Tarsal Navicular Stress Fractures Research Articles

Tarsal navicular stress fracture in a female gymnast

Tarsal navicular stress fracture in a female gymnast

Tarsal Navicular Stress Fractures: A Rare Soccer Injury Twelve-Year Follow-Up of the First Reported Case in a Professional Player and Literature Review

Tarsal navicular stress fractures are rare injuries, mostly occurring in long-distance runners, jumpers, and occasionally affecting athletes in high-contact sports such as rugby or American/Australian football. This condition generally represents a clinical challenge, resulting in considerable diagnostic delays. While the ideal treatment is still controversial, surgical treatment seems to provide good results in recovering function and return to play. Tarsal navicular stress fractures have been extremely rare in soccer players; only seven published cases have been located to date. This article is a paradigmatic report on a professional player with this injury and a successful outcome after a 12-year follow-up.

The Tarsal Navicular Stress Fracture Revisited

Category: Sports. Introduction/Purpose: The purpose of this paper is to both refute and condemn the current practice of open reduction and internal fixation in the treatment of both uncomplicated partial and complete tarsal navicular stress fractures. It will deal with issues that have violated the basic principals of clinical based evidence and resulted in unnecessary surgery, patient injury, and excessive costs. Methods: Ten cases managed by the senor author as well as a meta-analysis 250 cases in 19 published reports in the peer reviewed literature will be reported vis-a- vis surgical vs. conservative management. Management of the dorsal transverse fragment will be discussed, The large cost disparity between operative and non-operative management will be emphasized. The vascular and biomechanical factors will be presented. Results: The 10 cases of TNSF reported & treated by the senior author successfully healed by non-surgical, non-weight management. The meta-analysis of 250 reported cases treated conservatively had 96% successful outcomes. Conversely, those cases treated surgically with screw fixation had a 19% to 26% failure / major complication rates with repeat surgery and some with years of disability, Conclusion: Surgical management of TNSFs has resulted in a 19% to 26% non-union +/or morbidity rate, a marked increase in costs and is contra-indicated in the management of all non-displaced lesions. Non-weight bearing immobilization is indicated for both partial and complete sagittal fractures. Treatment should be based on established evidence based data and not on economic or remuneration factors. Orthopedic surgeons should subscribe to the concept of self regulation in dealing with this situation.

Vascularized Scapular Free Bone Graft after Nonunion of a Tarsal Navicular Stress Fracture: A Case Report

Nonunion of a tarsal navicular stress fracture, although relatively uncommon, is often amenable to open reduction and internal fixation. Furthermore, avascular necrosis of the navicular whether intact or occurring after fracture is rare, secondary to the adequate blood supply it receives. However, persistent nonunion after primary surgical repair in conjunction with avascular necrosis often results in limited treatment options. Thus, the purpose of the present case report is to describe the surgical approach and complications of a vascularized scapular free bone graft for augmentation of revision talonavicular and naviculocuneiform arthrodesis.

Clinical and Computed Tomography Evaluation of Surgical Outcomes in Tarsal Navicular Stress Fractures

Clinical and Computed Tomography Evaluation of Surgical Outcomes in Tarsal Navicular Stress Fractures

