Navicular Stress Fractures
Poor Joel Embiid! The former KU hoops star has had some bad luck recently. First he has a stress fracture in his back, now he has a navicular stress fracture in his foot that required surgery. Navicular injuries in the foot are tough to come back from and there is a host of former NBA athletes who have dealt with them. These are even tricky to diagnose as only 33% are visible on X-ray initially (de Clerrq et al, Acta Orthop Belg 2008). Some studies show that conservative treatment is a better option, and one study showed that regardless of operative or non-operative treatment, a 4-month recovery is expected. We’ve seen a few of these at SSOR and have expertise in how to treat them. You can have confidence that the sports physical therapists at SSOR are your first choice for helping you get back from these injuries. Hopefully, this post will help explain it a bit.
What’s the navicular?
The navicular is a bone that articulates with the talus (“ankle bone”). The bone really doesn’t move much and articulates with the calcaneus (“heel bone”) and cuboid bones too. The joint between the talus, calcaneus, and navicular (Talocalcaneonavicular joint ) is critical to foot function because joints that move distal to it (closer to the toes) move in response to and as compensation for movement or lack thereof in the talus and calcaneus.
When we walk, run, or jump, much of the loading at the foot takes place at this joint. Therefore, lack of movement will cause injury because of inability to absorb shock, and too much mobility will cause injury due to lack of support.
So, it is obvious that the navicular, while a small bone, is vital to foot function. The problem is that if the bone requires surgery, there isn’t much room to work with. The bone is relatively fixed. This is much different than fixing a knee or a shoulder.
What’s the post-operative plan look like?
First, non-operative treatment is usually 6 weeks of limited or no weight-bearing, then the athlete is re-evaluated for healing as well as function. If surgery is indicated, there is usually a brief period of non-weight bearing, then progressive weight bearing in a boot and crutches. However, this is largely determined by the operating physician so it’s difficult to predict and is dealt with on a case-by-base basis.
How are the outcomes after surgery?
Jacob and Paterson (Indian J Orthop, 2013) found that in a small sample of nine athletes found that 7 of 9 returned to their sport at an average of 5 months post-op. At seven-year follow up, six of eight were still playing with no symptoms, and one other had some discomfort only. This is only one study, but the results are promising for Mr. Embiid.
Physical Therapy and Rehab for Navicular Stress Fractures
Like many injuries, rehabilitation is a complex process. First, a thorough physical assessment is needed to determine any impairments in the foot, ankle, or elsewhere that may have contributed to the injury. Hip weakness or maybe even a leg length discrepancy may have put him at risk for the stress fracture, so these are just two other areas that will need to be addressed.
Once the weight-bearing restrictions are lifted, progressive weight-bearing will commence. Whether or not the athlete uses a boot or crutches is largely determined by the physician. That said, it is strongly advised that the athlete use an assistive device of some kind until gait is normal.
In cases like this, aquatic therapy is integral to the rehab plan. By nature of being more weightless in the water, athletes can begin walking and doing functional activities earlier in the rehab process. Gait will normalize faster in the water and an athlete can begin activities like running and jumping much sooner than if done exclusively on land.
Total leg strengthening as well as core strengthening are also key components of rehab after these injuries. The stronger the legs and core are, the less shock the foot has to attenuate (as the foot is the first thing to strike the ground with running and jumping).
Manual therapy to the foot and soft tissues in the lower leg will be integral in the process as well. When an athlete is in a boot, joints of the foot can get stiff. To minimize strain on the navicular, other joints and bones need to move like they’re supposed to. Plus, soft tissues in the ankle and calf can have many areas of dysfunction that need to be addressed to maximize foot and ankle function.
Lastly, orthotics may be used to augment rehabilitation to optimize foot control and positioning during functional activities.
Before an athlete moves to running/jumping after these injuries, they should be put through a thorough series of functional tests. Single leg heel raises, bounding, and hopping are all necessary functional activities that should be performed prior to discharge. Additionally, athletes should pass a series of hop tests within 10% of the uninvolved side.
Long term, athletes tend to have some discomfort or achiness with this procedure. Pain can be managed with ice and anti-inflammatory medications, but also activity modification. “Unweighting” workouts like the bike or elliptical can reduce loading on a sore foot while maintaining conditioning. Deep water running or running in the pool can also decrease some loading on a sore foot. Having a stable, comfortable shoe is also highly recommended.
The physical therapists at SSOR are very passionate about sports and orthopedic injuries. It would be a privilege to help you recover from your injury. We hope that we can earn your confidence – give us a call at (913) 904-1128 to schedule an appointment. Remember, in the state of Kansas, you no longer need a physician referral to get physical therapy.