Tarsal navicular is a wedge-shaped bone in the center of the foot that is critical for foot biomechanics and load transfer. It joins the hindfoot and forefoot in the center and connect with the talus, three cuneiforms and occasionally the cuboid. It aids in inversion and eversion while also maintaining the foot’s medial longitudinal arch.
Because of its restricted blood supply and substantial articular cartilage covering, it is particularly vulnerable to injury consequences. Despite their rarity, tarsal navicular fractures are clinically relevant because to the high likelihood of nonunion, malunion and osteonecrosis. These fractures are induced by acute trauma and recurrent stress in young, active persons. Imaging technologies like CT and MRI have improved diagnostic accuracy and enabled early intervention.
Epidemiology
Navicular stress fractures are common in populations like competitive athletes and military recruits. Up to 21% of track and field athletes may suffer a stress fracture each year with 15% of these injuries occurring in the navicular. The most frequent causes are high-energy mechanisms like blunt trauma, falls and auto accidents. Sport participation and activity intensity have a stronger global correlation with the distribution of navicular stress fractures than geographic region which suggest that repetitive mechanical stress plays a major role in their development.
Anatomy
Pathophysiology
Navicular stress fractures are overuse injuries which are produced by repeated tension and result in the microfractures in bone. These fractures are caused by a variety of causes like excessive training load, inadequate recuperation and poor fitness. Avulsion, tuberosity and body fractures are more correct terms for traumatic navicular fractures. Avulsion fractures can occur on the dorsal, medial or plantar sides of the navicular on the basis of the direction and severity of the trauma. Excessive traction of the posterior tibial tendon causes medial and tuberosity fractures whereas extreme plantar flexion stresses the dorsal capsule and deltoid ligament, causing dorsal avulsions. Axial loading or direct impact can cause body fractures.
Classification of Navicular Body Fractures
Sangeorzan et al.’s classification system for navicular body fractures categorizes them into Type I, Type II and Type III. Type I is a simple coronal-plane fracture without forefoot angulation or displacement. Type II is a dorsolateral-to-plantarmedial fracture line with medial displacement of the main fragment and forefoot. Type III is a comminuted sagittal-plane fracture with lateral displacement of the forefoot, with the poorest prognosis. This classification aids in surgical decision and prognosis.
Etiology
Trauma and stress-related causes can also produce navicular fractures. Traumatic fracture results from the high energy traumas like car accidents or fall that disturb the navicular joint. When repeated overloading exceeds the bone’s capacity to repair itself, stress fractures result. Unexpected changes in running surfaces, high training intensity, poorly fitting footwear and inadequate conditioning all increase the risk of stress fracture formation.
Intrinsic factors like female athletes with menstrual irregularities, limb-length discrepancies, biomechanical abnormalities and systemic conditions like hypothyroidism, rheumatoid arthritis and relative osteopenia contribute to fracture risk. Lifestyle factors like smoking, chronic steroid use and weight loss negatively affect the bone remodeling and contribute to fracture risk.
Genetics
Prognostic Factors
The prognosis of navicular fractures is dependent on timely diagnosis and proper treatment. A planned rehabilitation program and a normal 6-week non-weight-bearing regimen allow about 86% of patients to resume their previous level of activity. Post-traumatic arthritis, deformity and chronic pain are all potential results of problems such as delayed union, nonunion, malunion and osteonecrosis.
Because of the navicular’s restricted vascular supply, osteonecrosis is especially difficult to treat and can result in severe deformity that necessitates joint fusion. Functional impairment brought on by nonunion may occasionally necessitate surgical correction.
Clinical History
Navicular fractures can present with variable clinical features depending on whether the injury is acute and traumatic or the result of repetitive stress.
Navicular Stress Fractures: Navicular stress fractures might last for weeks or months before being diagnosed. Physical activity increases the discomfort while relaxation relieves it. Patients may feel soreness on the foot’s dorsum or along the medial longitudinal arch. Swelling is mild or nonexistent and physical exams typically reveal discomfort around the navicular midportion. Diagnosis is frequently delayed owing to mild symptoms. Navigational stress fractures are more prevalent in activities involving repeated midfoot loading like track and field events, ballet, gymnastics, basketball, soccer, rugby, equestrian sports and military recruitment.
