SLR - October 2023 - Fils-Aime
Title: Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent AthletesReference: Mehta S, Zheng E, Heyworth BE, et al. Tarsal navicular bone stress injuries: A multicenter case series investigating clinical presentation, diagnostic approach, treatment, and return to sport in adolescent athletes. Am J Sports Med. 2023; 51(8):2161-2168.
Level of Evidence: Case Series; 4
Reviewed By: Isana Fils-Aime, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Navicular stress injuries are a relatively rare condition in the general population, accounting for less than 5% of all foot injuries. These injuries are caused by repetitive and chronic mechanical loading of the navicular over an extended period, as seen in high energy athletes. Although rare, early diagnosis is critical to prevent fracturing that would require surgery and further extend return to activity time. This study aims to add to the limited body of knowledge in the literature in an adolescent cohort and aid the correct and timely diagnosis of this pathology by analyzing physical examination findings, characteristics of the cohort, imaging, treatment methods, and return to sport.
Methods: A level IV multicenter retrospective chart review was performed of 110 adolescent (aged 10-19 years) patients over a 9-year period with a stress fracture to the navicular as identified via imaging modalities. Using descriptive and comparative statistics, the study described patient characteries, physical examination findings, imaging, treatment approaches and clinical outcomes of patients managed with both operative and non-operative options.
Results: Amid the 110 adolescent patients identified, navicular bone stress injuries were most commonly found in females (comprising 65% of the cohort) and athletes (94%) participating in track, cross country, dance, and gymnastics. These athletes reported navicular tenderness to palpation (96%) and pain when walking (89%). The most common location of fracture line was within the dorsal aspect of the navicular bone. Most patients (85%) demonstrated healing with non-operative treatment alone, with a median time of 4 months to return to sport. Of the 16 patients who ultimately required operative treatment with single or double screw fixation, these patients were found to be older with higher BMIs and with a statistically significantly longer time of return of sport (median of 5 months) with low risk of complications.
Conclusions: There were several limitations given the study design, including no standardized criteria for deciding if surgical intervention is warranted, or the proper timing or indications for surgery. Given the rarity of this pathology, physicians need a high index of suspicion when treating adolescent athletes in high energy sports with midfoot pain. This case series provides insight on how providers can appropriately diagnose and manage this injury to prevent long term sequelae.