Post-Op Orthotic Considerations For An Athlete After Bilateral Navicular Fractures

I want to talk about an interesting case I had in my office late last year. A 20-year-old female Division 1 athlete presented after she had surgery for bilateral navicular fractures. She is a 400-meter sprinter and started having pain and swelling in her midfoot very suddenly and quickly in the fall of 2018. There was no specific trauma or overtraining that she was aware of, and no apparent issues with her medical history, calcium or vitamin D levels. Magnetic resonance imaging confirmed the fractures and another physician performed open reduction and screw fixation bilaterally. She was seeing me so she could obtain custom orthotics and be evaluated for rehabilitation and resumption of training.

At her initial visit, I performed an evaluation along with video and pressure mapping gait analysis, both walking and running. We discussed her training and competition shoes, and rated the comfort level of each. She had some Nikes that were the most comfortable, some Nike Free shoes that were less comfortable and her Nike spikes that hurt her no matter what. We determined that her Nike Free shoes were much too flexible for her needs. The spikes were conversely too rigid and the toe plate was in such a position that it caused dorsiflexion of her first metatarsal and overloading of the hallux during use. 

During her evaluation, I determined she had a long first metatarsal, functional hallux limitus of five cm or greater and some additional eversion issues at her heel. She also had moderate limitation of her ankle joint dorsiflexion or ankle joint equinus. Her X-rays showed good static images of her rearfoot with a good calcaneal inclination angle in stance. However, the first ray was definitely starting to dorsiflex in those X-ray images as well.

Her results from the pressure mapping exam showed very low pressures under the first MPJ and hallux bilaterally. She exhibited high pressures under the second, third and fourth MPJs bilaterally and at her heels as one can see in the image below.

We were using a pressure mat from RSscan International at the time and not in-shoe insoles. Either can work for testing a pre-orthotic prescription though if you think it through. I decided that I wanted to test her with a three mm heel lift bilaterally, two degrees of rearfoot varus posting of her left heel and three mm of digital elevation (essentially a pad under her hallux). I used Low Dye taping with planar rest straps as well. I used these prescription elements to expressly address her equinus, functional hallux limitus and moderate pronation issues at her rearfoot. 

We then had her walk and run over the pressure mat again to see if these adjustments made any difference. Immediately, the timing of her accelerations right versus left improved bilaterally. Her force versus time curves improved as well, especially in the forefoot and under the first MPJ. We also saw a huge decrease in the overall forefoot and heel pressures, and an increase in the pressure under the first MPJ and hallux as one can see in the image below. 

The patient did well initially with the change in shoes and the use of her new foot orthotics. We made her a pair for regular everyday wear and use in her training shoes as well as some for her sprint spikes. We also suggested that the athletictrainers take a hacksaw to the rigid plastic foot plate on the plantar aspect of her spikes. Seriously, I suggested that they make a curved cut, just enough to allow some increased flexibility in that area. My hope is that this modification further decreases her forefoot pressures and that it might also allow her to run a little faster or, at the very least, without as much pain.

I will discuss navicular fractures and the relevant biomechanics further in my next blog. Outside of plentiful cases of surgical repair, there is very little literature on the biomechanics of these injuries. 

Have a great summer and please comment below if you have any questions or thoughts on this case.

Dr. Williams is a Past President and Fellow of the American Academy of Podiatric Sports Medicine. He is the Director of Breakthrough Sports Performance, LLC in Chicago. Dr. Williams has disclosed that is the Medical Director for Go 4-D and a consultant for HP FitStation.