Stress fractures of the tarsal (foot) navicular
- Anthony Beutler, MD
Anthony Beutler, MD
- Associate Professor of Family Medicine
- Uniformed Services University
- Cole Taylor, MD
Cole Taylor, MD
- Assistant Professor of Family Medicine
- Uniformed Services University of the Health Sciences
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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".)
EPIDEMIOLOGY AND RISK FACTORS
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 . 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 . 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 . 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 . Other such variants may include cavus foot (high arch) .
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- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL ANATOMY AND BIOMECHANICS
- MECHANISM OF INJURY
- HISTORY AND EXAMINATION FINDINGS
- DIAGNOSTIC IMAGING
- INDICATIONS FOR SURGICAL REFERRAL
- DIFFERENTIAL DIAGNOSIS
- Selecting surgical or nonsurgical management
- Nonsurgical management
- FOLLOW-UP CARE AND PREVENTION
- RETURN TO WORK AND SPORT
- SUMMARY AND RECOMMENDATIONS