Navicular Body and Avulsion Fractures: Acute traumatic injuries like navicular body or avulsion fractures can produce significant midfoot discomfort and functional impairment. The examination reveals edema over the dorsal and medial regions of the foot which indicate medial column dislocation. Avulsion injuries generate severe agony whereas body fractures result in serious functional disability. A complete neurovascular examination is required owing to the danger of compartment syndrome.
Physical Examination
A systematic clinical assessment is crucial for guiding imaging and management decisions in patients with navicular fractures. Key findings include point tenderness at the “N spot,” localized tenderness over the mid-medial arch, pain with passive and active inversion of the foot, reproducible pain during hopping maneuvers, and mild dorsal midfoot swelling, which may or may not be present depending on the fracture type and severity.
Imaging Evaluation: The initial radiographic assessment for a tarsal navicular fracture involves a standard three-view series of the foot, including non-weight-bearing anteroposterior, lateral, and oblique radiographs. Weight-bearing radiographs may reveal subtle joint instability in minor or ligamentous injuries. External oblique radiographs are useful for tuberosity fracture evaluation. Clinicians should be mindful of normal anatomical variants and compare findings with contralateral foot radiographs to identify accessory navicular bones. Computed tomography (CT) is particularly valuable for high-energy trauma cases, as it allows precise delineation of complex fracture morphology and assessment of the talonavicular joint surface.
Age group
Associated comorbidity
Associated activity
Navicular fractures are caused by repetitive, high-impact or forceful activities that stress the midfoot particularly across the medial longitudinal arch. Athletes, ballet dancers, and athletes are at the highest risk, with stress fractures common in track and field competitors, ballet dancers and sports like basketball, soccer, rugby and American or Australian-rules football. Gymnasts, equestrians and military recruits also experience navicular injuries due to repetitive axial loading, high-impact landings, or endurance marching. Body fractures and avulsion injuries are more commonly associated with acute high-energy trauma like falls from height, motor vehicle collisions or direct impact during contact sports.
Acuity of presentation
Navicular stress fractures typically present insidiously with symptoms progressing gradually over weeks to months. Patients often experience vague midfoot discomfort or aching, worsening with physical activity and improving with rest. Acute navicular body or avulsion fractures usually present dramatically following a specific traumatic event, causing sudden, severe pain in the midfoot, swelling, bruising and an inability to bear weight. In high-energy cases, significant swelling, ecchymosis and open wounds may be noted, necessitating urgent evaluation for complications like compartment syndrome. Recognizing the difference between stress-related injury and acute traumatic fracture is crucial.
Differential Diagnoses
Metatarsalgia
Ankle Fracture in Sports Medicine
Metatarsal Stress Fracture
Ankle Sprain
Contusions
Athletic Foot Injuries
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Treatment Paradigm
Initial Assessment and Stabilization: A complete clinical assessment includes history, mechanism of injury, physical examination and neurovascular status evaluation, is the first step in management. A splint or cast must be used to immobilize the injured foot and prevent additional displacement while providing instant pain relief.
Pain Management: Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are administered to control the pain and inflammation during the acute phase.
Diagnostic Imaging: Radiographic evaluation with plain X-rays is the first step, followed by computed tomography (CT) in complex or high-energy injuries to delineate fracture patterns and assist in preoperative planning.
Non-Surgical Management: Navicular Stress Fractures are typically treated with immobilization and protected weight-bearing for 6 to 8 weeks. Patients are continuously evaluated for evidence of recovery and the remission of symptoms. Small avulsion fractures, tuberosity fractures and nondisplaced navicular body fractures can be conservatively treated with a short leg cast and walking boot.
Surgical Management: It is recommended for patients with displaced navicular body fractures or those with strong functional needs, such sportsmen. The standard approach is open reduction and internal fixation (ORIF) which aims to restore anatomic alignment maintain medial column length and create a stable construct for early range of motion. Surgery is required for comminuted fractures or failure of conservative management.
Rehabilitation and Physical Therapy: Patients who have been immobilized or undergone surgery require systematic rehabilitation. Physical therapy aims to restore ankle and midfoot strength, flexibility and functional mobility. Gradual advancement to weight-bearing exercises is encouraged under supervision.
Monitoring and Follow-Up: Regular clinical and radiological follow-up is required to monitor fracture healing, discover problems such non-union or avascular necrosis and alter treatment as necessary.
Nutritional and Lifestyle Support: A balanced diet with adequate calcium and vitamin D supports bone healing. Patients are recommended to avoid smoking and heavy alcohol use as these substances hinder bone healing.
