Navicular Stress # ??

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I would like some opinions on a recent patient I had:

- 17 year old female
- No significant medical history
- Healthy body weight and diet
- plays basketball 2 times per week
- Footwear: leather lace up school shoes, Suitable Netball shoe for sport, casually wears flat non-supportive 'volley'

Presented with
- 5-6 week history of pain on left foot anterior-medial foot. No acute injury
- Sport has stopped due to pain.
- non localised area, but when asked to point to where pain was coming from was superior to navicular. Medial to Tibialis anterior.
- Previous treatment with physio included some taping and theroband strengthening work.
- able to bear weight but pain still present especially on one leg hop.
When questioned about pain and timing reported sometimes especially at the start she would get a twinge of pain at night, but worst during sport and in the morning.

Biomechanics:
- (not significantly bad, and if there was no pain I would not address.)
- forefoot supinatus of both feet
- RCSP transverse plane medial deviation at talo-navicular, L>R. probably still within normal limits.

Treatment:
Last week I taped her with fairly aggresive inversion taping and reduced the forefoot supinatus. On review it had made no difference to the pain. No worse no better.

I have sent for plain x-rays just incase there is anything else going on I have missed, but I'm a bit lost.

Ddx:
- tendonitis?
- navicular stress fracture?
- nerve entrapment?

Can a Nav stress # be that diffuse?

Thanks

Sally

 

Please post the plain films. If inconclusive consider bone scan or MRI.

That will get to the bottom of it very quickly.

LL

 

Havent got them back yet. Only referred today

 

Hey Sally,

A ct scan and MRI is defently important part of the diagnosis. Ive had 2 navicular stress fractures in my life. I would suggest you look at the sports med book written by Bukner and Khan at olympic part sports med in Melb and look for the Nspot which they show how to find in the book. The symptoms can also be a stress reaction which will give almost they same symptoms as afracture . So MRI will be negative but CT positive treatment should be very conservative due to the lack of blood supply to the navicular, healing takes a long time.

Michael Weber

 

Michael

Respectfully disagree on the role of MR in imaging stress reaction and/or stress #.

Latest trends are that newer (ie 2+ Tesla) MR machines are now superceding CT and SPECT for most bone stress injuries. Associated marrow oedema can also not be fully appreciated via CT/SPECT.

LL

 

LL Thanks for pointing that out not so up to date with the lastest imaging as Im not allowed to order an xray in sweden as Im not a ´dr´, makes life a little harder to diagnosis.

But I guess my point is that if not a fracture but a reaction a very conservative treatment plan should be undertaken due to lack of blood supply and shape of bone.

Michael Weber

 

Sally:

Pain around the medial navicular generally means posterior tibial insertional tendinitis. If the pain is dorsal on the navicular and accompanied by some dorsal edema, then think navicular stress reaction or navicular stress fracture (MRI is best choice here for diagnostic study). If the pain is more distal and medial, then think anterior tibial insertional tendinitis.

Custom made foot orthoses are the treatment of choice here. Orthoses should be made with a 2-4 mm medial heel skive, minimal arch fill on positive cast, inverted slightly (2-5 degrees) and be made of at least a 4 mm polypropylene with 16-18 mm heel cups, rearfoot posts and with full length topcovers of your material of choice. Second choice would be a modified over-the-counter foot orthoses. Taping can be used along with foot orthoses during sports to further reduce the stress on the injured structures. Icing should be done 20 minutes three times a day and activities may be allowed if non-painful. If pain is present while walking, then patient should be put into cam-walker style boot until MRI scan confirms diagnosis.

Hope this helps.

 

Thanks for all your responses!

Michael, yes I agree, further investigation is necessary and I will follow through with this, I just wanted to see if anybody had other opinions of something I may be missing.
I have read quite a bit about n-spots in Nav stress and there is no N-spot present in this case. However I also know that Nav stress # can be diffuse, non localised pain, which does fit this pt.

Kevin, I have attached a pic (not of this girls foot) indicating the area that she could most closely localise the pain to.

 

Sally

That image appears to suggest the area of pain could be the TN joint or even talar head...

It is well proximal to the navicular tuberosity and PT insertion.

LL

 

LL, yes thats right, as I stated in pt description:

 

Sally

Given your image, the arrow points to the pocket formed by at the head neck of the talus.

I would interpret this as perhaps not even involving the navicular at all, or maybe the proximal side of the TN joint at best?

Rather than being superior to the navicular, it is proximal.

Semantics I know...but I think this would be a more accurate way to describe the situation, given the information provided.:drinks

If it is the indeed the talus or TN joint that is painful, that will change the differential diagnosis.

This is where a bone scan/SPECT is helpful to give an accurate idea of which particular tissue is inflamed.

LL