Navicular Stress Fracture

A navicular stress fracture is a crack or break in the navicular bone, which is a boat-shaped bone in the middle of the foot. These fractures often are due to overuse, ongoing forces, and/or stress on the bone rather than a sudden injury.

Symptoms

Patients with navicular stress fractures usually have gradual onset of aching pain across the top and/or middle of the foot. Pain usually improves with rest and support but then returns when activity resumes.

Causes

The navicular bone helps transfer force from the ankle to the forefoot (the ball of the foot). The navicular is covered by cartilage and lacks a rich blood supply, especially at its center. This makes it more susceptible to repetitive forces that can cause damage. The bone may break down because of excess force, underlying bone weakness, or a combination of these two factors.

Repetitive forces that could result in a navicular stress fracture include running/jumping sports (such as basketball) and similar activities, increased exercise, or even walking after a period of inactivity.

Prevention

There are steps you can take to help prevent navicular stress fractures:

Select supportive footwear before you start an exercise or training routine and replace your shoes after 300 to 500 miles of use. Supportive shoes typically have a stiff sole with lots of cushioning in the shoe, especially at the arch.

Start your new training routine slowly, especially after a period of relative inactivity. Do not increase your walking or running distance increments by more than 10 percent per week.

Incorporate stretching, particularly of the calf muscles and Achilles tendon, prior to exercise.

Diagnosis

A history and physical exam are important ways for diagnosing a navicular stress fracture. Physical examination will show tenderness across the top of the foot. Standing X-rays may reveal a fracture line. However, X-rays may appear normal in the early stages of the stress fracture. Imaging beyond X-rays such as CT, MRI, and bone scans can be helpful in showing a stress fracture at the navicular if X-rays can’t do this.

Treatments

Your foot and ankle orthopedic surgeon may recommend surgical or non-surgical options to treat navicular stress fractures. First, you must stop the activity that results in the pain of the stress fracture. Non-surgical treatment includes wearing a cast or boot without weightbearing for 6-8 weeks. Research shows wearing a cast has an 80-100% success rate.

Certain patients, including professional athletes, may choose surgical treatment to allow them to return to activity more quickly and reduce the risk of developing another stress injury. Surgical treatment involves placement of an internal screw or screws across the fracture. Recovery after surgical treatment usually requires at least 6-8 weeks of limited weightbearing and foot immobilization in a cast or boot with a gradual return to activities.

Risks and Complications

The most common complication after treatment of a navicular fracture is a nonunion, or failure of the bone to heal. Continued pain with activity after cast removal is a sign that the bone did not heal. If a nonunion develops, the treatment can be surgery. This often involves using a bone graft in the fracture site can help with navicular bone healing.

Another potential complication is the development of arthritis, resulting from damage to the cartilage that covers the joint connecting the navicular bone to the hindfoot (rear part of the foot).

A less common complication of navicular fracture is avascular necrosis (AVN), which results from a loss of blood supply to the navicular bone. AVN causes a collapse of the navicular bone and affects function of the joints in the middle of the foot. It can be difficult to treat.

FAQs

How long should I experience pain before making an appointment with my foot and ankle orthopedic surgeon?

Patients should call after 1-2 weeks of persistent foot pain with walking or participating in activities.

Morton’s Neuroma

Morton’s neuroma is a thickening of the tissue that surrounds the small nerve leading to the toes. It occurs as the nerve passes under the ligament connecting metatarsal bones in the forefoot (front part of the foot).

Morton’s neuroma most frequently develops between the third and fourth toes. It often occurs in response to irritation, trauma, or excessive pressure, and is more common in women.

Symptoms

Morton’s neuroma may feel like walking on a stone or marble. You may have burning pain in the ball of your foot that radiates into the toes. The pain can worsen with activity or wearing shoes. You may also experience numbness or a “clicking” feeling in the toes.

Runners may feel pain as they push off. High heeled and narrow toe box shoes also can aggravate the condition.

Diagnosis

During the examination, your foot and ankle orthopedic surgeon will feel for a mass or a “click” between the metatarsal bones. They will squeeze the spaces between the toes to try to recreate the pain. Range of motion tests are used to rule out arthritis or joint inflammation. X-rays can help rule out a stress fracture or arthritis.

Treatment

Initial treatment can involve several non-surgical options:

Changing shoes: Avoid high heels or tight shoes. Wear wider shoes with lower heels and a soft sole. This helps to decrease compression of the nerve.

Orthotics: Custom shoe inserts and pads may help relieve irritation by lifting and separating the bones, reducing the pressure on the nerve.

Injection: An injection of a corticosteroid will reduce the swelling and inflammation of the nerve, which should provide relief.

Several studies have shown that a combination of shoe changes, oral anti-inflammatory medications, orthotics, and/or cortisone injections will provide relief in more than 80% of people with Morton’s neuroma. If conservative treatment does not relieve your symptoms, or if symptoms return, you may require surgery.

