I’m an avid runner and have had recurring foot injuries for the past 18 months. Think the basis of it is I haven’t taken enough rest time and as a result have reinjured the area twice now. I’d love some advice from those who are either medical pros or people who have gone through navicular/talus stress reactions and/or fractures:
Some Background / Imaging:
MRI done a couple of days ago:
“Subchrondral edema within navicular bone…new subchondral edema found inferior margin of the head of the talus…talar dome intact…mild amount of subcutaneous edema about the partially visualized ankle…no talonavicular joint effusion.”
“Redemonstrated sprain of the intercuneiform ligament…new sprain of the cuneiform-cubodial ligament.”
Last CT Scan (July 2012) revealed:
“…small step off of the lateral cortex of the navicular…small fragment identified posterior to the most medial posterior aspect of the navicular…remainder of bones of the ankle and foot are intact…IMPRESSION: subtle cortical disruption of posteromedial navicular.”
Questions:
Should I be fully non weight bearing? I am in an Aircast walking boot, should I be in crutches as well? How long? My doctor has traditionally said I don’t need crutches since this is a reaction and not a fracture but since I’m now in my 3rd recovery stint in 18 months, my frustration level has peaked and I’d like to solve this once and for all.
I will be receiving a bone growth stimulator (Biomet electromagnetic) on Monday. Anyone have experience with this?
Has anyone else had a diagnosis like this? What was your “magic recipe” for recovery? Will I be a long distance runner again?
This has been an rough time for me as I’d love to get back to the sport I love. Thanks so much in advance.
#1 - I’m not a fan of your MRI/CT readings … verbage is not consistent with a skilled musculoskeletal radiologist IMO.
#2 Navicular stress fractures are famous slow healers, even with significant immobilization. Many aggressive specialists actually advocate ORIF (open screw fixation compression) across the navicular (I usually do not) depending on the injury. In either case, return to running usually takes at least 4 months
I am on my second 2nd metatarsal stress fracture…or stress reaction, only had an X-ray which was negative, but the pain is the same spot opposite foot as the one I fractured 20 months ago. I can’t give you any advice except I am using a bone stimulator…I hope it is helping because it is a PIA! Have the wires taped down well at night or expect to be woken up several times during the night.
Thanks so much for your response – may I ask a couple of follow up question?
#1 - I’m not a fan of your MRI/CT readings … verbage is not consistent with a skilled musculoskeletal radiologist IMO.
I’m seeing another foot/ankle specialist and bringing all my images – do you suggest I ask him to provide another reading?
#2 Navicular stress fractures are famous slow healers, even with significant immobilization. Many aggressive specialists actually advocate ORIF (open screw fixation compression) across the navicular (I usually do not) depending on the injury. In either case, return to running usually takes at least 4 months
I strongly want to avoid any kind of surgical procedure for this and though it super sucks, I’m willing to be patient if it means I can come back strong and put this behind me. Your response seems to suggest I should probably not worry about whether I’m on crutches or not, just should probably limit my overall movements day to day? For the next 2-3 weeks I’m trying to get a work-at-home situation established to limit my overall steps.
Last question: I’m trying to avoid all weight bearing activities, including swimming – is there a time frame in which I could at least begin to layer that in? I was thinking 3-4 weeks out.
I’d ask your specialist who he/she likes to read their MRIs. He/she can read as well, but still won’t be as good in most cases as a good musculoskeletal radiologist.
Of course, you should avoid surgery in most cases - but this is why “we” do studies to give athletes our best estimation of healing, time frame, etc. Sometimes, it is the right answer as much as athletes don’t want to hear it.
I think you would be fine swimming 3-4 weeks out, but running will be a LONG way out - follow your treating specialists instructions carefully.
I can be patient for my return to running, particularly as this has not gotten better since July 2011. If 4+ months is the time frame I can live with it. Thank you for your candor and insight, it is very much appreciated.
I will bring these questions to the specialist on Tuesday and update if I have any follow up questions.
All I can do is treat this like training for an actual race and be dedicated to my recovery.