The Non-Surgical and Surgical Treatment of Tarsal Navicular Stress Fractures

Stress fractures of the tarsal navicular, first described in 1970, were initially thought to be rare injuries. Heightened awareness and increased participation in athletics has resulted in more frequent diagnosis and more aggressive treatment. The vascular supply of the tarsal navicular results in a relatively avascular zone in the central one-third, which experiences severe compressive forces during explosive manoeuvers such as jumping and sprinting. Repetitive activities can result in stress reactions or even fracture. Patients often initially complain of vague midfoot pain localized to the medial border of the foot. The pain is usually exacerbated by activity and relieved with rest. The diagnosis of tarsal navicular stress fracture is challenging because of the high false negative rate of plain radiographs. Additional diagnostic testing with bone scan, CT and MRI are often required for diagnosis. The proper treatment of tarsal navicular stress fractures has become a topic of debate as surgical intervention for these injuries has increased. In a recent meta-analysis, Torg et al. found that 96% of tarsal navicular stress fractures treated with non-weight-bearing (NWB) conservative treatment for 5 weeks went on to successful outcomes. However, only 44% of patients treated with weight-bearing (WB) conservative treatment had successful outcomes. Surgical treatment resulted in successful outcome in 82% of patients. Interestingly, the meta-analysis also found that fracture type did not correlate with outcomes, regardless of treatment. The meta-analysis also found no difference in time to return to activity between patients treated surgically and those who underwent NWB conservative treatment. The recent literature indicates that patients are undergoing surgery or are receiving WB conservative management as a first-line treatment option with the expectation that they will return to their activity more quickly. Although surgical treatment seems increasingly common, the results statistically demonstrate an inferior trend to conservative NWB management. Conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular. WB conservative treatment and surgical intervention are not recommended.

Clinical and Computed Tomography Evaluation of Surgical Outcomes in Tarsal Navicular Stress Fractures

Background As clinical suspicion increases and radiographic evaluation improves, navicular stress fractures are becoming a more recognized injury. To date, there is a small volume of literature examining these stress fractures, particularly as it pertains to outcomes of surgical management. Purpose To evaluate the clinical and computed tomography (CT) outcomes of surgically treated navicular stress fractures. Study Design Case series; Level of evidence, 4. Methods Ten navicular stress fractures in 10 patients were available for follow-up at an average of 42.4 months postoperatively (range, 16.8-79.9). These patients underwent a clinical examination and a CT scan of their operatively treated foot. The American Orthopaedic Foot & Ankle Society (AOFAS) and SF-36 scores were completed for each fracture at the time of examination. The CT scans were blindly evaluated for bony union. Results According to the CT scan evaluation, 8 of 10 navicula (80%) had gone on to union. Clinical outcome scores on all patients were an average AOFAS hindfoot score of 88.5 and an average SF-36 score of 88.3. The feet with united fractures had an average AOFAS score of 92.1 (range, 83-100) and an average SF-36 score of 91.9 (range, 79-98). The 2 patients with nonunions had AOFAS scores of 74 and 74 and SF-36 scores of 70 and 78, respectively. Both nonunions were complete, displaced fractures on preoperative imaging. Conclusion In our series of operatively treated navicular stress fractures, 80% went on to union, as verified by CT scan. Patients with united fractures had a clinically significant improvement in outcome, with higher AOFAS and SF-36 scores as compared with the 2 patients with nonunions. Patients with complete, displaced navicular stress fractures may be more likely to develop nonunions.

The os supranaviculare and navicular stress fractures

Tarsal navicular stress fractures are injuries more commonly observed in athletes involved in sprinting and jumping sports. Known risk factors for the development of navicular stress fractures include pes cavus, metatarsus adductus, limited subtalar or ankle motion, medial narrowing of the talonavicular joint, as well as a short first metatarsal. The presence of an os supranaviculare has yet to be described as a predisposing factor in the occurrence of navicular stress fractures. We present two cases of navicular stress fractures in patients with an os supranaviculare and discuss possible reasons for such an association.

Management of Tarsal Navicular Stress Fractures: Conservative Versus Surgical Treatment: A Meta-Analysis

Management of Tarsal Navicular Stress Fractures: Conservative Versus Surgical Treatment: A Meta-Analysis

Surgery Unfounded for Tarsal Navicular Stress Fracture

Surgery Unfounded for Tarsal Navicular Stress Fracture

Surgical Treatment of Tarsal Navicular Stress Fractures

The tarsal navicular is part of the medial column of the foot. It articulates with the talus as well as the cuneiforms. The navicular can be injured with repetitive loading, such as in an athlete, resulting in a stress fracture. Patients complain of pain over the medial midfoot, especially with axial load. Plain radiographs may be normal, and MRI, CT or bone scan may be necessary to confirm the diagnosis. Nonoperative management can be successful with cast immobilization. For competitive athletes with delayed union or nonunion, surgical repair may be indicated. This is accomplished with interfragmentary screws and autogenous cancellous bone graft. Cast immobilization is important to prevent motion at the fracture site during the postoperative healing period. Nonweightbearing restrictions are used for eight to twelve weeks, or until radiographic bony union is verified. Using a comprehensive rehabilitative program, full motion and strength can be expected with eventual return to full athletic activity.

