A few days before my last triathlon in Canada in August, I felt pain in my left foot when running sprint intervals. I finished the race, but was in awful pain afterwards.
Diagnostic studies concluded the following:
MRI revealed marrow edema in the central to medial aspect of my navicular w/ some cystic changes seen dorsally at the talonavicular joint, but no fracture line seen
plain x-rays revealed mild spurring at the dorsal talonavicular joint
moderate perenoal brevis tendinopathy w/ evidence of intrasubstance longitudinal splitting in the region of the perenoal tubercle of the calcaneus
mild tendinopathy and tenosynovitis of the posterior tibial tendon
mild tenosynovitis of the flexor hallucis longus tendon. Residua of mild chronic incomplete sprain of the anterior talofibular, calcaneofibular and medial deltoid ligamentous structures
The doc’s orders were to keep the left foot in a ‘boot’ for four weeks. However, my return visit last week did not show any improvement. Therefore I got another four weeks in the ‘boot’ and a cat scan was administered yesterday (results still pending). I decided to go on crutches since the pain walking just got too much.
Any information from someone that has had the same injury or from a physician would be very helpful. Is there anything else I can do besides staying off my foot (i.e. ultrasound, laser therapy, electro stem, bone therapy, anti-inflammatories) to speed up the recovery time? I obviously want this injury to heal completely (and not have to deal with it again in a few months from now), but also go back to training. My goal is to continue competing in triathlons for a long time (including Ironman distances).
Well, first, your MRI report sounds horrible! You have findings all over the rearfoot/ankle! Since it was so soon after an IM, we will just chalk some of it up to that (like getting blood work after an IM).
But, navicular stress fractures/reactions heal very slowly (like 3 months) and are generally treated NON WEIGHTBEARING and not in a walking boot (pneumatic or otherwise). The CT scan is just to look for a fine fx line - doesn’t change the treatment here which is cast, crutches, no weight at all. An external bone stimulator (either pulsed electromagnetic or low frequency ultrasound (Exogen)) may halp speed this up, but most insurance payors won’t cover this unless the fx is 90 old or more. PM me and I’ll see if I have an extra around from a rep (but they run about $4,000 U.S. and I just gave one out to a local college CC runner with a heel stress fx).
Edit: also, with your plain film findings of spurring (early arthritic sign) at the dorsal aspect of the TN joint leads me to believe that you are eighter 1) older or 2) have a “fault” at the joint that needs to be addressed
PM if you want any more details - sorry about the injury!
Wow, You’ve got tendon, ligament and bone spur problems! I had and still do, a somewhat similar problem but it does not involve tendons or ligaments. Yours sound more like sprain damage and possibly residual damage from past injuries. My prognosis from a CT Scan read as follows: By the way, I’ve had this problem for over 5 years and it slowly got worse. At first I could work around it by starting my runs very slowly and easing into it, then there started to be days were I just had to turn around and go home because the pain wouldn’t go away. I finally started doing something about it as written below.
CT Scan - Result
“The ankle mortise is intact. There is no suggestion of joint space narrowingor any intra-artcular loose body. There is no evidence of narrowing of the subtalar joint space. There is however a fine intra-articular osseous body centrally within the joint space, This is of indeterminate etiology with no underlying donor site demonstrated to confirm the presence of prior fracture. This remains the most likely etiology however. No additional abnormality seen. No acute injury is identified.”
I’ve been to massage therapy, ART, two podiatrist, a GP, phisiotherapy, got new orthotics, took ibuprofen and about the only thing that helped was ibuprofen and rest. I’ve since weened myself off ibuprofen and took 5 weeks rest after IMC and am now just getting back to running. It seems the layoff has helped, (so far no pain) but I will know as I slowly increase my mileage. The last podiatrist I went to wanted to do a complete overhaul, scraping the tendons, ligaments and any bone spurs. Needless to say, I have an appointment with another doctor for another opinion. I’m hoping they can just “suck out” the loose bone chip with minimal invasive work.
Don’t know if that’s possible, maybe (rroof) can help me there??
