eMedicine Specialties > Sports Medicine > Foot and Ankle

Navicular Fracture

Author: Michael J Ameres, MD, Consulting Staff, Department of Emergency Medicine, Southampton Hospital
Coauthor(s): Greg Montalbano, MD, Assistant Clinical Professor, Department of Orthopaedics, New York University Medical School; Rafat Farouqui, MBBS, Consulting Staff, Department of Orthopedic Surgery, Brooklyn Hospital Center; Benson Yeh, MD, Assistant Program Director, Department of Emergency Medicine, Brooklyn Hospital Center; Clinical Instructor, Department of Medicine, Division of Emergency Medicine, Cornell University
Contributor Information and Disclosures

Updated: Feb 11, 2008

Introduction

Background

The navicular plays an important role in maintaining the medial longitudinal arch of the foot. Commonly, fractures of the navicular are not evident on plain radiographs. This often leads to a delay in diagnosis, which may result in prolonged disabling foot pain in individuals, particularly young athletes. The 4 types of navicular fractures are (1) cortical avulsion, (2) tuberosity, (3) body, and (4) stress.1,2,3,4,5

Cortical and tuberosity avulsion fractures

Avulsion fracture, the most common fracture of the navicular, is often associated with ligamentous injuries and results from twisting forces on the mid foot. These fractures are commonly treated conservatively, except for avulsion of the posterior tibial tendon insertion (tuberosity fracture), which may be repaired operatively, especially if a proximal dislocation of 1 cm or more is present. An avulsion of the posterior tibial tendon insertion must be differentiated from an accessory navicular (see Other Problems to Be Considered).

Fractures of the navicular body

Fractures of the body are commonly associated with other injuries of the midtarsal joint. Sangeorzan et al categorized navicular body fractures into 3 types, as follows6 :

  • Type 1 is a coronal fracture with no dislocation.
  • Type 2 is a dorsolateral to plantomedial fracture with medial forefoot displacement.
  • Type 3 is a comminuted fracture with lateral forefoot displacement and carries the worst prognosis.

All navicular body fractures with 1 mm or more of displacement require open reduction and internal fixation.

Stress fractures

The rest of this article primarily discusses the diagnosis and treatment of navicular stress fractures, which are usually sports-related injuries.

In 1855, Brehaulpt first described stress fractures in military recruits who were subjected to long marches. As more civilians took up physically demanding sports, the incidence of stress fractures has increased in the general population. Towne et al first described stress fracture of the tarsal navicular in 1970.7

In athletes, navicular stress fractures are of particular concern because they are underdiagnosed and can lead to significant disability if the diagnosis is delayed.1,2,3,4,5  In a study by Torg et al in 1982, the average time between the fracture and diagnosis was estimated to be 7 months.8 Given the significant improvement in outcome with early diagnosis and proper treatment, navicular stress fractures should be considered in any athlete with midfoot pain. In a 2006 study by Saxena and Fullem, navicular stress fractures took up to 4 months to heal posttreatment.9

Fracture-dislocation of the navicular may occur in athletes.10,11,12,13,14,15,16,17 This uncommon injury generally requires reduction and examination for stability via fluoroscopy, with the patient under general anesthesia. If the postreduction examination findings confirm stability of the navicular, treatment with a non–weight-bearing cast may be sufficient; otherwise, internal fixation is required.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Fractures and Broken Bones Center, Breaks, Fractures, and Dislocations Center, and Sports Injury Center. Also, see eMedicine's patient education articles Broken Foot and Cast Care.
 
Related eMedicine topics:
Dislocations, Foot
Fractures, Foot 
Stress Fracture [in the Radiology section]

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Trauma
CME/CE Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes

Frequency

United States

Navicular stress fractures may account for up to 35% of stress fractures in athletes. Because navicular stress fractures are not easily observed on plain radiographs, the reported incidence rates vary widely. The overall incidence may appear to be increasing due to advances in imaging.18,19,20,21,22,23,24

Among track-and-field athletes, up to 21% may experience a stress fracture in the course of a year.25,26 In these athletes, up to 15% of stress fractures are of the navicular.25 Other studies have demonstrated similar findings.27,28,29,30 The highest incidence of stress fractures is in jumping and sprinting events.

