You feel a bit of soreness on your foot as you finish up your Thursday morning run. Nothing you haven’t felt before, probably just your stubborn plantar fascia acting up. You add a few stretches to your warm-up, roll your foot out with a massage ball, and hope the pain goes away. Unfortunately, it doesn’t. The pain worsens to the point you can barely stand. You begrudgingly schedule an appointment with your local sports med doc.
MRI findings say…navicular stress fracture.
Ugh.
The navicular bone accounts for around ⅓ of all foot stress fractures and is common in runners and basketball players. It’s also at high risk of not healing and developing osteonecrosis (bone death)1. If a runner has worsening foot pain, a stress fracture should jump to the top of the potential diagnosis list. These injuries need to be taken seriously.
When you run, your navicular gets pinched between your 1st and 2nd MTC joints, tugged by your posterior tibialis tendon, and manages stress on the talar head. That’s a lot!
Unfortunately, most of these forces end up at that central ⅓1 the part with a poor blood supply.
We don’t do an efficient job of diagnosing these injuries with the average time to diagnosis of a navicular stress fracture is 6 months1. As the fracture progresses, it can become painful to walk and even stand.
The initial first step is often a radiograph which usually doesn’t show anything. An MRI and CT scan are often needed to completely rule in or out a stress fracture and determine the best management course. The typical fracture pattern is an incomplete fracture of the central ⅓ of the navicular1.
The navicular is a high-risk site meaning it has a higher chance of not healing or developing more severe complications. Surgery is often required to improve your chances for a good outcome.
The research is split on these decisions! Let’s break down this tough choice. You might have a quicker return to training and racing if you go under the knife. Mallee et al2 found a quicker time back to sport with surgical versus conservative (16.4 weeks to 21.7 weeks). Also, it’s often proposed you need surgery if you have certain injury characteristics. These include…
- Displaced stress fractures (a gap has formed between the broken segments)
- Non displaced complete fractures with sclerotic changes
- Comminuted fractures (the bone is broken in at least two places)
- Failed conservative management
- Athletes that can’t take a long rehab process (expand on this with high school/college)
The decision on what type of surgery can also leave us with questions. Nunley et al3 proposed this approach for determining what surgical procedure a specific patient may need.
Maybe you don’t need surgery?
Just because you get a navicular stress fracture doesn’t guarantee surgery is needed. Michael Jordan famously fractured his navicular while playing Golden State Warriors back in 85′. Jordan famously pressed his rehab even though Dr. Stan James said he had a 20% chance of reinjuring his foot. Jordan would drop 63 points in a double overtime loss to Larry Bird’s Celtics in the same season.
We also have studies that support being conservative might be the best route.
If you opt to pass on surgery be conservative! Torg et al3 found no advantage comparing surgical intervention with cast immobilization and complete non-weight bearing. The subjects that were allowed to weight-bear or didn’t immobilize only had a 47% success rate!
It’s a lot to ask a runner to manage a navicular stress fracture conservatively, “fail rehab”, and still have surgery six months later. Realistically that’s 18 months till you return to your previous level of the sport (if ever). If you are dealing with a high school or college runner, that’s likely two years of eligibility. It makes sense why many opt for the surgery, especially if they meet some of those surgical criteria.
These initial decisions are tough. Figure out your specific goals, discuss them with a skilled surgeon, and get with a rehab pro who knows how to handle these from start to finish.
Thanks for reading! The next blog will cover the keys to a successful rehab. If you enjoyed this blog I’d love it if you signed up for my monthly newsletter below. Be on the lookout for the next blog in this series on keys to successfully rehab navicular stress fractures.
-Nathan
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- Gross T, Venn-Watson E, Rossman T et al. Tarsal Navicular Stress Fractures in Runners. AJR 136: 201-203, 1981.
- 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.