Rehabbing a broken foot is no small task, and navicular stress fractures (NSFs) are particularly challenging. My last blog covered considerations of deciding on surgery or going the conservative route. Today, let’s focus on the critical elements of a successful rehab program.
Key Principle One: Absolute Rest
NSFs require absolute rest whether you have surgery or not. Complete non-weight bearing in a caste likely gives you the best chance of avoiding surgery. Runners who attempt conservative rehab but don’t go fully non-weight-bearing for six weeks have a much higher chance of needing surgery.
If you choose a surgical solution, you must respect the healing timeline of having a pin screwed into your broken foot. This likely means at least 12 weeks after surgery until you can walk around in your normal kicks.
Both situations require rest, but absolute rest comes with disadvantages.
There are “dose-dependent” skeletal deficits to modifying your weight-bearing. Specifically, your bones get less dense and at a greater chance of fracture. Your bones get weaker when you are on crutches, on a rolling scooter, or in a walking boot. Rest allows the injury to heal but puts your tissues in a worse spot physically when you return to exercise. This makes exercise prescription even more crucial because your bones are likely physically worse than before the injury.
Key Principle Two: Stress Specific Tissues
Your navicular specifically and your foot globally deal with various forces during running. The three-dimensional motion of pronation and supination places significant stress on your navicular. Bone only gets stronger if you load it, and you need to load it with the demands it has to deal with in the future. These stresses should slowly blend into a strength routine that continues to load the healed area in the future.
You can mimic this motion by incorporating various single-leg exercises during recovery. Just doing single-leg exercises is not enough! These need to be progressed throughout recovery with more weight and faster movement speed.
Below is a sample progression of three of my favorite exercises with video demos. I regularly include these before a runner begins their run progression.
(Timelines reflect how long they’ve been fully weight-bearing)
Exercise Progression One: Resisted Plantar Flexion
Exercise Progression Two: Single Leg Romanian Deadlifts (RDLs)
Exercise Progression Three: Rear-foot Elevated Split Squats (RFESS)
Key Principle Three: Some Pain May be Necessary
Stress fracture rehab should be completely pain-free —with NSFs being an exception.
Most patients still have some low-level pain even a decade after injury. Inconsistent, low-level pain is probably acceptable if it isn’t limiting your ability to complete your day-to-day tasks and run. This doesn’t give you the green light to push through every bit of pain but should provide reassurance that some low-level pain doesn’t indicate another injury.
Symptoms should be low-level, unchanging (stable), and not affecting day-to-day tasks. Continuing to have low-level soreness with palpating the injury site is also expected and not an indicator of regression or another injury.
At the end of the day, if a sensation is concerning, don’t push through it!
Thanks for taking the time to read. If you found this helpful, grab a copy of my Guidebook to Running After a Stress Fracture below. I break down all the key considerations of a successful rehab and how to navigate running, training, and competition after injury! You can grab a copy by clicking on the image below!
-Nathan Carlson, PT DPT USATF
References:
- Gross T, Venn-Watson E, Rossman T et al. Tarsal Navicular Stress Fractures in Runners. AJR 136: 201-203, 1981.
- Ko F, Riveros D, Nagy D et al. Dose-dependent skeletal deficits due to varied reductions in
- Nunley J, Green C, Morash J et al. Treatment of Navicular Stress Fractures with an Algorithmic Approach. Foot & Ankle International® 2022, Vol. 43(1) 12–20.
- Torg J, Moyer J, Gaughan J et al. Management of Tarsal Navicular Stress Fractures: Conservative Versus Surgical Treatment: a Meta-Analysis. Am J Sports Med 38:1048–1053.
- Potter N, Brukner P, Makdissi M et al. Navicular Stress Fractures: Outcomes of Surgical and Conservative Management. Br J Sports Med 40:692–695.
- Attia A, Mahoud K, Baritea J, et al. Return to Sport Following Navicular Stress Fracture: A Systematic Review and Meta Analysis of Three Hundred and Fifteen Fractures. International Orthopaedics (2021) 45:2699-2710.
- Khan K, Fuller P, Brukner P et al. Outcome of conservative and surgical management of navicular stress fracture in athletes. Eighty-six cases proven with computerized tomography. Am J Sports Med.1992. 20(6):657-66mechanical loading in rats. Microgravity (2020)6;15.