can be considered as an adjunct in the operating room
    • Requires further research, but early in vitro and in vivo studies are promising[22]

Gross et al approach

  • Treatment based on 3 factors[23]
    • CT Scan findings
    • Athletes level of participation
    • Patient's functional status
  • Type I
    • Week 1: Short Leg Cast, non weight bearing for 6 weeks
    • Week 6: order CT, if it shows healing
      • Place in Walking Boot, participate in nonimpact activities, progressive weight bearing
      • Week 8: if no pain, fully weight bearing, begin physical therapy
      • Week 12: full return to sport if clears physical therapy, pain free on exam
    • Week 6: CT shows no evidence of osseous bridging
      • Patient is placed back in Short Leg Cast, non weight bearing, bone stimular
      • Week 12: New CT, if no evidence of healing offer surgery
  • Type II non-displaced
    • Week 1: Short Leg Cast, non weight bearing for 6 weeks
      • Non-elite athlete: treated similar to type I
      • Elite athlete: Offer early surgical intervention to those who wish to RTP quickly
  • Type II displaced, Type III
    • Early surgical management

Rehab and Return to Play

Rehabilitation

  • General
    • Ankle range of motion
    • Ankle proprioception,
    • Ankle strengthening
  • Postoperative protocol[23]
    • Weeks 1-2: Bulky splint
    • Weeks 2-6: Non-weight bearing cast
    • Week 6: CAM boot walker, partial weight bearing, range of motion
    • Week 8: Increase to full weight bearing, strengthening PT
    • Week 12: CT scan, resume sport specific training if progressing

Return to Play/ Work

  • Resume sport specific training
    • Takes about 4 months to heal
    • If surgical, generally delayed until at least 5-6 months
      • This varies based on progress, clinical picture, demands of sport, etc
    • Must have normal range of motion, strength
    • Must be able to perform repetitive single limb rises without any pain
  • Return to sport
    • Usually begins around 12 weeks
    • Full return usually takes 6-12 months

Complications and Prognosis

Prognosis

  • Outcomes of surgical vs non-surgical
    • Saxena and Fullem found no clinical difference in patients treated operatively vs nonoperatively[24]
      • Return to activity was similar for both patient populations at 3.9 ± 1.3 months
    • Potter at al: 10 year follow up found similar CT findings, pain levels, and functional outcomes[25]
    • Fitch et al: found better outcomes with surgical management than nonsurgical management[26]
  • 2010 Meta-analysis comparing nonoperative vs operative management[27]
    • No advantage in surgical intervention when compared with cast immobilization and complete non–weight bearing (P = .6441)
    • Nonsignificant trend favoring the success of nonoperative management (96%) over surgery (82%)
    • Weight bearing with or without immobilization had significantly worse clinical outcomes compared to non– weight bearing or surgery
  • Return to sport
    • Mallee et al found RTP was faster in surgical patients (16.4 weeks) vs nonsurgical patients (21.7 weeks)[28]

Complications

  • Cortical break
  • Nonunion
    • May be as high as 20% based on post-operative CT imaging[29]