Use of NSAID’s to manage Navicular Fractures
In most cases of navicular stress fractures, immobilization and strict rest substantially reduce discomfort, and first-line therapy with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen is often sufficient for acute pain control. Persistent pain throughout the recovery period indicates insufficient healing or the existence of the fracture.
Ibuprofen: It is used for mild pain. It inhibits the inflammatory reaction and pain by reducing prostaglandin synthesis.
Naproxen: This NSAID is effective to manage fracture-related pain. It works by reducing inflammation at the fracture site and in adjacent soft tissues, thereby helping to relieve discomfort and improve patient mobility during recovery.
Use of Analgesics to manage Navicular Fractures
If pain relief is inadequate with NSAIDs, escalation should be considered. In select cases, particularly when patients experience severe or breakthrough pain, short courses of opioid analgesics (e.g., oxycodone) may be prescribed to ensure adequate comfort, particularly during the acute phase of injury. Opioid use should remain carefully limited and monitored, given the risk of dependence and side effects.
Acetaminophen: It is indicated for moderate pain. It provides effective pain relief, is safe for repeated/long-term use and does not interfere with bone healing.
Use of Nutritional Supplements to manage Navicular Fractures
Calcium and Vitamin D: These are essential to maintain the bone strength. Calcium is necessary component of bone structure. Vitamin D promotes calcium absorption. Calcium and vitamin D supplementation is usually recommended for those who have an insufficient diet and malabsorption issues or are at risk of osteoporosis. Proper amounts of essential nutrients helps to retain the bone density and reduces the risk of fractures specifically in the older population.
Use of Intervention to manage Navicular Fractures
Operative management of navicular fractures is generally reserved for fractures that are displaced, intra-articular, involve avulsion fragments, or compromise more than 25% of the articular surface. The goal of surgery is to restore the anatomical alignment of the navicular, maintain the integrity of the medial column of the foot, and preserve joint function while minimizing long-term complications such as arthritis, non-union, or chronic pain.
Open Reduction and Internal Fixation (ORIF): Open Reduction and Internal Fixation (ORIF) is a procedure used for navicular body fractures, intra-articular fractures, or those affecting joint congruity. The fracture site is exposed through a dorsal or dorsomedial incision, and fracture fragments are reduced to restore normal navicular shape. Internal fixation is achieved using screws, plates, or a combination. Postoperative care involves non-weight bearing for 6-8 weeks, gradually progressing to partial and full weight-bearing as healing is confirmed radiographically.
Fragment excision: It is a surgical procedure used to remove avulsed fragments that remain symptomatic despite conservative treatment or develop non-union. This reduces pain and mechanical obstruction without compromising midfoot stability.
Primary fusion: It is a procedure used for severe comminution, collapse of the navicular, chronic fractures, or non-union where reconstruction is not feasible. This involves fusion of the navicular with adjacent bones to provide a stable medial column, aiming to restore foot stability, alleviate pain, and prevent progressive deformity.
External fixation: It is utilized for complicated navicular fractures caused by significant soft tissue injury, high-energy trauma, or when fast internal fixation is not an option.
Tarsal navicular is a wedge-shaped bone in the center of the foot that is critical for foot biomechanics and load transfer. It joins the hindfoot and forefoot in the center and connect with the talus, three cuneiforms and occasionally the cuboid. It aids in inversion and eversion while also maintaining the foot’s medial longitudinal arch.
Because of its restricted blood supply and substantial articular cartilage covering, it is particularly vulnerable to injury consequences. Despite their rarity, tarsal navicular fractures are clinically relevant because to the high likelihood of nonunion, malunion and osteonecrosis. These fractures are induced by acute trauma and recurrent stress in young, active persons. Imaging technologies like CT and MRI have improved diagnostic accuracy and enabled early intervention.
Navicular stress fractures are common in populations like competitive athletes and military recruits. Up to 21% of track and field athletes may suffer a stress fracture each year with 15% of these injuries occurring in the navicular. The most frequent causes are high-energy mechanisms like blunt trauma, falls and auto accidents. Sport participation and activity intensity have a stronger global correlation with the distribution of navicular stress fractures than geographic region which suggest that repetitive mechanical stress plays a major role in their development.
