Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Stress fractures of the tarsal (foot) navicular

Anthony Beutler, MD
Cole Taylor, MD
Section Editors
Patrice Eiff, MD
Chad A Asplund, MD, FACSM, MPH
Deputy Editor
Jonathan Grayzel, MD, FAAEM


The tarsal navicular bone is the keystone of the medial column of the foot, bearing the majority of the load applied to the tarsal complex during weight-bearing [1,2]. The biomechanical and vascular properties of the navicular make it susceptible to stress fracture. Among athletes involved in cutting, pivoting, and especially running sports, stress fractures of the tarsal navicular are an important cause of midfoot pain. The absence of acute trauma, relatively low level of pain, minimal swelling and inconsistent examination findings, and the difficulty identifying these fractures on routine radiographs, all combine to make stress fractures of the navicular one of the most commonly missed or delayed diagnoses in the foot. Delay in diagnosis is particularly problematic with navicular stress fractures, which at baseline are at increased risk of nonunion.

The presentation, diagnosis, and management of tarsal navicular stress fractures is reviewed here. Acute fractures to the tarsal navicular and injuries of the other tarsal bones, ankle, and leg are discussed separately. (See "Tarsometatarsal (Lisfranc) joint complex injuries" and "Metatarsal shaft fractures" and "Proximal fifth metatarsal fractures" and "Talus fractures" and "Fibula fractures" and "Overview of ankle fractures in adults".)


Stress fractures of the tarsal navicular are relatively common, comprising approximately 10 to 35 percent of all stress fractures [3-5]. Navicular stress fractures are seen in elite and recreational athletes, and in military personnel, with an average patient age at the time of injury of 25 to 29 years [6-9]. Overuse or excessive mechanical stress due to improper training programs, poor equipment (eg, worn running shoes, hard surfaces), improper running technique, and anatomic variants may all increase the risk for navicular stress fracture [10]. Female athletes appear to be at greater risk. Of note, up to 30 percent of tarsal navicular stress fractures are missed primarily or are treated in a delayed manner. Delays in treatment result in poorer outcomes compared with injuries diagnosed and treated promptly [11]. The general risk factors for stress fractures are reviewed in detail separately. (See "Overview of stress fractures", section on 'Risk factors'.)

Athletes who participate in track and running sports, including sprinters and hurdlers, are especially prone to navicular stress fracture [7,9,12-14]. In one retrospective study of 180 high-level athletes with stress fractures, 59 percent of all tarsal navicular stress fractures occurred in track athletes and the majority of these were found among distance runners [3]. However, these fractures have been reported in military recruits and participants in soccer (football), Australian rules football, and jumping sports (eg, basketball).

