The timetable for everything seems to be shifted toward speed. We want our computers to work faster and faster. We mentally urge our microwaves to hurry up and finish popping that popcorn! Even orthopedic injuries are expected to recover faster by doing surgery rather than giving the body time to heal as nature intended.
One injury in particular has been treated surgically in order to get athletes back on the field and maybe it shouldn’t be that way. We are talking about the management of tarsal-navicular stress fractures.
The navicular bone is the one you can feel sticking up the most on top of the foot. For people with a high arch, that bone is often prominent enough to rub against the shoe causing irritation. The tarsal bone is between the navicular and the calcaneus (the heel bone). A stress fracture means there is a tiny crack in the bone where pressure from overuse has stressed the bone.
In this study, orthopedic experts took a look at all the published reports on the care and treatment of tarsal navicular stress fractures. This type of study is called a systematic review. Because this injury is uncommon, there aren’t large studies with 100s of people to learn from. So in order to find out how these injuries respond to treatment, it becomes necessary to look at the combined data from many smaller studies.
A systematic review makes it possible to look at type of navicular stress fractures, how they are treated, and the result of that treatment. There are two main types of navicular stress fractures: complete and incomplete. Treatment is also broken down into two main categories: conservative (nonoperative) and surgical.
Conservative care means the patient’s foot and lower leg are put in a cast until the fracture heals — usually six to eight weeks. Patients treated conservatively use crutches to get around without putting weight on the foot.
Based on X-ray findings, they are gradually allowed to slowly start putting weight on the foot. The radiographs help show the stage of healing. They wear a special weight-bearing boot that protects the healing bone while still allowing some pressure from the ground up.
Surgery is done to help return athletes to their sports activities more quickly. The procedure usually involves an open incision and pins or screws to hold the bone together while healing. Sometimes a bone graft is used to help things along.
Two main questions arise: is surgery necessary? Alternately stated: are unnecessary surgeries being done to manage these injuries? And secondly, what type of conservative care works best — weight-bearing or nonweight-bearing?
By looking at time required to return to full activity, pain levels, and rate of fracture recurrence, the authors were able to make several helpful observations. First, surgery doesn’t speed up healing, recovery, or provide a faster return to play. In fact, there was no difference between results for this injury when treated conservatively versus surgically. The outcomes were the same no matter what type of tarsal navicular fracture was involved (complete and incomplete fractures).
Second, the conservative approach actually showed slightly better results with a 96 per cent success rate compared to only 82 per cent for surgery. Success meant the athlete could return to his or her previous level of play without pain and without suffering from another fracture at the same site.
And third, there was some indication that a nonweight-bearing conservative approach might be better than weight-bearing. When they took a closer look at timetables for the conservative nonweight-bearing approach, they found that a short-leg cast for six to eight weeks was all that was needed. Patients returned to full sports activities on average after six months.
Finally, patients treated with a conservative approach that allowed weight-bearing but who failed to recover were then successfully treated with nonweight-bearing cast immobilization.
The authors conclude that the nonweight-bearing treatment for tarsal-navicular stress fractures is really the best overall approach. It’s possible this type of management could even be done without the cast but specific studies looking at the difference in results between nonweight-bearing with and without immobilization must be done before coming to any firm recommendations about this approach.