Tarsal Navicular Stress Injury

Background: Tarsal navicular stress fracture is a condition that has curtailed many athletic careers. Management protocols remain varied and somewhat controversial.

Hypotheses: (1) Clinical practice does not mirror the recommendations reported from previous case series. (2) Clinical outcome is poor when navicular stress fracture is managed in a variety of ways. (3) Imaging does not correlate strongly with clinical status at long-term follow-up after navicular stress fracture.

Study Design: Case series (prognosis); Level of evidence, 4.

Methods: From a computer registry, we identified patients who had attended a university sports medicine center between 1996 and 2002 and whose final diagnosis was navicular stress fracture (n = 11) or navicular stress reaction (n = 9). All patients had provided demographic and clinical data at their original evaluation, and all had undergone bone scans and computed tomographic imaging. These data were extracted by chart review. Follow-up clinical and imaging assessments took place a median of 3.7 years later (range, 1-15.7 years). At these assessments, we administered a questionnaire, performed a structured physician examination (blinded to other data), scanned both feet with computed tomography, and obtained magnetic resonance images of the affected foot.

Results: Only 2 of 11 patients (18%) with navicular stress fractures received the literature-recommended treatment of at least 6 weeks’ nonweightbearing cast immobilization. Of these 11 patients, only 6 (55%) returned to sports at their previous level. Only 3 patients with navicular stress fractures regained normal imaging appearance at follow-up. Pain score, stiffness, sporting success, current sporting involvement, and recurrence/time to recurrence were not statistically associated with computed tomographic or magnetic resonance imaging parameters. Of 9 patients with navicular stress reactions, 7 developed clinical and radiological features of navicular stress fracture, but 6 of 9 patients (67%) returned successfully to sports.

Conclusions: Contemporary management of navicular stress fracture differs from that recommended in the literature. This stress fracture prevented almost half of the participants in this study from returning to sports at their previous level. Imaging parameters do not correlate with the clinical assessment of a patient at long-term follow-up of navicular stress fracture.