16 Year Old Elite Female Gymnast With Foot Pain - Page #4
 

Working Diagnosis:
Right Navicular Stress Fracture With Remote Avulsion Fracture With Borderline Vitamin D Deficiency

Treatment:
Vitamin D3 5,000 IU daily, Exogen bone stimulator, NWB cast immobilization for 6 weeks followed by progressive weight bearing and return to full gymnastics within 6 months.

Outcome:
Because of college showcase events planned in the next 2-3 months, patient elected to train as tolerated. If able to continue, would then undergo immobilization after the season. Discussed concerns regarding displacement, difficulty with surgical treatment, possible long-term disability, and failure to return to gymnastics.

Within 2 weeks of treatment with bone stimulator, ice, and activity modification, patient was pain free. Able to do beam, bars, and run on tumble track without pain. Had only minimal tenderness of the dorsal navicular bone. At 5 weeks, able to do all activities except vault. At 7 weeks, able to do all activities and completed showcase events. Pain free with a normal exam. It was elected to proceed with follow up CT scan prior to casting.

Repeat CT scan Right Foot 7/24/13 (Case Photo 4): Remodeling of bone fragment and near resolution of fracture line.

Because of clinical recovery and radiographic evidence of healing, elected to allow her to train without the use of analgesics. Continued to use bone stimulator and ice, and completed the season. Subsequently accepted an athletic scholarship to a Division I university.

Author's Comments:
Navicular stress fractures are relatively common which are most effectively treated by either non-weight bearing cast immobilization or surgical fixation, followed by a graded return to sport. Usually an aggressive surgical intervention is taken as these are high-risk fractures. However, this case demonstrates a non-traditional approach to treatment with conservative therapy alone that healed the fracture completely.

Editor's Comments:
Navicular stress fractures are challenging injuries to identify, so maintaining a high index of suspicion is key. The navicular bone, like other high risk stress fractures present a 2 fold challenge. First, since they, like the femoral neck, calcaneous, and tibal plateau are cancellous bone. These stress fractures do not present with the usual periosteal reaction. So if they are suspected, advanced imaging is needed in the early stages. Secondly, the blood supply leaves the central portion of the bone prone to injury and delay/non union.
A gymnast with a stress fracture should also raise suspicion for the female athlete triad, so making sure she was getting adequate calories and having regular menses is key.
Vitamin D supplementation in the healing of stress fractures is still inconclusive. Some studies have shown calcium and vit D may be helpful in the prevention of stress fractures. However, no treatment or supplement has been conclusively shown to speed up the healing rate. Rest, is still the best medicine.

References:
1. Potter, N J, et al. Navicular Stress Fractures: Outcomes of Surgical and Conservative Management. British Journal of Sports Medicine: 2006 - Volume 40 - pp 692 - 695.

2. Jones, Morgan H, et al. Navicular Stress Fractures. Clinics in Sports Medicine. 2006 - Volume 25 - pp 151 - 158.

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