Tarsal Navicular Stress Injury

Background Tarsal navicular stress fracture is a condition that has curtailed many athletic careers. Management protocols remain varied and somewhat controversial. Hypotheses (1) Clinical practice does not mirror the recommendations reported from previous case series. (2) Clinical outcome is poor when navicular stress fracture is managed in a variety of ways. (3) Imaging does not correlate strongly with clinical status at long-term follow-up after navicular stress fracture. Study Design Case series (prognosis); Level of evidence, 4. Methods From a computer registry, we identified patients who had attended a university sports medicine center between 1996 and 2002 and whose final diagnosis was navicular stress fracture (n = 11) or navicular stress reaction (n = 9). All patients had provided demographic and clinical data at their original evaluation, and all had undergone bone scans and computed tomographic imaging. These data were extracted by chart review. Follow-up clinical and imaging assessments took place a median of 3.7 years later (range, 1-15.7 years). At these assessments, we administered a questionnaire, performed a structured physician examination (blinded to other data), scanned both feet with computed tomography, and obtained magnetic resonance images of the affected foot. Results Only 2 of 11 patients (18%) with navicular stress fractures received the literature-recommended treatment of at least 6 weeks’ nonweightbearing cast immobilization. Of these 11 patients, only 6 (55%) returned to sports at their previous level. Only 3 patients with navicular stress fractures regained normal imaging appearance at follow-up. Pain score, stiffness, sporting success, current sporting involvement, and recurrence/time to recurrence were not statistically associated with computed tomographic or magnetic resonance imaging parameters. Of 9 patients with navicular stress reactions, 7 developed clinical and radiological features of navicular stress fracture, but 6 of 9 patients (67%) returned successfully to sports. Conclusions Contemporary management of navicular stress fracture differs from that recommended in the literature. This stress fracture prevented almost half of the participants in this study from returning to sports at their previous level. Imaging parameters do not correlate with the clinical assessment of a patient at long-term follow-up of navicular stress fracture.

FOOT INJURY - WOMEN??S BASKETBALL

HISTORY An 18 year old women's basketball player in her freshman year presented to the training room after a recent road trip with a three week history of right midfoot pain. She denied any specific injury to the right foot. She stated the pain began approximately three weeks prior to her presentation to the training room and that the pain had been progressing, particularly with ambulation. She had played in only four games her freshman year, and the schedule included three recent road trips in which practices and conditioning had been light intensity. She denied any numbness, tingling, weakness, or radiation of pain. PHYSICAL EXAM Initial examination in the training room revealed moderate tenderness over the medial, dorsal aspect of the right foot. There were no skin changes or ecchymosis. She had full range of motion and strength in her ankle and foot. Her right lower extremity was neurovascularly intact throughout. DIFFERENTIAL DIAGNOSIS Tarsal navicular stress fracture. Foot sprain. Other tarsal stress fractures. Tarsal coalition. TESTS AND RESULTS Right foot radiograghs - AP, lateral, and oblique - no evidence of fractures or dislocations MRI right foot - subacute, nondisplaced fracture of the dorsal, lateral aspect of the navicular bone. FINAL/WORKING DIAGNOSIS Navicular stress fracture. TREATMENT AND OUTCOME Immobilization and nonweightbearing for eight weeks with continued pain. Repeat radiograghs demonstrated unusual sclerosis and dorsal spurring. Continued immobilization and addition of a bone stimulator for eight weeks with continued pain. Repeat radiograghs demonstrated increased sclerosis in the dorsal aspect of the navicular bone. The athlete remained frustrated with her continued pain and lack of progress, and a CT scan was ordered showing poor evidence of healing with peri-fracture sclerosis and delayed healing. Open reduction and internal fixation of the navicular bone was performed with two threaded screws without complications. The athlete was treated with immobilization and nonweightbearing for 8 weeks without any post-operative complications. Radiographs, 4 weeks after surgery, showed some sclerosis. Despite 8 weeks of immobilization and nonweightbearing, the athlete developed pain with the resumption of ambulation, and repeat radiograghs showed loose screws and no healing. Open reduction and internal fixation with a threaded screw and tibial bone graft was performed. The athlete was treated with immobilization and nonweightbearing for eight weeks. Repeat CT scan approximately 7 weeks post-operatively showed bone bridging across the lateral half of the fracture site. 12 weeks after the second surgery, she is doing well with only minimal discomfort.

