How should I evaluate and manage a patient with navicular bone osteonecrosis (Müller‑Weiss disease) presenting with sclerosis on radiograph?

Evaluation and Management of Navicular Bone Osteonecrosis with Sclerosis

For a patient presenting with navicular bone osteonecrosis (Müller-Weiss disease) showing sclerosis on radiograph, obtain MRI without IV contrast immediately to characterize the extent of bone marrow involvement, assess for fragmentation, and evaluate surrounding soft tissue structures, as MRI is the most sensitive and specific imaging modality for osteonecrosis with sensitivity and specificity approaching 100%. 1

Initial Diagnostic Approach

Imaging Strategy

• Start with plain radiographs in multiple views (anteroposterior, lateral, and oblique) to document the baseline appearance of sclerosis, navicular collapse, and any talonavicular joint destruction 1

  • Radiographs in Müller-Weiss disease characteristically show collapse of the dorsolateral portion of the navicular with medial protrusion of the talar head and progressive fragmentation 2, 3, 4
  • Sclerosis on radiograph represents late-stage disease with chronic bone remodeling 1

• Proceed immediately to MRI without IV contrast as the definitive imaging study 1

  • MRI demonstrates bone marrow edema patterns, extent of osteonecrosis, presence of subchondral collapse, and associated soft tissue inflammation 1
  • MRI helps differentiate Müller-Weiss disease from other causes of midfoot pain including stress fractures, transient bone marrow edema syndrome, and subchondral insufficiency fractures 1
  • The characteristic MRI finding is signal abnormality in the navicular with fragmentation and collapse of the lateral aspect 4

• CT without IV contrast may be obtained as an adjunct when surgical planning is being considered 1

  • CT is superior to MRI for showing the exact location and extent of articular collapse and osseous architectural details needed for preoperative planning 1
  • CT better delineates the degree of navicular fragmentation and periarticular osteoarthritis 1

Key Imaging Pitfalls to Avoid

• Do not rely solely on the initial radiograph showing sclerosis, as plain films significantly underestimate the extent of osteonecrosis and cannot assess bone marrow viability 1
• Do not order bone scintigraphy, as it has been replaced by MRI due to poor spatial resolution, low specificity, and inability to quantify the size of the necrotic lesion 1
• Do not order MRI with IV contrast unless there is clinical suspicion for infection or tumor, as unenhanced MRI provides all necessary diagnostic information for osteonecrosis 1

Clinical Evaluation Specifics

History Elements to Document

• Duration and progression of medial midfoot pain, as Müller-Weiss disease presents with chronic progressive pain over the dorsomedial aspect of the foot 2, 3
• History of trauma or repetitive stress, though Müller-Weiss is spontaneous osteonecrosis without clear precipitating injury 2, 5, 3
• Functional limitations, including inability to bear weight, walk distances, or perform work/recreational activities 5, 6
• Previous treatment attempts, including orthotics, activity modification, and analgesics 5, 3

Physical Examination Findings

• Tenderness over the dorsomedial midfoot at the talonavicular joint 2, 3
• Visible or palpable deformity with medial prominence of the talar head and collapse of the medial longitudinal arch 3, 4
• Limited range of motion at the talonavicular and naviculocuneiform joints 6
• Gait abnormalities with antalgic pattern and avoidance of push-off phase 3

Management Algorithm

Conservative Management (Initial Approach)

• Trial of non-operative management for 3-6 months in patients with early-stage disease or minimal symptoms 5, 3
  • Custom orthoses with medial arch support to offload the navicular
  • Activity modification avoiding high-impact activities
  • NSAIDs for pain control
  • Consider immobilization in a walking boot for acute exacerbations

Surgical Indications

Proceed to surgical consultation when:

• Conservative management fails after 3-6 months 5, 6
• Progressive deformity documented on serial radiographs 3, 6
• Severe functional limitation affecting activities of daily living 5, 6
• Advanced radiographic changes with significant navicular fragmentation and talonavicular joint destruction 6

Surgical Options Based on Disease Stage

For early-stage disease with preserved navicular architecture:

• Core decompression with bone grafting may be considered, though evidence is limited 2, 5
• Autologous bone grafting after removal of necrotic bone has shown success in case reports 2
• Vascularized bone graft (medial femoral condyle) represents a novel approach with excellent reported outcomes 5

For advanced disease with navicular collapse and joint destruction:

• Talonavicular and naviculocuneiform joint fusion is the definitive treatment 6
  • Use tricortical autologous iliac crest block fixated with screws and plate 6
  • Expected fusion time is 12-16 weeks 6
  • American Orthopaedic Foot and Ankle Society scores improve from median 49 preoperatively to 82 postoperatively 6
  • All patients in reported series achieved solid fusion 6

Prognosis and Follow-up

• Serial radiographs every 3-4 months during conservative management to monitor for progression 1
• Post-surgical follow-up with radiographs at 6,12, and 16 weeks to assess fusion 6
• Long-term monitoring as Müller-Weiss disease is progressive, and even successfully treated patients may develop adjacent joint arthritis 3, 6

Critical Clinical Pearls

• Müller-Weiss disease is bilateral in some cases, so consider imaging the contralateral foot if symptoms develop 3
• The sclerosis you see on radiograph represents chronic remodeling and indicates established disease, not early osteonecrosis 1, 3
• Surgical fusion provides reliable pain relief and functional improvement with median AOFAS scores improving by 33 points 6
• This is distinct from pediatric Köhler disease (navicular osteochondrosis in children), which is self-limiting; adult Müller-Weiss disease is progressive and often requires surgical intervention 3