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Tarsal navicular stress fractures

  • Foot and Ankle Sports Medicine (M Drakos, section editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of review

Navicular stress fractures are common in athletes and management is debated. This article will review the evaluation and management of navicular stress fractures.

Recent findings

Various operative and non-operative adjunctive treatment modalities are reviewed including the relevance of vitamin D levels, use of shock wave therapy and bone marrow aspirate concentrate (BMAC), and administration of teriparatide. Surgical treatment may be associated with earlier return to sports.

Summary

The author’s preferred treatment algorithm with corresponding images is presented which allows for safe and rapid return to activities in the athletic patient. Future research is needed in evaluating the preventative effects of vitamin D and use of other adjunctive treatments to increase the healing rates of this fracture.

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References

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  1. Mallee WH, Weel H, van Dijk CN, van Tulder MW, Kerkhoffs GM, Lin CW, et al. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med. 2015;49:370–6. Systematic review of lower extremity stress fractures showing earlier return to sports after operatively treated navicular stress fractures compared to non-surgical treatment.

    Article  PubMed  Google Scholar 

  2. Torg JS, Pavlov H, Cooley LH, Bryant MH, Arnoczky SP, Bergfeld J, et al. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. J Bone Joint Surg Am. 1982;64(5):700–12.

    Article  CAS  PubMed  Google Scholar 

  3. Pearce CJ, Brooks JH, Kemp SP, Calder JD. The epidemiology of foot injuries in professional rugby union players. Foot Ankle Surg : Off J Eur Soc Foot Ankle Surg. 2011;17(3):113–8.

    Article  Google Scholar 

  4. Weel H, Opdam KTM, Kerkhoffs GM. Stress fractures of the foot and ankle in athletes, an overview. Clin Res Foot Ankle. 2014;2(4):160.

    Google Scholar 

  5. Mann JA, Pedowitz DI. Evaluation and treatment of navicular stress fractures, including nonunions, revision surgery, and persistent pain after treatment. Foot Ankle Clin. 2009;14(2):187–204.

    Article  PubMed  Google Scholar 

  6. Snyder RA, Koester MC, Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37–52. viii.

    Article  PubMed  Google Scholar 

  7. Hossain M, Clutton J, Ridgewell M, Lyons K, Perera A. Stress fractures of the foot. Clin Sports Med. 2015;34(4):769–90.

    Article  PubMed  Google Scholar 

  8. Fitch KD, Blackwell JB, Gilmour WN. Operation for non-union of stress fracture of the tarsal navicular. J Bone Joint Surg Br Vol. 1989;71(1):105–10.

    Article  CAS  Google Scholar 

  9. Gross CE, Nunley 2nd JA. Navicular stress fractures. Foot Ankle Int. 2015;36(9):1117–22.

    Article  PubMed  Google Scholar 

  10. McKeon KE, McCormick JJ, Johnson JE, Klein SE. Intraosseous and extraosseous arterial anatomy of the adult navicular. Foot Ankle Int. 2012;33(10):857–61. Cadaver study mapping the arterial supply to the navicular.

    Article  PubMed  Google Scholar 

  11. Waugh W. Structural deformities of the outer third of the adult tarsal navicular. Proc Royal Soc Med. 1956;49(11):965–7.

    CAS  Google Scholar 

  12. Kahanov L, Eberman LE, Games KE, Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015;6:87–95.

    Article  PubMed  PubMed Central  Google Scholar 

  13. McInnis KC, Ramey LN. High-risk stress fractures: diagnosis and management. PM & R : J Injury, Function, Rehab. 2016;8(3 Suppl):S113–24.

    Article  Google Scholar 

  14. Mann G, Hetsroni I, Constantini N, Dolev E, Palmanovich E, Finsterbush A, et al. Navicular stress fractures of the foot. Sports Injuries. 2015;168:2103–13.

    Article  Google Scholar 

  15. Khan KM, Brukner PD, Kearney C, Fuller PJ, Bradshaw CJ, Kiss ZS. Tarsal navicular stress fracture in athletes. Sports Med. 1994;17(1):65–76.

    Article  CAS  PubMed  Google Scholar 

  16. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med. 1999;28(2):91–122.

    Article  CAS  PubMed  Google Scholar 

  17. Wright AA, Taylor JB, Ford KR, Siska L, Smoliga JM. Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med. 2015;49(23):1517–23.

    Article  PubMed  Google Scholar 

  18. Ingalls J, Wissman R. The os supranaviculare and navicular stress fractures. Skelet Radiol. 2011;40(7):937–41.

    Article  Google Scholar 

  19. McCormick JJ, Bray CC, Davis WH, Cohen BE, Jones 3rd CP, Anderson RB. Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. Am J Sports Med. 2011;39(8):1741–8. Case series of 10 operatively treated navicular stress fractures with functional and radiologic outcomes at 42 months.

    Article  PubMed  Google Scholar 

  20. Khan KM, Fuller PJ, Brukner PD, Kearney C, Burry HC. Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med. 1992;20(6):657–66.