One follow up: As it looks like I won’t require crutches, I’d still like to be maximally effective with non weight bearing. Any best practices / tips on making sure I maximize my recovery while in the walking boot? Does doing band exercises / stretches help? Extended time with leg elevated? Icing?
The only issue I see here are your 2 readings. Your initial CT scan seems to imply an actual fracture “step off” fracture of the posteromedial navicular (which would be unusual and probably a simple accessory navicular/os tibiale externum read by a poor radiologist, but who knows). This was July 2012. These would usually require cast immobilization/complete non weightbearing to heal properly.
Your recent MRI only shows “subchondral edema” in/around the talo-navicular joint which usually would not require complete non weight bearing. Most athletes lose/gain lower leg muscle tone quickly and I generally don’t find it to be much of an issue (though most physical therapists disagree for obvious reasons)
Band exercises right now - don’t bother IMO. They are best for range of motion mostly, not really for building/maintaining muscle at your level. Elevation and Icing - not gonna’ help right now and would be for comfort measures only. Have plenty of questions for your doc on Tues
Thanks. I picked up some crutches, just to be safe. Pending my meeting with the specialist on Tuesday I’m going to see when/if he recommends a CT to see if there is still any kind of disruption of the bone that would require complete immobilization
I’m a little frustrated my original doctor wasn’t more straightforward in terms of how essential non-weight bearing was for an extended period of time. Feel like I’ve had several false starts due to a lack of overall knowledge of a recovery protocol.
Will relay more info once I’ve gone to see my next doc, thanks all.
Went to foot and ankle specialist yesterday and had a very informative consultation.
In general, he described a phenomenon in which this injury needs a long amount of time (which should generally be benchmarked and checked on a monthly basis) to create a greater threshold between the current trauma in my foot and the types of activities I’d like to do. In short, hard to predict how long and what type of running activities I’ll be able to do in the long term.
It’s disappointing for sure (particularly the uncertainty as to whether I’ll be able to run as much and as far as I’d like), but I’m willing to treat this like race preparation and work my hardest to stay off of my foot for the long term and layer in appropriate activities over the next several months (e.g., crutches to boot, pool activities, light cycling, walking, short jog, etc.).
I’ve been using crutches and a cam boot for the last week and will continue to use crutches for at least another week or two before seeing how my foot feels walking in the boot.
I also received the EMI bone healing system today, which I’m wearing while I sleep as well as a few waking hours per day.
I’ll circle back in about 4-6 weeks to provide status updates on how I’m feeling etc. Will be requesting consultation notes today as well.
Thank you to everyone who provided their insights, greatly appreciated!
Wanted to give a quick follow up and throw out some questions, as it’s been about ~8 weeks for me in a walking boot / crutches (I used crutches for the initial 3-4 weeks of my time and then utilized just a walking boot for the past four).
Where I am now: So this Wednesday will be eight weeks since I put on the aircast airwalker. In general, I feel much better than I did in late March, but I cannot say that the feeling in my injured (left) foot is indistinguishable to the feeling in my right foot. In all I’d say my left foot is at about 85-90% of where it would need to be (and I say that fully understanding I have several months to go before I could begin doing those things such as running).
Next steps: I am scheduled for a follow-up MRI on June 1st, after which I’ll meet with the two doctors (one a sports med / family medicine DO, the other a foot and ankle specialist) I’ve been seeing. Obviously I’m hopeful the MRI shows that the navicular and Talus edema has nearly fully resolved and I can begin walking without the boot, potentially ride a bike more frequently, etc.
Questions:
Why still any discomfort in the left foot*? *A little frustrated that I cannot seem to shake that last bit of feeling of instability in the navicular area; this seems to be repeating a similar pattern of 90% resolution, but never getting over that last hump? What can I do to quicken this process? Has anyone else had this type of progression?
What activities are reasonable at this stage?* *For the last week, I’ve been spending time out of the boot (e.g., I’ll walk around my office or apartment without the boot, but anytime I’m going for walks outside or commute to work, I wear the book). In addition, I’ve ridden a bike a little bit locally and hit some golfballs without the boot (without pain, but some concern I’m rushing activities .
