From the Guidelines
Navicular stress fractures are considered high-risk stress fractures due to their tendency for nonunion or delayed union, and thus, require prompt identification and management to prevent complications. When managing a navicular stress fracture, it is essential to consider the patient's overall risk factors, including osteoporosis, bisphosphonate therapy, and athletic status, as these can impact the risk of fracture completion and complications 1. Some key points to consider in the management of navicular stress fractures include:
- High-risk stress fractures, such as those in the navicular bone, often require more aggressive management to prevent nonunion or delayed union 1
- Patients with osteoporosis, those on bisphosphonate therapy, and athletes are at higher risk for fracture completion and complications, and thus, require closer monitoring and more aggressive management 1
- Preventive strategies, including identifying and modifying risk factors, may help deter progression to complete fracture, and include proper footwear, gradual training progression, cross-training, and maintaining adequate calcium and vitamin D intake 1
- Treatment typically involves 6-8 weeks of non-weight bearing with a cast or boot, followed by gradual return to activity over several months, and may include conservative treatment with rest, ice, and anti-inflammatory medications, or surgical intervention with internal fixation using screws. It is crucial to prioritize the management of navicular stress fractures to prevent chronic pain and potential career-ending complications, and to ensure complete healing before returning to full activity.
From the Research
Navicular Stress Fracture Treatment Options
- Navicular stress fractures are uncommon injuries that occur predominantly in athletes, and their treatment can be challenging due to the variable clinical outcome with conservative management 2, 3.
- The available literature indicates that limited weight-bearing is not an appropriate treatment for navicular stress injuries, and non-weight-bearing (NWB) cast immobilization for 6-8 weeks appears to be the gold standard treatment 3, 4.
- Surgical fixation of navicular stress fractures, such as percutaneous screw fixation, has been proposed as a reliable and successful treatment regimen, allowing early return to full sporting activity without long-term complications or recurrences 2, 5.
- A systematic review and meta-analysis of 315 navicular stress fractures found that operative management provides a higher success rate, a lower refracture rate, and a lower non-union rate compared to non-operative management 6.
Return to Sport and Complications
- The return to play (RTP) rate and time to RTP are important outcomes for athletes with navicular stress fractures, and studies have reported varying results depending on the treatment approach 5, 6.
- A meta-analysis found that RTP was noted in 98.98% of navicular stress fractures treated operatively and in 73.43% of those treated conservatively, with no significant difference between operative and conservative management 6.
- The pooled mean time to RTP in navicular stress fractures treated operatively was 4.17 months, while those treated conservatively returned to play at 4.67 months postoperatively, with no significant difference between operative and conservative management 6.
- Refractures and non-unions are potential complications of navicular stress fractures, and operative management has been found to have a lower refracture rate and non-union rate compared to non-operative management 6.
Diagnosis and Treatment Algorithm
- The diagnosis of navicular stress fractures can be challenging and requires a high index of suspicion, with adjunct CT imaging strongly recommended in the case of any work-up 3, 6.
- A proposed algorithm for non-operative treatment of partial tarsal navicular stress fractures includes immobilization in a short-leg cast with non-weight-bearing for 6 to 8 weeks, followed by a treatment consisting of 4 two-week stages, which are clinically monitored 4.
- The choice of treatment approach for navicular stress fractures depends on various factors, including the severity of the fracture, the athlete's level of competition, and the presence of any complications, and should be individualized based on the specific case 2, 5, 6.