Navicular stress fractures are overuse injuries which are produced by repeated tension and result in the microfractures in bone. These fractures are caused by a variety of causes like excessive training load, inadequate recuperation and poor fitness. Avulsion, tuberosity and body fractures are more correct terms for traumatic navicular fractures. Avulsion fractures can occur on the dorsal, medial or plantar sides of the navicular on the basis of the direction and severity of the trauma. Excessive traction of the posterior tibial tendon causes medial and tuberosity fractures whereas extreme plantar flexion stresses the dorsal capsule and deltoid ligament, causing dorsal avulsions. Axial loading or direct impact can cause body fractures.
Classification of Navicular Body Fractures
Sangeorzan et al.’s classification system for navicular body fractures categorizes them into Type I, Type II and Type III. Type I is a simple coronal-plane fracture without forefoot angulation or displacement. Type II is a dorsolateral-to-plantarmedial fracture line with medial displacement of the main fragment and forefoot. Type III is a comminuted sagittal-plane fracture with lateral displacement of the forefoot, with the poorest prognosis. This classification aids in surgical decision and prognosis.
Trauma and stress-related causes can also produce navicular fractures. Traumatic fracture results from the high energy traumas like car accidents or fall that disturb the navicular joint. When repeated overloading exceeds the bone’s capacity to repair itself, stress fractures result. Unexpected changes in running surfaces, high training intensity, poorly fitting footwear and inadequate conditioning all increase the risk of stress fracture formation.
Intrinsic factors like female athletes with menstrual irregularities, limb-length discrepancies, biomechanical abnormalities and systemic conditions like hypothyroidism, rheumatoid arthritis and relative osteopenia contribute to fracture risk. Lifestyle factors like smoking, chronic steroid use and weight loss negatively affect the bone remodeling and contribute to fracture risk.
The prognosis of navicular fractures is dependent on timely diagnosis and proper treatment. A planned rehabilitation program and a normal 6-week non-weight-bearing regimen allow about 86% of patients to resume their previous level of activity. Post-traumatic arthritis, deformity and chronic pain are all potential results of problems such as delayed union, nonunion, malunion and osteonecrosis.
Because of the navicular’s restricted vascular supply, osteonecrosis is especially difficult to treat and can result in severe deformity that necessitates joint fusion. Functional impairment brought on by nonunion may occasionally necessitate surgical correction.
Navicular fractures can present with variable clinical features depending on whether the injury is acute and traumatic or the result of repetitive stress.
Navicular Stress Fractures: Navicular stress fractures might last for weeks or months before being diagnosed. Physical activity increases the discomfort while relaxation relieves it. Patients may feel soreness on the foot’s dorsum or along the medial longitudinal arch. Swelling is mild or nonexistent and physical exams typically reveal discomfort around the navicular midportion. Diagnosis is frequently delayed owing to mild symptoms. Navigational stress fractures are more prevalent in activities involving repeated midfoot loading like track and field events, ballet, gymnastics, basketball, soccer, rugby, equestrian sports and military recruitment.
Navicular Body and Avulsion Fractures: Acute traumatic injuries like navicular body or avulsion fractures can produce significant midfoot discomfort and functional impairment. The examination reveals edema over the dorsal and medial regions of the foot which indicate medial column dislocation. Avulsion injuries generate severe agony whereas body fractures result in serious functional disability. A complete neurovascular examination is required owing to the danger of compartment syndrome.
A systematic clinical assessment is crucial for guiding imaging and management decisions in patients with navicular fractures. Key findings include point tenderness at the “N spot,” localized tenderness over the mid-medial arch, pain with passive and active inversion of the foot, reproducible pain during hopping maneuvers, and mild dorsal midfoot swelling, which may or may not be present depending on the fracture type and severity.
Imaging Evaluation: The initial radiographic assessment for a tarsal navicular fracture involves a standard three-view series of the foot, including non-weight-bearing anteroposterior, lateral, and oblique radiographs. Weight-bearing radiographs may reveal subtle joint instability in minor or ligamentous injuries. External oblique radiographs are useful for tuberosity fracture evaluation. Clinicians should be mindful of normal anatomical variants and compare findings with contralateral foot radiographs to identify accessory navicular bones. Computed tomography (CT) is particularly valuable for high-energy trauma cases, as it allows precise delineation of complex fracture morphology and assessment of the talonavicular joint surface.