Yeah, run from that one “overhaul” guy. There was a discussion the other day about OCD (osteochondral defects). These are usually removed easily via ankle joint arthroscopy by someone skilled with this - very minimally invasize in most cases. But, your CT read makes no sense: “no intra-articular loose body” but a later comment about a “fine” (whatever the radiologist means by that is anyone’s guess) intraarticular osseus body. So which is it?
I can totally empathize. I got a navicular stress fracture in 2001 in the last month before the Columbus marathon (just before my 40th birthday too!) and with a fracture of my lateral cuneiform as well. Stupid overtraining scenario with no rest. I tore my plantar fascia, kept running which changed my gait and I ended up with the fracture. Oh, to add to that, I am a radiologist.
I was made completely non-weight bearing for 8-10 weeks by an orthopedist and put in a removable boot. I also used a bone stimulator, but like the other thread said, insurance may not cover this. I had serial MRI’s which did not show a great deal of change over the months, even though my pain resolved. It was agony looking at the MRI’s, which looked bad, when my symptoms had improved. The time in the boot also resulted in muscular atrophy and weakness.
I saw a great sports medicine physician (fellow marathoner) who told me that no pain was a good sign, no matter what the imaging tests show, basically because they lagged symptoms. After physical therapy with a sports PT specialist and slow, steady but smart return to running, I had no problems. FInished 4 marathons since then including 2 IMLP’s.
Naviciular fractures are tricky to manage, but if you have or find a good, empathetic sports medicine doc or orthopedist, they should be able to handle it. I can’t emphasize it enough - the exam is the key thing, i.e. is or isn’t there pain when one presses on the navicular bone.
Wow, that’s what I was afraid of. Three months is an awful long time. The good thing is it happened towards the end of the tri season. However, as you can imagine I’m already getting antsy. The only thing I can do right now swim between 2,000-2,500 yards as well as weight training (leg extensions & curls, abs, upper body).
I don’t feel old, but I’m 42. I started training for triathlons roughly 15 months ago. Before that I did track and field, basketball, tennis, golf, etc. How would you address the ‘fault’ in the joint? With orthodics ro surgical? The doctor already told me that if I had to have surgery, I would never compete again. Apparently, the cyste in the bone has weakened it quite substantially.
I would very much appreciate it if you could look into an additional external bone stimulator. What state are you located at?
The first part talks about the ankle mortise, which is fine.
The second part talks about the subtalar joint. According to the report, the osseous body is located in the center of this joint. He indicates he cannot find where it came from and there is no indication of prior injury, which would have caused it.
I agree with you, I think a full overhaul is overkill. I really think he is just “fishing” since he really doesn’t know the cause of my pain. With a “blank check”, he can do what he pleases once he gets inside.
Maybe there is light at the end of the tunnel after all. Congratulatsions! I know I will need to have a lot of patience. The muscular atrophy and weakness scares me though. That’s why I keep swimming more than 2,000 yards every day and keep up my weight training (obviously, whatever is non-weight-bearing). But I know my endurance spiraled way down already - just within 7 weeks. By the way, there is tremendous pain when pressing on the navicular bone. That’s why the physician ordered another 4 weeks ‘boot camp’ right away. 20 years ago I did injure my left foot at exactly that same spot during track and field (I think is was either high jumping or running hurdles). I iced it with an ice spray so I didn’t have to postpone my final exam for my Master’s by another 6 months. In hintsight definitely a bad decision.
Oh, I was missing the exam. So no loose body in the ankle, but a loose body in the subtalar joint. 2 different areas. Well, the bad news is that you can’t “scope” the subtalar joint (too small, although there are a few crazies around the country who claim to be able to do this) - I sure can’t/won’t. I’m reading into this a lot, but it seems like you have some major rearfoot instability issues with some early degenerative osteoarthritis setting in (the talo-navicular and subtalar joints). Yes, orthotics and the like are not a bad idea to start with. Surgery for these kinds of issues/instability is for salvage only, not restorative - so absolutely last resort as you will not run a marathon again after that (just google triple arthrodesis to see what I’m speaking of).