Time frame to running?* *Though I’m trying nto exercise patience and take few half measures in my recovery, I’d like to think running is a possibility this autumn? Is another 3-4 months a reasonable time frame?
Thanks for all your thoughts and comments. Watched my wife participate in a triathalon this weekend and it was really hard to watch so many athletes effortlessly run, bike, and swim. It’s been a very tough year or so with this injury but I’m hopeful and encouraged by my progress overall.
Glad to hear you are feeling better. I’ll take a stab at one of your questions: Why doesn’t you leg feel great yet? Whenever a joint is immobilized, such as in a cast or aircast most of the day, the joint remodels, becomes stiff, and can just plain feel funny. The older one is the more pain is expected. I’ve seen several kids hop out of an ankle cast with no pain or stiffness, but never an adult. So in short, I would not become disheartened with mild discomfort now. Your leg won’t feel great until you can put it back into use. Since you’re gong to see your doctors in two weeks I’ll hold my comments on the other two questions.
On a side note:
I realize you may have just been typing fast as we all make typos, but I would assume your family medicine physician is a D.O. (Doctor of Osteopathic Medicine), not an O.D. (Oculus Doctor, Optometrist). Just trying to help out my DO friends as they deserve better PR/public awareness then they currently have.
Not much to add other than to say I’m just now over the effects of a double navicular stress fracture from July of 2011. You’re doing the right thing in being as cautious as you are; I probably doubled my recovery period by trying to nudge things along too quickly.
Thanks! Truth be told I was first given the diagnosis July 2011 as well! But I just could never fully turn the corner and am now in my third recovery cycle. I just keep saying, “no half measures.” Trying to treat it as if it were a fracture and hold off.
I’m just glad to hear you made it through the recovery period. Have you been able to run long distances? Doctors have been reticent to say whether or not I’ll be able to train for middle and longer distance runs again, but I’m hopeful they’re just trying to management expectations.
And yes, made edits to my original post, those were typos, thanks!
Unfortunately, recent studies (several from Australia and prospective ones by Saxena in the US) do NOT correlate radiographic findings with long term success. Most advocate non weight-bearing cast immobilization for at least 6 weeks for true stress fractures (with some evidence for ORIF for type II or III types) followed by CAM boot. Usually, return to activity is 4-6 months (long!)
Unfortunately, recent studies (several from Australia and prospective ones by Saxena in the US) do NOT correlate radiographic findings with long term success. Most advocate non weight-bearing cast immobilization for at least 6 weeks for true stress fractures (with some evidence for ORIF for type II or III types) followed by CAM boot. Usually, return to activity is 4-6 months (long!)
Sorry, this was a bit over my head so a couple of questions.
What is ORIF type II or III? I know I was told I have a stress reaction and not a fracture. I think the CT scan showed some kind of irregularity on the bone surface, but wasn’t entirely clear on what that meant. Think the CT findings from 7/12 are listed above.
I’ve worn a walking boot and used crutches for the first 3 weeks, then utilized a walking boot for the last five (while minimizing overall movement). Is that okay?
I can live with long, heck it’s already been two months. I’m content to wait. I just want to make sure I’m’ doing everything possible to get back to 100% Is this protocol reasonable?
I thought you had a CT scan where there was a cortical fracture, not just “marrow edema” on an MRI? Depending on location/cortex (or both cortices), it gets graded I-III with grade I stress fx usually treated by non weight-bearing BK cast for 6 weeks+, Grade III (as least in athletes) ORIF surg, Grade II will depend on lots of things (surgeon, patient, time of year/training/racing goals, etc.)
Thanks for the clarification. The CT scan from 2012 noted a subtle cortical disruption of the postermedial navicular, but didn’t mention degree of fracture, or if that is in fact considered a fracture.
By contrast the '13 MRI didn’t say anything about a fracture. I know this is not apples to apples but perhaps I need further clarification.