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Tarsal Navicular Stress Fracture
Aka: Tarsal Navicular Stress Fracture
- See Also
- Tarsal Navicular Fracture
- Foot Fracture
- Foot Pain
- Epidemiology
- Accounts for 14-35% of Stress Fractures
- Track athletes account for 59% of these injuries
- Mechanism of injury
- Central one third of navicular is avascular
- Chronic Trauma from repetitive foot strike
- Risk factors
- No Statistically Significant risk factors identified
- Most common in track and field athletes
- Also seen in Australian football and basketball
- Symptoms
- Cramping pain or ache at the dorsal midfoot
- Radiates along medial arch
- Usually unilateral
- Provocative activities
- Running
- Jumping
- Palliative
- Altered gait with less pressure on forefoot
- Relieved with rest
- Timing
- Onset occurs with provocative activities above
- Duration of pain increases as injury progresses
- Signs
- Pain localized to 'N' Spot
- Small area approximately the size of a nickel
- Find talonavicular joint (Evert and invert the foot)
- Navicular bone is just distal and medial to joint
- Test Sensitivity: 81% tenderness in Stress Fracture
- Provocative maneuvers
- Hopping
- Toe hopping
- Standing on tip-toes
- Radiology
- Foot XRay (Recommended as Initial study)
- Test Sensitivity for navicular Stress Fracture: 33%
- Fractures appearance may also be delayed 3 weeks
- Triple Phase Bone scan (Recommended as second study)
- Test Sensitivity: 100%
- Poor Specificity (e.g. bone stress reaction)
- Confirm positive result with other imaging below
- Delayed-phase images normalize 2 years after union
- CT Foot (Use to confirm bone scan results)
- 1.5 mm slices Through plane of talonavicular joint
- Allows for classifying Fracture as below
- MRI Foot
- Test Sensitivity: 100% for Stress Fracture
- Highly specific and good anatomic resolution
- Offers similar information as bone scan with CT
- Bone scan and CT foot are preferred due to cost
- Classification (Based on CT above)
- Type I: Dorsal cortical break
- Type II: Fracture propagates into navicular body
- Type III: Fracture propagates into other cortex
- Requires longest healing time
- May require internal fixation
- Management: Protocol
- Non-weight bearing short-leg cast for 6 weeks
- Check navicular tenderness on cast removal
- Navicular tenderness at cast removal
- Recast for two weeks and re-examine
- Non-tender at cast removal and at every 2 week checks
- Functional rehabilitation for 6 weeks (See below)
- Full activity resumes 6 weeks after cast removal
- Repeat imaging not indicated
- Repeat XRay, bone scan or CT are not usually helpful
- Surgery indications (Intramedullary nailing)
- Displaced or fragmented Tarsal Navicular Fracture
- Failed conservative therapy
- Delayed union or nonunion
- Type III Fracture (relative indication)
- High level athlete for faster return to play
- Management: Functional Rehabilitation
- Stop program and reassess if any 'N' Spot tenderness
- Week 1-2: Activities of Daily Living, Swimming
- Gradual weight bearing in semirigid shoe
- Week 3-4: Jog on grass for 5 minutes on alternate days
- Week 5-6: Run at half speed on alternate days
- Week 6: Gradually return to full activity
- Course
- Delayed diagnosis is very common
- Average time to return to sport
- Non-weight bearing cast: 3-4 month
- Surgical intervention: 5-6 months
- References
- Coris (2003) Am Fam Physician 67(1):85-90 [PubMed]
- Khan (1994) Sports Med 17:65-76 [PubMed]
- Ostlie (2001) J Am Board Fam Pract 14(5):381-5 [PubMed]