Surgery involves either removing a small portion of the nerve including the neuroma or releasing the tissue around the nerve to decompress it. It is an outpatient procedure, meaning the patient can go home the same day as surgery. Patients may be immobilized for 1-2 weeks to allow for healing of the incision, and then transitioned to regular shoes as tolerated.

Lisfranc Injury

A Lisfranc injury involves the joints and/or the ligaments of the midfoot (middle of the foot). The Lisfranc is a ligament of the foot that runs between two bones called the medial cuneiform and the second metatarsal. The name comes from French surgeon Jacques Lisfranc de St. Martin (1790-1847), who was the first physician to describe injuries to this ligament.

There are a variety of causes for a Lisfranc injury such as a car accident, sports injury, or a simple slip and fall. Sometimes the injury can be mistaken for a foot sprain when X-rays do not show any broken bones. Delaying treatment can sometimes lead to more significant problems. Proper diagnosis from a foot and ankle orthopedic surgeon is key.

Symptoms

The common symptoms of a Lisfranc injury are swelling and pain on the top of the foot near the instep. Bruising is common, and a bruise on the bottom of the foot can be a clue that this injury has occurred. With a severe injury, the foot may be distorted and putting any weight on it may be very painful. With a mild injury, the foot may appear normal and you may be able walk on it with only mild pain.

Causes

Low-energy injuries can happen when the back of the foot twists or presses down with the ball of the foot planted on the ground. This can happen during athletic activities such as football but also can occur from a misstep or even missing a stair and stumbling over the top of the foot. High-energy injuries occur from direct trauma such as a car accident or a fall from a height.

Specialized ligaments in the midfoot hold the bones in this area together like puzzle pieces to maintain the arch of the foot. When the ligaments, joints, or bones in this area are injured, they may shift out of place, making the arch unstable.

Diagnosis

A Lisfranc injury diagnosis is made based on what happened at the time of injury, your symptoms, and an examination of the foot and ankle that compares the injured foot to your uninjured foot. Your foot and ankle orthopedic surgeon will examine the middle part of your foot to identify the location of your pain and perform tests to check the stability of this area. X-rays may show broken or shifted bones in the middle of the foot. Sometimes X-rays will be taken while you are standing in order to better identify the shifting of bones in the foot. An MRI scan may be helpful to see if the ligaments in the foot are damaged. A CT scan can help determine the extent of the bone injury and is useful when planning surgery if needed.

Treatments

Non-surgical Treatment

If the ligaments and the bones in the middle of the foot are not severely injured, and bones are not shifted out of their normal positions, non-surgical treatment can be successful. A cast or CAM boot may be needed for at least 6 weeks in order for the ligament and/or bone to heal. Your foot and ankle orthopedic surgeon will follow up regularly with X-rays to make sure the bones maintain good position during the recovery.

Surgical Treatment

If the bones or ligaments are injured in a way that causes them to shift out of their normal positions, Lisfranc surgery may be necessary to restore the anatomy of the foot. Surgery may involve the placement of plates and screws that may need to be removed later, once the bones and ligaments have healed.

Recovery

Recovery from Lisfranc surgery depends on the severity of the injury. Most patients will be in a non-weightbearing cast for 6 weeks, followed by 6 weeks in a walking boot. Physical therapy may be needed to strengthen the foot and ankle and help regain walking ability. Return to maximal function, running, and sports can take up to one year.

Risks and Complications

Lisfranc injuries may cause arthritis and chronic pain in the middle of the foot. This may require additional treatment. With surgery, injury to the nerves and tendons may occur. Because of the swelling that often occurs with this injury, complications such as wound opening, infection, and/or further swelling of the foot may occur after surgery.

The outcome for Lisfranc injuries depends on their severity. Some patients will not be able to return to their pre-injury level of functioning or athletic activities even with well-performed treatment. The cartilage joint surfaces commonly are injured and some patients may develop midfoot arthritis (arthritis of the middle of the foot). It is also common for pain to continue in the joints after this injury. For some patients, surgery such a fusion of the joints may be necessary to relieve arthritis pain.

FAQs

How can I tell if it’s a sprain or a Lisfranc injury?

Unrecognized and untreated Lisfranc injuries can have serious complications, including joint degeneration and a buildup of pressure within muscles that can damage nerves and blood vessels. If the standard treatment for a sprain (rest, ice, and elevation) doesn’t reduce the pain and swelling within a day or two, or there is extensive bruising on the bottom of the foot, see your foot and ankle orthopedic surgeon immediately.

How soon can I get back to normal activity?

It is important to follow your doctor’s orders and refrain from activities until you are given the go-ahead. If you return to activities too soon after a Lisfranc injury or surgery, you may suffer another injury that results in damage to blood vessels, arthritis, or an even longer healing time.

Jones Fracture

A Jones fracture is the name often used for a fracture at the base of the fifth metatarsal, the bone on the outer side of your foot. Jones fractures are one of the most common foot injuries. This broken bone may heal slowly because of poor blood supply to the area and the amount of force placed on this part of the foot. Those with high-arched feet especially are at risk for a Jones fracture because they put more pressure on the outside of their feet.

Symptoms

Jones fractures produce pain, swelling, bruising, and difficulty walking. Some people may experience pain before the fracture occurs.