Navicular stress fractures typically present insidiously with symptoms progressing gradually over weeks to months. Patients often experience vague midfoot discomfort or aching, worsening with physical activity and improving with rest. Acute navicular body or avulsion fractures usually present dramatically following a specific traumatic event, causing sudden, severe pain in the midfoot, swelling, bruising and an inability to bear weight. In high-energy cases, significant swelling, ecchymosis and open wounds may be noted, necessitating urgent evaluation for complications like compartment syndrome. Recognizing the difference between stress-related injury and acute traumatic fracture is crucial.
Navicular fractures are caused by repetitive, high-impact or forceful activities that stress the midfoot particularly across the medial longitudinal arch. Athletes, ballet dancers, and athletes are at the highest risk, with stress fractures common in track and field competitors, ballet dancers and sports like basketball, soccer, rugby and American or Australian-rules football. Gymnasts, equestrians and military recruits also experience navicular injuries due to repetitive axial loading, high-impact landings, or endurance marching. Body fractures and avulsion injuries are more commonly associated with acute high-energy trauma like falls from height, motor vehicle collisions or direct impact during contact sports.
Metatarsalgia
Ankle Fracture in Sports Medicine
Metatarsal Stress Fracture
Ankle Sprain
Contusions
Athletic Foot Injuries
Treatment Paradigm
Initial Assessment and Stabilization: A complete clinical assessment includes history, mechanism of injury, physical examination and neurovascular status evaluation, is the first step in management. A splint or cast must be used to immobilize the injured foot and prevent additional displacement while providing instant pain relief.
Pain Management: Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are administered to control the pain and inflammation during the acute phase.
Diagnostic Imaging: Radiographic evaluation with plain X-rays is the first step, followed by computed tomography (CT) in complex or high-energy injuries to delineate fracture patterns and assist in preoperative planning.
Non-Surgical Management: Navicular Stress Fractures are typically treated with immobilization and protected weight-bearing for 6 to 8 weeks. Patients are continuously evaluated for evidence of recovery and the remission of symptoms. Small avulsion fractures, tuberosity fractures and nondisplaced navicular body fractures can be conservatively treated with a short leg cast and walking boot.
Surgical Management: It is recommended for patients with displaced navicular body fractures or those with strong functional needs, such sportsmen. The standard approach is open reduction and internal fixation (ORIF) which aims to restore anatomic alignment maintain medial column length and create a stable construct for early range of motion. Surgery is required for comminuted fractures or failure of conservative management.
Rehabilitation and Physical Therapy: Patients who have been immobilized or undergone surgery require systematic rehabilitation. Physical therapy aims to restore ankle and midfoot strength, flexibility and functional mobility. Gradual advancement to weight-bearing exercises is encouraged under supervision.
Monitoring and Follow-Up: Regular clinical and radiological follow-up is required to monitor fracture healing, discover problems such non-union or avascular necrosis and alter treatment as necessary.
Nutritional and Lifestyle Support: A balanced diet with adequate calcium and vitamin D supports bone healing. Patients are recommended to avoid smoking and heavy alcohol use as these substances hinder bone healing.
Use of NSAID’s to manage Navicular Fractures
In most cases of navicular stress fractures, immobilization and strict rest substantially reduce discomfort, and first-line therapy with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen is often sufficient for acute pain control. Persistent pain throughout the recovery period indicates insufficient healing or the existence of the fracture.
Ibuprofen: It is used for mild pain. It inhibits the inflammatory reaction and pain by reducing prostaglandin synthesis.
Naproxen: This NSAID is effective to manage fracture-related pain. It works by reducing inflammation at the fracture site and in adjacent soft tissues, thereby helping to relieve discomfort and improve patient mobility during recovery.
Use of Analgesics to manage Navicular Fractures
If pain relief is inadequate with NSAIDs, escalation should be considered. In select cases, particularly when patients experience severe or breakthrough pain, short courses of opioid analgesics (e.g., oxycodone) may be prescribed to ensure adequate comfort, particularly during the acute phase of injury. Opioid use should remain carefully limited and monitored, given the risk of dependence and side effects.
Acetaminophen: It is indicated for moderate pain. It provides effective pain relief, is safe for repeated/long-term use and does not interfere with bone healing.
Use of Nutritional Supplements to manage Navicular Fractures
Calcium and Vitamin D: These are essential to maintain the bone strength. Calcium is necessary component of bone structure. Vitamin D promotes calcium absorption. Calcium and vitamin D supplementation is usually recommended for those who have an insufficient diet and malabsorption issues or are at risk of osteoporosis. Proper amounts of essential nutrients helps to retain the bone density and reduces the risk of fractures specifically in the older population.