Small observational and laboratory studies suggest that certain anatomic variants may place greater stress on the tarsal navicular during running, thereby increasing the risk for stress fracture. Metatarsus adductus (forefoot varus) and the combination of a short first metatarsal and a relatively long second metatarsal may increase biomechanical stress and have been noted in a number of case reports [15]. Other such variants may include cavus foot (high arch) [16].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 14, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Sammarco GJ, Hockenbury RT. Biomechancis of the foot and ankle. In: Basic Biomechanics of the Musculoskeletal System, 3rd ed, Lippincott Williams & Wilkins, Philadelphia 2001. p.222.
  2. Shindle MK, Endo Y, Warren RF, et al. Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg 2012; 20:167.
  3. Brukner P, Bradshaw C, Khan KM, et al. Stress fractures: a review of 180 cases. Clin J Sport Med 1996; 6:85.
  4. Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med 1996; 24:211.
  5. Jones MH, Amendola AS. Navicular stress fractures. Clin Sports Med 2006; 25:151.
  6. Saxena A, Fullem B. Navicular stress fractures: a prospective study on athletes. Foot Ankle Int 2006; 27:917.
  7. Saxena A, Fullem B, Hannaford D. Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. J Foot Ankle Surg 2000; 39:96.
  8. McCormick JJ, Bray CC, Davis WH, et al. Clinical and computed tomography evaluation of surgical outcomes in tarsal navicular stress fractures. Am J Sports Med 2011; 39:1741.
  9. Sanders TG, Williams PM, Vawter KW. Stress fracture of the tarsal navicular. Mil Med 2004; 169:viii.
  10. Eiff MP, Hatch RL. Fracture Management for Primary Care, 3rd ed, WB Saunders, Philadelphia 2011. p.276.
  11. Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin 2003; 8:61.
  12. Kindred J, Trubey C, Simons SM. Foot injuries in runners. Curr Sports Med Rep 2011; 10:249.
  13. Coris EE, Lombardo JA. Tarsal navicular stress fractures. Am Fam Physician 2003; 67:85.
  14. Yoho RM, Wells SK. Navicular stress reactions in runners: a review of evaluation and management of a competitive athlete. J Am Podiatr Med Assoc 2011; 101:447.
  15. Gross CE, Nunley JA 2nd. Navicular Stress Fractures. Foot Ankle Int 2015; 36:1117.
  16. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. Stress fractures of the foot and ankle in athletes. Sports Health 2014; 6:481.
  17. McKeon KE, McCormick JJ, Johnson JE, Klein SE. Intraosseous and extraosseous arterial anatomy of the adult navicular. Foot Ankle Int 2012; 33:857.
  18. Agosta J, Holzer K. Foot pain. In: Brukner and Khan's Clinical Sports Medicine, 4th ed, Brukner P, Karim Khan (Eds), McGraw-Hill, Sydney 2012. p.853.
  19. Torg JS, Pavlov H, Cooley LH, et al. Stress fractures of the tarsal navicular. A retrospective review of twenty-one cases. J Bone Joint Surg Am 1982; 64:700.
  20. Schildhauer TA, Coulibaly MO, Hoffman MF. Fractures and dislocations of the midfoot and forefoot. In: Rockwood and Green's Fractures in Adults, 8th ed, Bucholz RW, Heckman JD, McQueen MM (Eds), Lippincott Williams & Wilkins, Philadelphia 2015. p.2690.
  21. de Clercq PF, Bevernage BD, Leemrijse T. Stress fracture of the navicular bone. Acta Orthop Belg 2008; 74:725.
  22. Beltran J, Shankman S. MR imaging of bone lesions of the ankle and foot. Magn Reson Imaging Clin N Am 2001; 9:553.
  23. Burne SG, Mahoney CM, Forster BB, et al. Tarsal navicular stress injury: long-term outcome and clinicoradiological correlation using both computed tomography and magnetic resonance imaging. Am J Sports Med 2005; 33:1875.
  24. Khan KM, Brukner PD, Kearney C, et al. Tarsal navicular stress fracture in athletes. Sports Med 1994; 17:65.
  25. Torg JS, Moyer J, Gaughan JP, Boden BP. Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis. Am J Sports Med 2010; 38:1048.
  26. Potter NJ, Brukner PD, Makdissi M, et al. Navicular stress fractures: outcomes of surgical and conservative management. Br J Sports Med 2006; 40:692.
  27. Mallee WH, Weel H, van Dijk CN, et al. Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. Br J Sports Med 2015; 49:370.
  28. Khan KM, Fuller PJ, Brukner PD, 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; 20:657.
  29. Mann JA, Pedowitz DI. Evaluation and treatment of navicular stress fractures, including nonunions, revision surgery, and persistent pain after treatment. Foot Ankle Clin 2009; 14:187.
  30. Bojanic I, Pecina MM. [Conservative treatment of stress fractures of the tarsal navicular in athletes]. Rev Chir Orthop Reparatrice Appar Mot 1997; 83:133.
  31. Wright AA, Taylor JB, Ford KR, et al. Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. Br J Sports Med 2015; 0:1.
  32. Jacobs JM, Cameron KL, Bojescul JA. Lower extremity stress fractures in the military. Clin Sports Med 2014; 33:591.
  33. Joy EA, Campbell D. Stress fractures in the female athlete. Curr Sports Med Rep 2005; 4:323.