Navicular Fracture Treatment & Management

  • Author: Michael J Ameres, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Jul 28, 2010
 

Acute Phase

Rehabilitation Program

Physical Therapy

Most patients are placed in a non–weight-bearing cast for 6 weeks. The importance of following a strict non–weight-bearing protocol must be emphasized to the patient. After 3 weeks, the state of the cast and the patient's adherence to the non–weight-bearing protocol must be assessed.[44]

An exception to non–weight-bearing treatment is in patients who have pain only after significant exertion (eg, pain after running 2 miles). In these individuals, avoidance of running for 6-8 weeks may be sufficient to heal the fracture. The patient can then gradually return to his or her normal routine. If pain returns, then a non–weight-bearing cast may be indicated.

Surgical Intervention

Most physicians do not recommend immediate open surgical procedures when treating uncomplicated navicular stress fractures. In a comparison study by Potter et al, surgery had similar long-term return-to-activity rates relative to conservative therapy.[48] In another study, bone healing took up to 4 months, for both operative and nonoperative treatment.[10]

Fractures that are complicated by dislocation are assessed for stability following reduction. If the navicular is stable, then treatment may continue as outlined for uncomplicated navicular fractures. If the navicular is unstable, then internal fixation is required.

A complete fracture with wide separation may benefit from early surgical intervention. In addition, if the patient is not expected to tolerate the rehabilitation program, surgical correction may be considered.

Other Treatment

Although no trials support the use of bone growth stimulators for navicular stress fractures, they may be a helpful adjunct.[11] In particular, bone growth stimulators that use pulsed electromagnetic fields (PEMFs) have been shown to have similar success rates when compared with open repair in tibial fracture nonunions.[49, 50, 51, 52] Whether these results are applicable to acute fractures and fractures of the navicular remains to be determined.

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Recovery Phase

Rehabilitation Program

Physical Therapy

After the affected foot has been placed in a non–weight-bearing cast for 6 weeks, the cast is removed and tenderness at the N spot is assessed. If tenderness persists, then an additional 2 weeks of non–weight-bearing cast immobilization is recommended. However, if tenderness is not present at the N spot, then weight-bearing activity may begin. This activity is limited to a gradual return to normal activity under the care of a sports physician or physical therapist. The therapy may include muscle strengthening, range-of-motion exercises, and soft-tissue massage.

A stepwise regimen for the course of activity is as follows:

  1. The patient participates in his or her normal activities of daily life (ADLs), which may include swimming, for 2 weeks (Weeks 1 and 2).
  2. If the athlete remains free of pain after 2 weeks, a gradual return to jogging may be prescribed.
  3. After 2 weeks of a gradually progressive jogging regimen (Weeks 3 and 4), the patient is again assessed for pain.
  4. If the patient remains free from pain after 2 weeks after gradually progressing in the jogging regimen, then the athlete may gradually return to full activity over the final 2 weeks of the rehabilitation program (Weeks 5 and 6).

Medical Issues/Complications

Delayed union and nonunion produce persistent pain at the navicular.[53] Plain radiographs and/or a CT scan may show the persistent fracture. In such cases, referral to a surgeon is required for open reduction and fixation. In addition, fracture of the tarsal navicular may be complicated by avascular necrosis.

Surgical Intervention

A comparison study of surgery relative to conservative treatment by Potter showed no difference in an athlete's long-term return to activity.[48] However, tenderness was more common in the surgical group. Some athletes who successfully returned to activity for 2 years or more had persistent tenderness at the N-spot.

In a study by Saxena and Fullem that compared nonoperative treatment with operative treatment, navicular stress fractures took up to 4 months to heal, regardless of the therapy.[10]

Delayed union and nonunion of the navicular may require surgical intervention. A variety of techniques have been used for repair. These include (1) curettage and bone grafting, (2) internal fixation, (3) excision of the symptomatic ossicles, or (4) a combination of these techniques.

Other Treatment (Injection, manipulation, etc.)

A custom-molded orthotic with longitudinal and transverse arch support may be prescribed to help relieve stress on the navicular during this transition phase.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

In the maintenance phase, the athlete must adhere to the general guidelines that are indicated for preventing stress fractures. A constant level of daily activity should be maintained, and the athlete should increase or decrease this level only gradually. The athlete should initiate new activities and sports in the same gradual manner.

Medical Issues/Complications

As outlined in the Clinical, Causes section, an attempt should be made to identify a precipitating event or defect in training that contributed to the stress fracture.

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Contributor Information and Disclosures
Author

Michael J Ameres, MD  Consulting Staff, Department of Emergency Medicine, Southampton Hospital

Michael J Ameres, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Greg Montalbano, MD  Assistant Clinical Professor, Department of Orthopaedics, New York University Medical School

Greg Montalbano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Sierra Cascade Trauma Society

Disclosure: Nothing to disclose.

Benson Yeh  MD, Vice President, Designated Institutional Official, Chief Academic Officer, Program Director, Department of Emergency Medicine, The Brooklyn Hospital Center; Clinical Assistant Professor of Emergency Medicine in Medicine, Weill-Cornell Medical School

Benson Yeh is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Andrew L Sherman, MD, MS  Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, University of Miami, Leonard A Miller School of Medicine

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Rafat Farouqui, MBBS, to the development and writing of this article.

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