Use of Intervention to manage Navicular Fractures
Operative management of navicular fractures is generally reserved for fractures that are displaced, intra-articular, involve avulsion fragments, or compromise more than 25% of the articular surface. The goal of surgery is to restore the anatomical alignment of the navicular, maintain the integrity of the medial column of the foot, and preserve joint function while minimizing long-term complications such as arthritis, non-union, or chronic pain.
Open Reduction and Internal Fixation (ORIF): Open Reduction and Internal Fixation (ORIF) is a procedure used for navicular body fractures, intra-articular fractures, or those affecting joint congruity. The fracture site is exposed through a dorsal or dorsomedial incision, and fracture fragments are reduced to restore normal navicular shape. Internal fixation is achieved using screws, plates, or a combination. Postoperative care involves non-weight bearing for 6-8 weeks, gradually progressing to partial and full weight-bearing as healing is confirmed radiographically.
Fragment excision: It is a surgical procedure used to remove avulsed fragments that remain symptomatic despite conservative treatment or develop non-union. This reduces pain and mechanical obstruction without compromising midfoot stability.
Primary fusion: It is a procedure used for severe comminution, collapse of the navicular, chronic fractures, or non-union where reconstruction is not feasible. This involves fusion of the navicular with adjacent bones to provide a stable medial column, aiming to restore foot stability, alleviate pain, and prevent progressive deformity.
External fixation: It is utilized for complicated navicular fractures caused by significant soft tissue injury, high-energy trauma, or when fast internal fixation is not an option.
Tarsal navicular is a wedge-shaped bone in the center of the foot that is critical for foot biomechanics and load transfer. It joins the hindfoot and forefoot in the center and connect with the talus, three cuneiforms and occasionally the cuboid. It aids in inversion and eversion while also maintaining the foot’s medial longitudinal arch.
Because of its restricted blood supply and substantial articular cartilage covering, it is particularly vulnerable to injury consequences. Despite their rarity, tarsal navicular fractures are clinically relevant because to the high likelihood of nonunion, malunion and osteonecrosis. These fractures are induced by acute trauma and recurrent stress in young, active persons. Imaging technologies like CT and MRI have improved diagnostic accuracy and enabled early intervention.
Navicular stress fractures are common in populations like competitive athletes and military recruits. Up to 21% of track and field athletes may suffer a stress fracture each year with 15% of these injuries occurring in the navicular. The most frequent causes are high-energy mechanisms like blunt trauma, falls and auto accidents. Sport participation and activity intensity have a stronger global correlation with the distribution of navicular stress fractures than geographic region which suggest that repetitive mechanical stress plays a major role in their development.
Navicular stress fractures are overuse injuries which are produced by repeated tension and result in the microfractures in bone. These fractures are caused by a variety of causes like excessive training load, inadequate recuperation and poor fitness. Avulsion, tuberosity and body fractures are more correct terms for traumatic navicular fractures. Avulsion fractures can occur on the dorsal, medial or plantar sides of the navicular on the basis of the direction and severity of the trauma. Excessive traction of the posterior tibial tendon causes medial and tuberosity fractures whereas extreme plantar flexion stresses the dorsal capsule and deltoid ligament, causing dorsal avulsions. Axial loading or direct impact can cause body fractures.
Classification of Navicular Body Fractures
Sangeorzan et al.’s classification system for navicular body fractures categorizes them into Type I, Type II and Type III. Type I is a simple coronal-plane fracture without forefoot angulation or displacement. Type II is a dorsolateral-to-plantarmedial fracture line with medial displacement of the main fragment and forefoot. Type III is a comminuted sagittal-plane fracture with lateral displacement of the forefoot, with the poorest prognosis. This classification aids in surgical decision and prognosis.
Trauma and stress-related causes can also produce navicular fractures. Traumatic fracture results from the high energy traumas like car accidents or fall that disturb the navicular joint. When repeated overloading exceeds the bone’s capacity to repair itself, stress fractures result. Unexpected changes in running surfaces, high training intensity, poorly fitting footwear and inadequate conditioning all increase the risk of stress fracture formation.
Intrinsic factors like female athletes with menstrual irregularities, limb-length discrepancies, biomechanical abnormalities and systemic conditions like hypothyroidism, rheumatoid arthritis and relative osteopenia contribute to fracture risk. Lifestyle factors like smoking, chronic steroid use and weight loss negatively affect the bone remodeling and contribute to fracture risk.