Causes

A Jones fracture can occur when the foot twists. Stress fractures can occur in this area when there is a sudden increase in high-impact activity (for example, marathon training).

Diagnosis

A Jones fracture typically is visible on X-rays of the injured foot. An MRI may be helpful if the fracture is not seen on X-ray. A CT scan can be useful to gauge fracture healing.

Treatments

Your foot and ankle orthopedic surgeon may recommend treating the Jones fracture without surgery. This involves a period of immobilization in a non-weightbearing cast or boot. Studies have shown that some of these injuries fail to heal. For this reason, repeat X-rays are necessary to ensure appropriate healing. If X-rays do not show healing in six weeks, then surgical treatment should be considered.

Surgery is most common for Jones fractures in athletes or when non-surgical treatment isn’t successful. During surgery, your foot and ankle orthopedic surgeon will insert a screw to stabilize the fracture while it heals.

Recovery

Recovery is about eight weeks with or without surgery. After the bone has healed, some patients will need physical therapy to regain motion and strength.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Sometimes the bone will take longer than eight weeks to heal. If this happens, either surgery or a bone stimulator is recommended to help healing. Rarely, the fracture may not heal and the screw can break. If this happens, a second surgery may be performed. Jones fractures also have a high rate of refracture, which occurs more frequently with non-surgical treatment.

FAQs

When can I return to playing sports after a Jones fracture?

Athletes typically return to playing sports at around 8 weeks. Athletic trainers and physical therapists help with this process. Some may wear a clamshell orthosis or turf toe plate when returning to sports, particularly athletes who play on hard surfaces such as artificial turf.

Can I wait to have surgery until I see if the fracture doesn’t heal?

Yes, you can wait. However, postponing surgery may make it more difficult.

Does the hardware need to come out?

No, the hardware does not need to come out for you to return to activities. However, if the screw head or hardware is prominent and irritated by shoes, it may need to be removed.

Joint Injection

A joint injection is a procedure your foot and ankle orthopedic surgeon uses to introduce medication into a joint. The injection is done under sterile conditions using a syringe and needle.

The goals of a joint injection are to relieve pain and improve joint function. Your doctor also may confirm your diagnosis when giving a joint injection.

Diagnosis

An injection may be needed if you have redness, pain, swelling, loss of smooth motion, and trouble with walking normal distances.

Joint injection should be avoided in certain situations. Some of these include the presence of skin or blood infections and a history of allergic response to the injectable medication or its components. In addition, your surgeon may rule out a joint injection if there was little improvement after a previous injection, you have a bleeding disorder or are on blood thinning medication, you have poorly controlled diabetes, or your body has problems fighting infections.

Treatment

Your surgeon will position your foot for the injection procedure. The skin over the joint will be cleaned and sterilized with topical iodine, chlorhexidine or alcohol. The medication will be injected using a syringe and needle. The injection site may need to be covered with a bandage or have pressure applied for a few minutes.

Specific Techniques

The ankle, subtalar, and metatarsophalangeal joints are the common joints for injections. An ultrasound or X-ray may be used to help guide the injection. In addition, fluid can be drawn from the joint before an injection and sent for testing. The symptoms of infection, gout, and autoimmune disease can be similar, and lab testing can help determine a diagnosis.

Recovery

You may be asked to remain in the office for 30 minutes or so to be observed for side effects of the injection. You may be instructed to avoid or limit activity for a day or so after the injection. Your foot and ankle orthopedic surgeon may prescribe other medication, splinting, or physical therapy as part of your treatment plan. Your specialist will tell you when to schedule your next appointment.

Risks and Complications

Potential complications include infection at the injection site, infection of the joint, tenderness, swelling, and warmth. There can sometimes be nerve or blood vessel injury, or damage to the joint surfaces.

When corticosteroids are used, they may cause loss of skin pigment or thinning of the skin. Corticosteroids also can cause weakening of a nearby ligament or tendon with the possibility of complete tears. This medication also may temporarily increase blood sugar and disrupt the body’s own steroid hormone balance, particularly in patients with hormone disorders.

Local anesthetic may cause flushing, hives, chest or abdominal discomfort, and nausea. Viscosupplements, substances that act like naturally occurring joint fluid, may cause joint pain, swelling, and inflammation. Contrast agent may cause allergic reaction.

FAQs

Should I apply ice or heat after a joint injection?

It is generally recommended that you apply ice once or twice per hour for 10-15 minutes for the first few hours after a joint injection. You should avoid applying heat to the affected joint.

How should I clean the injection site at home?

No specific cleaning of the injection site is typically needed. You generally are able to resume normal showering or bathing after joint injections.

Will a joint injection interfere with my other medications?

You doctor will be able to answer this question for you. Be sure to bring a current list of your medications to your appointment.

Will a steroid injection raise my blood sugar?

If you are diabetic, a joint injection with a corticosteroid may cause your blood sugar to increase for a short time. It is a good idea to talk to the doctor who manages your diabetes medication and your surgeon before you receive a joint injection.