ANKLE INJURY-VOLLEYBALL

HISTORY: 20 year old female Division I college volleyball player sustained right ankle inversion injury after spiking during practice. She was initially weightbearing with pain, and complained mostly of lateral and medial ankle discomfort. Trainer evaluation was a routine ankle sprain. She was held from practice for 3 days and began an ankle rehab program immediately. After a functional progression, she resumed play with ankle stirrup taping for 4 weeks. The medial ankle pain progressively increased, and ultimately became daily. There was no history of bruising, but she did have subsequent intermittent medial and lateral swelling. She described no traumatic re-injury, instability symptoms, numbness, or weakness. PHYSICAL EXAMINATION: Physician examination approximately 4 weeks after initial injury revealed a slightly antalgic gait and increased pain with single leg hop. She had mild pes planus with overpronation bilaterally. She went into varus on toe raise. There was slight fullness medially, but no appreciable effusion or ecchymoses was noted medially or Iaterally. Sensation was intact. There was a negative ankle drawer and talar tilt with firm endpoints. Symmetrical range of motion although she did have significant discomfort with resisted plantar flexion and inversion. There was significant tenderness on the medial aspect of the navicular without dorsal tenderness. Some tenderness was noted in the anteromedial tibiotalar space. A walking boot with non weightbearing status was given pending further clarification of diagnosis. DIFFERENTIAL DIAGNOSIS: Painful accessory navicular. Posterior tibialis tendon rupture Occult tarsal navicular fracture Tarsal navicular stress fracture Contusion of tarsal navicular Medial talar dome osteochondral defect Anteromedial impingement TEST AND RESULTS: Radiographs of ankle (3-V): Possible small accessory navicular. No fracture. MRI ankle: Increased edema in medial navicular with linear low intensity uptake in the mid-medial portion consistent with a navicular stress fracture. CT ankle: Linear cortical fracture of the mid-medial portion of the tarsal navicular with slight displacement and minimal healing. Athlete referred to sports foot and ankle orthopedic specialist. Without a history of bruising and unusual location for a fracture, a working diagnosis of a painful accessory navicular was given. She had continued pain despite custom orthotes and ankle bracing, and opted for operative excision of the fragment. Intraoperative findings showed an apparently fused accessory navicular with a fracture non-union through navicular fragment. Both were removed with reattachment of the posterior tibialis tendon (Kidner procedure). FINAL WORKING DIAGNOSIS: Non-union fracture through partially fused accessory navicular. TREATMENT AND OUTCOME: (Post-operative) Two weeks non-weightbearing with crutches Four weeks of cryocuff and boot. Return to sports with functional progression after three months.

Foot Injuries of the Recreational Athlete

Adult recreational athletes, or ‘weekend warriors,’ are vulnerable to foot injuries such as Achilles tendon ruptures, plantar fasciitis, retrocalcaneal bursitis, midfoot tendinitis, metatarsal stress fractures, and interdigital neuroma. Physicians also need to be alert for less common injuries such as Jones fractures and tarsal navicular stress fractures because of the risk of delayed healing or nonunion. Many foot injuries can be treated conservatively, but some Achilles tendon ruptures, Jones fractures, and tarsal navicular stress fractures may require surgery.

Tarsal navicular stress fracture in athletes.