    Article  CAS  PubMed  Google Scholar 

  21. Van Meensel AS, Peers K. Navicular stress fracture in high-performing twin brothers: a case report. Acta Orthop Belg. 2010;76(3):407–12.

    PubMed  Google Scholar 

  22. Barrack MT, Gibbs JC, De Souza MJ, Williams NI, Nichols JF, Rauh MJ, et al. Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women. Am J Sports Med. 2014;42(4):949–58.

    Article  PubMed  Google Scholar 

  23. Gorter EA, Hamdy NA, Appelman-Dijkstra NM, Schipper IB. The role of vitamin D in human fracture healing: a systematic review of the literature. Bone. 2014;64:288–97. Systematic review of in vitro and in vivo studies on Vitamin D and its effect on fracture healing.

    Article  CAS  PubMed  Google Scholar 

  24. Michelson JD, Charlson MD. Vitamin D status in an elective orthopedic surgical population. Foot Ankle Int. 2016;37(2):186–91.

    Article  PubMed  Google Scholar 

  25. Angeline ME, Gee AO, Shindle M, Warren RF, Rodeo SA. The effects of vitamin D deficiency in athletes. Am J Sports Med. 2013;41(2):461–4.

    Article  PubMed  Google Scholar 

  26. Bogunovic L, Kim AD, Beamer BS, Nguyen J, Lane JM. Hypovitaminosis D in patients scheduled to undergo orthopaedic surgery: a single-center analysis. J Bone Joint Surg Am. 2010;92(13):2300–4.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Sprague S, Petrisor B, Scott T, Devji T, Phillips M, Spurr H, et al. What is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthop Trauma. 2016;30(2):53–63.

    Article  PubMed  Google Scholar 

  28. Smith JT, Halim K, Palms DA, Okike K, Bluman EM, Chiodo CP. Prevalence of vitamin D deficiency in patients with foot and ankle injuries. Foot Ankle Int. 2014;35(1):8–13. Prospective case control study showing greater risk of Vitamin D insufficiency in patients with low energy lower extremity fractures.

    Article  PubMed  Google Scholar 

  29. Shimasaki Y, Nagao M, Miyamori T, Aoba Y, Fukushi N, Saita Y, et al. Evaluating the risk of a fifth metatarsal stress fracture by measuring the serum 25-hydroxyvitamin D levels. Foot Ankle Int. 2016;37(3):307–11.

    Article  PubMed  Google Scholar 

  30. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344–53.

    Article  CAS  PubMed  Google Scholar 

  31. Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg : Off Publ Am College Foot Ankle Surg. 2000;39(2):96–103.

    Article  CAS  Google Scholar 

  32. Burne SG, Mahoney CM, Forster BB, Koehle MS, Taunton JE, Khan KM. Tarsal navicular stress injury: long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging. Am J Sports Med. 2005;33(12):1875–81.

    Article  PubMed  Google Scholar 

  33. Pavlov H, Torg JS, Freiberger RH. Tarsal navicular stress fractures: radiographic evaluation. Radiology. 1983;148(3):641–5.

    Article  CAS  PubMed  Google Scholar 

  34. Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, Hoffman AR, et al. Do capacitively coupled electric fields accelerate tibial stress fracture healing? A randomized controlled trial. Am J Sports Med. 2008;36(3):545–53.

    Article  PubMed  Google Scholar 

  35. Graff J, Richter KD, Pastor J. Effect of high-energy shock waves on bony tissue. Urolithiasis. 1989:997–8.

  36. Valchanou VD, Michailov P. High energy shock waves in the treatment of delayed and nonunion of fractures. Int Orthop. 1991;15(3):181–4.

    Article  CAS  PubMed  Google Scholar 

  37. Schaden W, Fischer A, Sailler A. Extracorporeal shock wave therapy of nonunion or delayed osseous union. Clin Orthop Relat Res. 2001;387:90–4.

    Article  Google Scholar 

  38. Cacchio A, Giordano L, Colafarina O, Rompe JD, Tavernese E, Ioppolo F, et al. Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions. J Bone Joint Surg Am. 2009;91(11):2589–97.

    Article  PubMed  Google Scholar 

  39. Rompe JD, Rosendahl T, Schollner C, Theis C. High-energy extracorporeal shock wave treatment of nonunions. Clin Orthop Relat Res. 2001;387:102–11.

    Article  Google Scholar 

  40. Xu ZH, Jiang Q, Chen DY, Xiong J, Shi DQ, Yuan T, et al. Extracorporeal shock wave treatment in nonunions of long bone fractures. Int Orthop. 2009;33(3):789–93.

    Article  PubMed  Google Scholar 

  41. Taki M, Iwata O, Shiono M, Kimura M, Takagishi K. Extracorporeal shock wave therapy for resistant stress fracture in athletes: a report of 5 cases. Am J Sports Med. 2007;35(7):1188–92.

