Listen to Dr Amy Touzell, orthopaedic surgeon, discuss stress fractures and their management with sport and exercise physician Dr Leesa Huguenin and the team from Trivelo Cycling and Triathlon Coaching in their weekly 'Get Fast' podcast below.
Mr OW is an 18 year old young man who had a six month history of niggling foot pain, left worse than right. Whilst the pain was not severe enough to prevent him playing, he was often sore after football games and training, and was experiencing intermittent night pain.
During a game, Mr OW was tackled and sustained a vertical force to his left foot. He had immediate pain and, although was able to finish the game, was very sore that evening and developed swelling in his left foot. He was unable to weight bear the following day.
His astute osteopath was concerned about the possibility of a midfoot fracture given his presentation. An x-ray and CT scan demonstrated a displaced fracture of the navicular:
On examination, Mr OW had a painful, swollen left navicular tuberosity and was unable to weight bear. However, he also had pain to palpation of his right navicular tuberosity so an MRI scan was arranged. This demonstrated an undisplaced stress fracture in his right navicular:
Given the displacement and chronicity of his left navicular fracture, this was treated with open reduction, internal fixation and bone grafting. Mr OW was non weight bearing on his left foot for six weeks before gradually progressing his weight bearing in a CAM boot until three months following his surgery. His right navicular fracture was treated non operatively and Mr OW was permitted to weight bear as tolerated in a CAM boot for six weeks.
Six months later, his left navicular fracture united although Mr OW developed some forefoot bursitis during his rehabilitation. His right foot remained symptom free. He will start a gradual return to running program.
Discussion:
Navicular stress fractures are incredibly frustrating injuries for patients and their treating practitioners. If diagnosed and treated early by a period of non weight bearing and offloading in a CAM boot, patients have an opportunity to recover and avoid surgery. If the fracture becomes chronic and/or displaced, it is unlikely to heal without surgical intervention requiring a prolonged period of recovery and rehabilitation.
We suggest involving a sport and exercise physician in the management of stress fractures due to the possibility of over-training, biomechanical stressors and nutritional deficiencies as cause of the injury.
If a stress fracture in the lower limb is suspected, it is advised to make the patient non weight bearing and seek medical advice. Stress fractures are best diagnosed using a high-quality MRI scan.
All cases and clinical photographs have been shared following discussion and written permission from the patient and/or guardian.