The prognosis of navicular fractures is dependent on timely diagnosis and proper treatment. A planned rehabilitation program and a normal 6-week non-weight-bearing regimen allow about 86% of patients to resume their previous level of activity. Post-traumatic arthritis, deformity and chronic pain are all potential results of problems such as delayed union, nonunion, malunion and osteonecrosis.
Because of the navicular’s restricted vascular supply, osteonecrosis is especially difficult to treat and can result in severe deformity that necessitates joint fusion. Functional impairment brought on by nonunion may occasionally necessitate surgical correction.
Navicular fractures can present with variable clinical features depending on whether the injury is acute and traumatic or the result of repetitive stress.
Navicular Stress Fractures: Navicular stress fractures might last for weeks or months before being diagnosed. Physical activity increases the discomfort while relaxation relieves it. Patients may feel soreness on the foot’s dorsum or along the medial longitudinal arch. Swelling is mild or nonexistent and physical exams typically reveal discomfort around the navicular midportion. Diagnosis is frequently delayed owing to mild symptoms. Navigational stress fractures are more prevalent in activities involving repeated midfoot loading like track and field events, ballet, gymnastics, basketball, soccer, rugby, equestrian sports and military recruitment.
Navicular Body and Avulsion Fractures: Acute traumatic injuries like navicular body or avulsion fractures can produce significant midfoot discomfort and functional impairment. The examination reveals edema over the dorsal and medial regions of the foot which indicate medial column dislocation. Avulsion injuries generate severe agony whereas body fractures result in serious functional disability. A complete neurovascular examination is required owing to the danger of compartment syndrome.
A systematic clinical assessment is crucial for guiding imaging and management decisions in patients with navicular fractures. Key findings include point tenderness at the “N spot,” localized tenderness over the mid-medial arch, pain with passive and active inversion of the foot, reproducible pain during hopping maneuvers, and mild dorsal midfoot swelling, which may or may not be present depending on the fracture type and severity.
Imaging Evaluation: The initial radiographic assessment for a tarsal navicular fracture involves a standard three-view series of the foot, including non-weight-bearing anteroposterior, lateral, and oblique radiographs. Weight-bearing radiographs may reveal subtle joint instability in minor or ligamentous injuries. External oblique radiographs are useful for tuberosity fracture evaluation. Clinicians should be mindful of normal anatomical variants and compare findings with contralateral foot radiographs to identify accessory navicular bones. Computed tomography (CT) is particularly valuable for high-energy trauma cases, as it allows precise delineation of complex fracture morphology and assessment of the talonavicular joint surface.
Navicular stress fractures typically present insidiously with symptoms progressing gradually over weeks to months. Patients often experience vague midfoot discomfort or aching, worsening with physical activity and improving with rest. Acute navicular body or avulsion fractures usually present dramatically following a specific traumatic event, causing sudden, severe pain in the midfoot, swelling, bruising and an inability to bear weight. In high-energy cases, significant swelling, ecchymosis and open wounds may be noted, necessitating urgent evaluation for complications like compartment syndrome. Recognizing the difference between stress-related injury and acute traumatic fracture is crucial.
Navicular fractures are caused by repetitive, high-impact or forceful activities that stress the midfoot particularly across the medial longitudinal arch. Athletes, ballet dancers, and athletes are at the highest risk, with stress fractures common in track and field competitors, ballet dancers and sports like basketball, soccer, rugby and American or Australian-rules football. Gymnasts, equestrians and military recruits also experience navicular injuries due to repetitive axial loading, high-impact landings, or endurance marching. Body fractures and avulsion injuries are more commonly associated with acute high-energy trauma like falls from height, motor vehicle collisions or direct impact during contact sports.
Metatarsalgia
Ankle Fracture in Sports Medicine
Metatarsal Stress Fracture
Ankle Sprain
Contusions
Athletic Foot Injuries
Treatment Paradigm
Initial Assessment and Stabilization: A complete clinical assessment includes history, mechanism of injury, physical examination and neurovascular status evaluation, is the first step in management. A splint or cast must be used to immobilize the injured foot and prevent additional displacement while providing instant pain relief.
Pain Management: Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) are administered to control the pain and inflammation during the acute phase.
Diagnostic Imaging: Radiographic evaluation with plain X-rays is the first step, followed by computed tomography (CT) in complex or high-energy injuries to delineate fracture patterns and assist in preoperative planning.
