Review Question - QID 5831

This patient has a tarsal navicular stress fracture (TNSF) and should be treated with cast immobilization and non-weightbearing (NWB).

Tarsal navicular stress fractures are often caused by chronic overuse, especially with repetitive activity. Clinical symptoms involve midfoot pain and swelling. Examination is usually notable for swelling and tenderness over the midfoot. Range of motion of the ankle and subtalar joints is usually intact. This injury is often missed on radiographs and is better demonstrated on CT, which will show a nondisplaced fracture through the navicular. Management of a tarsal navicular stress fracture is NWB with cast immobilization.

Torg et al performed a systematic review of TNSF studies to compare the outcomes of NWB with cast immobilization versus surgical treatment. They found that there was no statistically significant difference between NWB cast immobilization and surgery, but there was a trend favoring NWB cast immobilization. Weight-bearing was shown to be significantly less effective than either NWB cast immobilization or surgery. The authors recommend that NWB cast immobilization should be the initial treatment of TNSFs.

Burne et al performed a retrospective review of patients with TNSFs who attended a university sports medicine center between 1996-2002. They found that only 2/11 patients received the recommended treatment of NWB with cast immobilization for 6 weeks and only 6/11 patients returned to previous level of activity. CT and MR imaging did not correlate with clinical symptoms. They concluded that current management of TNSFs is not in accordance with what is recommended by literature and there is no correlation between imaging and clinical status at long term follow up.

Figure A is an axial CT of the mid foot from Burne SG et al, which demonstrates a stress fracture of the navicular.

Incorrect Responses:
Answer 1: NWB with cast immobilization should be initial management rather than surgery.
Answers 2-4: Weight bearing as tolerated, and partial weight bearing have been shown to have inferior outcomes as compared to NWB with cast immobilization. NWB cast immobilization is a more effective treatment than surgery.