I will absolutely look/ask around for a bone stim for 'ya if I can - you are about 1 week to late
I live in Pennsylvania. I can’t remember the bone stimulator company, but I can get this for you.
I was non-weight bearing for my rehab, until I had no pain. You want this thing to heal right, but unfortunately, this is what most good docs recommend.
I also swam and weight lifted like you. Read anything by any athlete who dealt with injury rehab or illness. That helped tremendously. I didn’t race tris the following summer, even though I probably could have done so.
Again, I understand totally what you are going through with this one.
One more thing. I swear by orthotics. I have a high arch, which I was told predisposes me to navicular injury. After I was off crutches, I used a walking boot which I actually put a custom orthotic in to take the stress off the navicular bone with walking. I used one crutch and then progressed to no crutches. The orthotic I use now is a different one.
Is all that swimming I’m doing possibly too much? My other problem is that since I’m back on the crutches my other foot started hurting again at the navicular joint as well. I asked the doctor to have it x-rayed. But since nothing was visible he refused to order an MRI. I want to make sure that by the time the left foot is healed I don’t have to get off my right one. Any thoughts?
Sure, you have some DJD (arthritis) in both joints, poor foot mechanics (likely a high arched foot) and now you are stressing the contralateral foot. Is swimming too much? If you can feel it then yes.
Again, as in my first reponse (and from the 2 others that had these), these are usually treated NON WEIGHTBEARING and I often cast athletes that I think won’t slow down (you - and I would do the same damn thing too).
Thanks. That would be great. I live in Florida, just in case they have a sister company down here.
I’m not sure if I should even consider racing in 2007 and just play it by ear. However, as you well know, you have to sign up for some of those races so far in advance. Which, obviously, at this point I don’t want to do. Also from a mental perspective it might be devastating if you have to cancel one race after the other OR being tempted to race even though the foot is not even healed yet. So, reading articles about rehab for the type of injury I have is definitely a good idea. Will do.
By the way, I am not pushing off the wall with my left foot. And swimming (I mainly breast stroke to give my legs a better workout) does not hurt. Thank goodness!
I did develop a mild plantar fascitis on my good foot while on crutches. Biomechnical changes affecting the other side. This did resolve however.
I remember being overly focused on my injury. When I was ambulating without a boot or crutches, I was hypersensitive to every ache. Undergoing PT, there will be some aching. I would get totally bummed at the smallest things. It was a real learning experience. I think you need to be patient with healing. If you do it correctly, your injury should heal
I talked to a PT guy yesterday, and he gave me hope that my insurance might cover a bone stimulator. So, I’ll try to get an answer from them today. It seems that the cyste in the bone structure might be the biggest obstacle. Is there anything else that can be done? It seems that it will continue weakening the bone/joint.
We see cystic changes in bones all the time on MRI around joints everywhere. They usually are related to degenerative change, wear and tear, that we all get. I have them and they aren’t symptomatic in my case. I think they are usually a concern if they are big or associated with tumor or tumor-like conditions that can predispose to fracture. They can be associated with inflammatory arthritis disorders too. Do you know the size of the cysts? From what you are saying so far, I would think they are degenerative.
I Googled “triple arthrodesis” and after reading all the info on it, I wouldn’t have that procedure done unless it was just impossible to walk!! No way!!! That’s even worse then what one of the podiatrist wanted to do, “a complete overhaul” as referenced before.
I think tho, you have hit on something. When I got my orthotics, just before IMC, the main function of them was to control heel instability, as you had mentioned. I more or less walked/ran the marathon at IMC, with the help of ibuprofen, to get thru it w/o any difficulties. I’ve had them now for approx 11 weeks and since have weened myself off ibuprofen. I’ve also included some ankle and arch exercises in my daily routine. I’m back to running around 2 to 3 miles a day with no pain in the ankle or subtalar joint. I will VERY SLOWLY increase my mileage over the winter months and see how it goes. Hopefully, the orthotics and ankle/arch exercices take care of the problem.