Non-Surgical Management: Navicular Stress Fractures are typically treated with immobilization and protected weight-bearing for 6 to 8 weeks. Patients are continuously evaluated for evidence of recovery and the remission of symptoms. Small avulsion fractures, tuberosity fractures and nondisplaced navicular body fractures can be conservatively treated with a short leg cast and walking boot.
Surgical Management: It is recommended for patients with displaced navicular body fractures or those with strong functional needs, such sportsmen. The standard approach is open reduction and internal fixation (ORIF) which aims to restore anatomic alignment maintain medial column length and create a stable construct for early range of motion. Surgery is required for comminuted fractures or failure of conservative management.
Rehabilitation and Physical Therapy: Patients who have been immobilized or undergone surgery require systematic rehabilitation. Physical therapy aims to restore ankle and midfoot strength, flexibility and functional mobility. Gradual advancement to weight-bearing exercises is encouraged under supervision.
Monitoring and Follow-Up: Regular clinical and radiological follow-up is required to monitor fracture healing, discover problems such non-union or avascular necrosis and alter treatment as necessary.
Nutritional and Lifestyle Support: A balanced diet with adequate calcium and vitamin D supports bone healing. Patients are recommended to avoid smoking and heavy alcohol use as these substances hinder bone healing.
Use of NSAID’s to manage Navicular Fractures
In most cases of navicular stress fractures, immobilization and strict rest substantially reduce discomfort, and first-line therapy with acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen is often sufficient for acute pain control. Persistent pain throughout the recovery period indicates insufficient healing or the existence of the fracture.
Ibuprofen: It is used for mild pain. It inhibits the inflammatory reaction and pain by reducing prostaglandin synthesis.
Naproxen: This NSAID is effective to manage fracture-related pain. It works by reducing inflammation at the fracture site and in adjacent soft tissues, thereby helping to relieve discomfort and improve patient mobility during recovery.
Use of Analgesics to manage Navicular Fractures
If pain relief is inadequate with NSAIDs, escalation should be considered. In select cases, particularly when patients experience severe or breakthrough pain, short courses of opioid analgesics (e.g., oxycodone) may be prescribed to ensure adequate comfort, particularly during the acute phase of injury. Opioid use should remain carefully limited and monitored, given the risk of dependence and side effects.
Acetaminophen: It is indicated for moderate pain. It provides effective pain relief, is safe for repeated/long-term use and does not interfere with bone healing.
Use of Nutritional Supplements to manage Navicular Fractures
Calcium and Vitamin D: These are essential to maintain the bone strength. Calcium is necessary component of bone structure. Vitamin D promotes calcium absorption. Calcium and vitamin D supplementation is usually recommended for those who have an insufficient diet and malabsorption issues or are at risk of osteoporosis. Proper amounts of essential nutrients helps to retain the bone density and reduces the risk of fractures specifically in the older population.
Use of Intervention to manage Navicular Fractures
Operative management of navicular fractures is generally reserved for fractures that are displaced, intra-articular, involve avulsion fragments, or compromise more than 25% of the articular surface. The goal of surgery is to restore the anatomical alignment of the navicular, maintain the integrity of the medial column of the foot, and preserve joint function while minimizing long-term complications such as arthritis, non-union, or chronic pain.
Open Reduction and Internal Fixation (ORIF): Open Reduction and Internal Fixation (ORIF) is a procedure used for navicular body fractures, intra-articular fractures, or those affecting joint congruity. The fracture site is exposed through a dorsal or dorsomedial incision, and fracture fragments are reduced to restore normal navicular shape. Internal fixation is achieved using screws, plates, or a combination. Postoperative care involves non-weight bearing for 6-8 weeks, gradually progressing to partial and full weight-bearing as healing is confirmed radiographically.
Fragment excision: It is a surgical procedure used to remove avulsed fragments that remain symptomatic despite conservative treatment or develop non-union. This reduces pain and mechanical obstruction without compromising midfoot stability.
Primary fusion: It is a procedure used for severe comminution, collapse of the navicular, chronic fractures, or non-union where reconstruction is not feasible. This involves fusion of the navicular with adjacent bones to provide a stable medial column, aiming to restore foot stability, alleviate pain, and prevent progressive deformity.
External fixation: It is utilized for complicated navicular fractures caused by significant soft tissue injury, high-energy trauma, or when fast internal fixation is not an option.
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