Stress fracture of the tarsal navicular bone is now frequently recognised. The majority of navicular stress fractures are partial fractures in the sagittal plane. They occur mainly in track and field athletes. A number of theories regarding the aetiology of this fracture have been proposed. Athletes with a history of vague, activity-related midfoot pain, with associated tenderness over the dorsal proximal navicular ('N' spot) should be suspected of having a navicular stress fracture. Plain radiography frequently fails to demonstrate the fracture, thus radionuclide scanning is the investigation of choice to detect navicular stress injury. A computed tomography (CT) scan should be performed to confirm the presence of the fracture. Various methods of treatment have been employed. A minimum of 6 weeks of strict non-weightbearing cast immobilisation is the treatment of choice. After removal of the cast, a further 6 week programme of rehabilitation with a graduated return to activity, joint mobilisation and soft tissue massage is required. Surgery for nonunion or delayed union is rarely required if initial treatment is appropriate.

Stress fractures of the tarsal navicular bone: CT findings in 55 cases.

The purpose of this article is to present the CT findings in 55 cases of tarsal navicular stress fracture before and after treatment and to describe the CT protocol used. Fifty-five navicular stress fractures in 54 patients whose initial and follow-up CT scans were available for study were retrospectively reviewed. In most cases, contiguous 1.5-mm axial and 3-mm coronal scans of the navicular bone had been obtained. Both feet were scanned for comparison. Follow-up scans were obtained between 4 weeks and 6 years. On review, fractures were evident in all cases, but six small fractures (11%) were missed at the initial interpretation. All fractures involved the central third of the proximal dorsal margin of the navicular bone. Fifty-three fractures (96%) were partial. Forty-three partial fractures were linear, five were linear with bone fragments, and five were rim defects with ossicles. In 13 cases (24%) the fracture was small, 10% or less of bone height. The earliest sign of healing, slight dorsal cortical bridging, was seen in three of eight cases in which follow-up was done at 6 weeks. Firm cortical union was noted in 10 (32%) of 31 by 4 months. Nonunion occurred in 12 and was indicated by the persistence of the fracture gap and lack of cortical healing. Medullary cysts (five) and cortical notching (two) were noted to persist after complete healing. CT scanning is a suitable method for detecting navicular stress fracture and for performing follow-up examinations. Small fractures may be overlooked owing to lack of familiarity with their appearance.

Stress fractures in figure skaters

In 1987, during two great skating contests--the Universiade in the Tatra Mountains and the Gold Pirouette in Zagreb--a total of 42 world class skaters were asked through a questionnaire if they had ever in their career suffered from a stress fracture. Of the 42 skaters, 9 had stress fractures. Four stress fractures occurred during preseason training (two fibular, one second metatarsal, and two fourth metatarsal stress fractures). Increased mileage was reported by three skaters and the fourth had done too much speed training on hills. Five stress fractures occurred during the season (one tibial and two tarsal navicular stress fractures and two stress fractures of the base of the fifth metatarsal). In all cases, the fracture occurred in the take-off leg. All of the subjects were competitive figure skaters with a daily training period of 3 to 8 hours, six times a week. The time from the onset of symptoms to definite diagnosis ranged from 2 to 10 weeks. Of the nine injured skaters, eight were treated conservatively and one skater with Jones' fracture was treated surgically. All of the skaters were able to resume a preinjury level of activity 3 to 7 months after treatment began. In conclusion, it may be emphasized that stress fractures in figure skaters are not rare and should, therefore, always be considered as a possibility.

Stress Fractures of the Tarsal Navicular in Long-Distance Runners

The authors report on a study that attempted to (1) determine anatomic variations that predispose runners to tarsal navicular stress fractures; (2) study that loading responses of runners with stress fractures and of uninjured runners; (3) study the mechanical factors and biomechanics of the foot during running; (4) define a population at risk for developing stress fractures; and (5) propose an alteration in footwear that may reduce the force across the talonavicular joint.

Overuse Injuries in Sport: The Foot

The authors discuss the clinical characteristics and treatment of such overuse injuries of the foot as plantar fasciitis, Haglund's syndrome, Jones' fracture, and tarsal navicular stress fractures. A consideration of orthotic devices is also provided.