    Article  PubMed  Google Scholar 

  42. Wang CJ, Huang HY, Chen HH, Pai CH, Yang KD. Effect of shock wave therapy on acute fractures of the tibia: a study in a dog model. Clin Orthop Relat Res. 2001;387:112–8.

    Article  Google Scholar 

  43. Moretti B, Notarnicola A, Garofalo R, Moretti L, Patella S, Marlinghaus E, et al. Shock waves in the treatment of stress fractures. Ultrasound Med Biol. 2009;35(6):1042–9.

    Article  PubMed  Google Scholar 

  44. Fu L, Tang T, Miao Y, Hao Y, Dai K. Effect of 1,25-dihydroxy vitamin D3 on fracture healing and bone remodeling in ovariectomized rat femora. Bone. 2009;44(5):893–8.

    Article  CAS  PubMed  Google Scholar 

  45. Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, Thompson K. Calcium and vitamin d supplementation decreases incidence of stress fractures in female navy recruits. J Bone Mineral Res : Off J Am Soc Bone Mineral Res. 2008;23(5):741–9.

    Article  CAS  Google Scholar 

  46. Alkhiary YM, Gerstenfeld LC, Krall E, Westmore M, Sato M, Mitlak BH, et al. Enhancement of experimental fracture-healing by systemic administration of recombinant human parathyroid hormone (PTH 1-34). J Bone Joint Surg Am. 2005;87(4):731–41.

    PubMed  Google Scholar 

  47. Aspenberg P, Genant HK, Johansson T, Nino AJ, See K, Krohn K, et al. Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Mineral Res : Off J Am Soc Bone Mineral Res. 2010;25(2):404–14.

    Article  CAS  Google Scholar 

  48. Almirol EA, LGao LY, Khurana B, Hurwitz S, Bluman EM, Chiodo CP, et al. Short-term effects of teriparatide versus placebo on bone biomarkers, structure, and fracture healign in women with lower-extremity stress fractures: a pilot study. J Clin Transl Endocrinol. 2016;5:7–14. Randomized controlled trial showing benefit of teriparatide administration for lower extremity stress fractures.

    Article  Google Scholar 

  49. Tashjian Jr AH, Gagel RF. Teriparatide [human PTH(1-34)]: 2.5 years of experience on the use and safety of the drug for the treatment of osteoporosis. J Bone Mineral Res : Off J Am Soc Bone Mineral Res. 2006;21(3):354–65.

    Article  CAS  Google Scholar 

  50. Andrews EB, Gilsenan AW, Midkiff K, Sherrill B, Wu Y, Mann BH, et al. The US postmarketing surveillance study of adult osteosarcoma and teriparatide: study design and findings from the first 7 years. J Bone Mineral Res : Off J Am Soc Bone Mineral Res. 2012;27(12):2429–37.

    Article  CAS  Google Scholar 

  51. Adams SB, Lewis Jr JS, Gupta AK, Parekh SG, Miller SD, Schon LC. Cannulated screw delivery of bone marrow aspirate concentrate to a stress fracture nonunion: technique tip. Foot Ankle Int. 2013;34(5):740–4.

    Article  PubMed  Google Scholar 

  52. Gianakos A, Ni A, Zambrana L, Kennedy JG, Lane JM. Bone marrow aspirate concentrate in animal long bone healing: an analysis of basic science evidence. J Orthop Trauma. 2016;30(1):1–9.

    Article  PubMed  Google Scholar 

  53. Hsu AR, Lee S. Evaluation of tarsal navicular stress fracture fixation using intraoperative O-arm computed tomography. Foot Ankle Specialist. 2014;7(6):515–21.

    Article  PubMed  Google Scholar 

  54. Saxena A, Fullem B. Navicular stress fractures: a prospective study on athletes. Foot Ankle Int. 2006;27(11):917–21.

    Article  PubMed  Google Scholar 

  55. Varley I, Greeves JP, Sale C, Friedman E, Moran DS, Yanovich R, et al. Functional polymorphisms in the P2X7 receptor gene are associated with stress fracture injury. Purinergic Signal. 2016;12(1):103–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Rothman Institute, 3300 Tillman Drive, 2nd Floor, Bensalem, PA, 19020-2071, USA

    Rachel J. Shakked

  2. University of Texas McGovern Medical School, Houston, TX, USA

    Emily E. Walters

  3. Hospital for Special Surgery, New York, NY, USA

    Martin J. O’Malley

Authors
  1. Rachel J. Shakked
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  2. Emily E. Walters
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  3. Martin J. O’Malley
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Correspondence to Rachel J. Shakked.

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None of the authors has a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Foot and Ankle Sports Medicine

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Shakked, R.J., Walters, E.E. & O’Malley, M.J. Tarsal navicular stress fractures. Curr Rev Musculoskelet Med 10, 122–130 (2017). https://doi.org/10.1007/s12178-017-9392-9

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  • DOI: https://doi.org/10.1007/s12178-017-9392-9

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