Last Updated on November 12, 2012 by Jimson Lee
This article is guest blogged by Amol Saxena, a Podiatrist at the Palo Alto Medical Foundation near Stanford. Visit Dr. Saxena’s website at www.amolsaxena.com
Navicular stress fractures by Amol Saxena, DPM
Until recently, little has been known about these injuries. Unfortunately they often get mis-diagnosed as arch pain, plantar fasciitis and various strains, or arthritis (which, if untreated can end up arthritic). The classic symptoms are pain on the top of the foot right where it joins the ankle, on the center point of the Navicular (arch) bone. This is known as the “N-spot”. Pain increases with activity, particularly with sprinting, bounding or being “en pointe” (on your toes). Sometimes symptoms come about gradually and other times it can occur acutely; an ankle sprain can precipitate a stress “riser” to the top of the foot. There is generally little swelling or bruising but there is often a dull ache, throbbing; sharp pain can occur with intense activity or when the stress fracture breaks completely.
Surgery usually requires general anesthesia and involves placing one or two screws across the fracture to compress it and allow for healing. (Rarely do the screws need to be removed, though with some sports such as soccer, removal may be beneficial.) Bone graft from your own body may be used particularly for older injuries. Bone stimulators can be used (and even for non-surgical treatment) but it is important to have proper non-weightbearing and protection in a cast or boot for several weeks. Patients can ride stationary bikes with the boot on, swim at some point, but return to sport is usually 12 or more weeks. Saxena and Fullem have reported on the largest number of cases of NSF in North America, and most athletes who have surgery are able to resume sports. Some authors claim all NSF should be treated non-surgically first, however the data from experienced authors who have long-term follow-up does strongly favor immediate surgical intervention at least for Type II and II injuries. Many other studies do not report whether athletes eventually go elsewhere for surgery, give up their sport, nor do they reveal about arthritis, etc. Follow-up CAT scans are sometime needed to assess healing. MRIs are inconclusive. Fullem and Saxena recently reported on a less severe Navicular injury (termed Type 0.5) which there is dorsal pain, a positive bone scan and MRI but a negative CAT scan). These can be treated with a shorter period of non-weightbearing (3 weeks) and a boot (4-6 weeks) with a faster return to activity (RTA). It is difficult to say exactly what causes them as both high- and low-arched feet are associated, though high intensity training often precipitates them. Navicular stress fractures are usually season ending injuries, however, if evaluated, staged, and treated properly initially, they do not have to be career ending.
About the Author:
Amol Saxena (www.amolsaxena.com) is a Podiatrist at the Palo Alto Medical Foundation near Stanford, and the editor of International Advances in Foot and Ankle Surgery (2012 Edition).
Dr Saxena is also:
- Fellow, American College of Foot & Ankle Surgeons
- Board Certified, Foot, Reconstructive Rearfoot & Ankle Surgery
- Chief, Division of Podiatric Surgery, Stanford Hospital
- Consultant, USA Track & Field
RFERENCES:
1.Burne, Sg, Mahoney CM, Forster BB, Koehle MS, Taunton JE, Khan KM. Tarsal Navicular Stress Injury Long-term Outcome and Clinico-radiological Correlation Using Both Computed Tomography and Magnetic Resonance Imaging. Am J Sports med. 2005;33(12):1875-1881
2. Haverstock BD. Stress Fracture of the Foot and Ankle. Clin Podiatr Med Surg 2001;18 (2):273-84.
3. Lee S, Anderson RB. Stress Fractures of the Tarsal Navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104.
4. 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. 2000;39 (2):96-103
5. Saxena A, Fullem B. Navicular Stress Fracture: A Prospective Study on Athletes. Foot Ankle Int. 2006;27(11):917-921.
6. Saxena A, Fullem B. Comment on Torg et al “Management of tarsal Navicular stress fractures: conservative versus surgical treatment”. Am J Sports Med 2010 38(10); 3-5
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