Navicular Fracture Treatment & Management

Updated: May 18, 2017
  • Author: Michael J Ameres, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Treatment

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. [40] A study by Torg et al confirms the superiority of non–weight-bearing as the preferred initial treatment for navicular stress fractures. [46]

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. [47] 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.

Return to sport, particularly in elite athletes, may be quicker with surgical vs non-surgical treatment. [44]

A retrospective analysis by Coulibaly et al that compared operative and non-operative treatment of navicular fractures reported that the operative treatment group had considerably more complications of secondary osteoarthritis. [48]

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.

Platelet-rich plasma (PRP) may help bone healing. Whole blood taken from the patient is processed to be used at the injury site. Although evidence suggests that PRP is safe and can promote bone formation, no clear evidence of benefit in fracture healing has been reported. [53, 54] No controlled trials of PROP use in healing of navicular fractures are underway. [55]

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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).

Therapeutic Ultrasound may have a role in determining return to play decisions as pain with therapeutic ultrasound has corelated with MRI finding in navicular stress injuries. [56]

Medical Issues/Complications

Delayed union and nonunion produce persistent pain at the navicular. [57] 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. [47] 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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Diet

Assess diet for deficiencies in Calcium and Vitamin D as well as an overall Nutritional assessment. 

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Prevention

There is some evidence that Calcium and Vitamin D supplements decrease the incidence of stress fractures, particularly in females. Smoking, low physical activity and poor nutritional status are also known risk factors for stress fractures.

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