See Also


References

  1. Towne LC, Blazina ME, Cozen LN. Fatigue fracture of the tarsal navicular. J Bone Joint Surg Am. 1970;52:376-378.
  2. 2.0 2.1 Bennell KL, Malcolm SA, Thomas SA, Wark JD, Brukner PD. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24:211-217.
  3. Mallee, Wouter H., et al. "Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review." British journal of sports medicine 49.6 (2015): 370-376.
  4. Pearce CJ, Brooks JH, Kemp SP, Calder JD. The epidemiology of foot injuries in professional rugby union players. Foot Ankle Surg : Off J Eur Soc Foot Ankle Surg. 2011;17(3):113–8.
  5. Gross CE, Nunley JA., 2nd Navicular stress fractures. Foot Ankle Int. 2015;36(9):1117–22.
  6. Eichenholtz SN, Levine DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res. 1964; 34:142-157.
  7. 7.0 7.1 Wright AA, Taylor JB, Ford KR, Siska L, Smoliga JM. Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med. 2015;49(23):1517–23.
  8. Weel, H., K. T. M. Opdam, and G. M. M. J. Kerkhoffs. "Stress fractures of the foot and ankle in athletes, an overview." Clinical Research on Foot & Ankle (2014): 1-6.
  9. Mann JA, Pedowitz DI. Evaluation and treatment of navicular stress fractures, including nonunions, revision surgery, and persistent pain after treatment. Foot Ankle Clin. 2009;14: 187-204.
  10. 10.0 10.1 Torg JS, Pavlov H, Cooley LH, et al. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. J Bone Joint Surg Am. 1982;64:700-712.
  11. Fitch KD, Blackwell JB, Gilmour WN. Operation for nonunion of stress fracture of the tarsal navicular. J Bone Joint Surg Br. 1989;71:105-110.
  12. 12.0 12.1 Khan KM, Fuller PJ, Brukner PD, Kearney C, Burry HC. Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med. 1992;20: 657-666.
  13. Kiss ZS, Khan KM, Fuller PJ. Stress fractures of the tarsal navicular bone: CT findings in 55 cases. AJR Am J Roentgenol. 1993;160:111-115.
  14. Rosenbaum AJ, Uhl RL, DiPreta JA. Acute fractures of the tarsal navicular. (2014) Orthopedics. 37 (8): 541-6.
  15. Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg : Off Publ Am College Foot Ankle Surg. 2000;39(2):96–103.
  16. Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, Hoffman AR, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med. 2008;36(3):545–53.
  17. Taki M, Iwata O, Shiono M, Kimura M, Takagishi K. Extracorporeal shock wave therapy for resistant stress fracture in athletes: a report of 5 cases. Am J Sports Med. 2007;35(7):1188–92.
  18. Xu ZH, Jiang Q, Chen DY, Xiong J, Shi DQ, Yuan T, et al. Extracorporeal shock wave treatment in nonunions of long bone fractures. Int Orthop. 2009;33(3):789–93.
  19. Gorter EA, Hamdy NA, Appelman-Dijkstra NM, Schipper IB. The role of vitamin D in human fracture healing: a systematic review of the literature. Bone. 2014;64:288–97.
  20. Aspenberg P, Genant HK, Johansson T, Nino AJ, See K, Krohn K, et al. Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Mineral Res : Off J Am Soc Bone Mineral Res. 2010;25(2):404–14.
  21. Almirol EA, LGao LY, Khurana B, Hurwitz S, Bluman EM, Chiodo CP, et al. Short-term effects of teriparatide versus placebo on bone biomarkers, structure, and fracture healign in women with lower-extremity stress fractures: a pilot study. J Clin Transl Endocrinol. 2016;5:7–14.
  22. Adams SB, Lewis JS, Jr, Gupta AK, Parekh SG, Miller SD, Schon LC. Cannulated screw delivery of bone marrow aspirate concentrate to a stress fracture nonunion: technique tip. Foot Ankle Int. 2013;34(5):740–4.
  23. 23.0 23.1 Gross, Christopher E., and James A. Nunley. "Navicular stress fractures." Foot & ankle international 36.9 (2015): 1117-1122.
  24. Saxena A, Fullem B. Navicular stress fractures: a prospective study on athletes. Foot Ankle Int. 2006;27:917-921.
  25. Potter NJ, Brukner PD, Makdissi M, et al. Navicular stress fractures: outcomes of surgical and conservative management. British J Sports Med. 2006;40:692-695; discussion 695.
  26. Fitch KD, Blackwell JB, Gilmour WN. Operation for nonunion of stress fracture of the tarsal navicular. J Bone Joint Surg Br. 1989;71:105-110.
  27. Torg JS, Moyer J, Gaughan JP, Boden BP. Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis. Am J Sports Med. 2010;38: 1048-1053.
  28. Mallee WH, Weel H, van Dijk CN, et al. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med. 2015;49:370-376.
  29. McCormick JJ, Bray CC, Davis WH, Cohen BE, Jones CP, 3rd, Anderson RB. Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. Am J Sports Med. 2011;39(8):1741–8.
Created by:
John Kiel on 30 September 2021 13:53:14
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Last edited:
4 October 2022 12:36:47
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