Among military recruits, the incidence is approaching that of athletes, as the training of military recruits more closely mirrors the training of athletes.27,31,32,33

Related eMedicine topics:
Metatarsals, Fractures [in the Radiology section]
Metatarsal Stress Fracture [in the Sports Medicine section]
Stress Fracture [in the Physical Medicine and Rehabilitation section]

International

Worldwide, the incidence of navicular stress fracture is related to the sport of participation and to the training that is involved rather than to geographic location.

Functional Anatomy

The tarsal navicular is a disk-shaped bone that articulates distally with the 3 cuneiforms, proximally with the talar head, and, occasionally, laterally with the cuboid. The distal articulation with the 3 cuneiforms is by means of 3 facets that have a common synovial cavity. The plantar and dorsal cuneonavicular ligaments reinforce the distal articulation.

On the lateral side are the plantar, dorsal, and interosseous cuboideonavicular ligaments and, occasionally, a syndesmotic joint with the cuboid. Medially, the distal articulation serves as an attachment for the posterior tibial tendon and the spring, or plantar calcaneonavicular, ligament. On the proximal side, it envelops the talar head completely. The thickened talonavicular ligaments reinforce the talonavicular joint in a plantar and dorsal orientation. Medially, the anterior fibers of the deltoid ligament add support.

Along with the calcaneocuboid joint, the talonavicular joint forms the transverse tarsal joint, which allows motion of the forefoot on the hindfoot. The ligamentous structure is such that when the hind part of the foot is everted, the joint is mobile, and when the hind part of the foot is inverted, the joint is fixed.

The blood supply of the navicular comes from small branches of the posterior tibial and dorsalis pedis arteries. This supply leaves the medial and lateral areas of the navicular relatively well supplied compared with the central section of the navicular. This relative difference correlates with the common site of stress fractures.

Sport-Specific Biomechanics

The navicular is part of 2 important structures that are essential for normal gait: (1) the medial longitudinal arch and (2) the transverse tarsal joint (also called the midtarsal or Chopart joint).

The medial longitudinal arch is composed of the navicular, calcaneus, talus, 3 cuneiforms, and 3 medial metatarsals. This arch provides support for normal gait, in particular from mid stance until push-off.

The transverse tarsal joint is essential for normal gait and is composed of the talonavicular joint and the calcaneocuboid joint. At heel strike, this joint is flexible and plays an important role in absorbing ground impact and accommodating the foot to the ground. At push-off, the transverse tarsal joint is locked and is helpful in forward propulsion.

Clinical

History

Navicular stress fractures must be considered in any athlete with midfoot pain. Typically, the pain is of insidious onset and may have been present for months. In addition, the pain often worsens with activity and improves with rest. Pain may be present at the dorsum of the foot, or it may radiate along the medial longitudinal arch. Slight swelling may or may not be present.

Historically, persons participating in the following sports and activities have a relatively high risk of navicular fracture:

  • Track and field25,26,27,28,29,30 – Particularly sports involving jumping and sprinting
  • Ballet and other dancing activities34
  • Equestrian sports
  • Basketball
  • Soccer35
  • American football
  • Australian-rules football
  • Rugby
  • Gymnastics36
  • Military training27,31,32,33

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Trauma
CME/CE Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes

Physical

Possible findings from the physical examination in an individual who has a navicular fracture include the following:

  • Tenderness at the "N spot," which is defined as the proximal dorsal portion of the navicular (see Image 1). This is the most important physical finding.
  • Tenderness at the midmedial arch over the navicular
  • Pain with passive eversion
  • Pain with active inversion
  • Pain that is often reproduced if the patient hops while in the equinus position
  • Possible mild dorsal midfoot swelling

Causes

The particular cause of stress fractures in athletes or military recruits is often elusive. Obviously, the repetitive stress of their chosen activity leads to the fracture, but identifying a defect in technique, equipment, or schedule of activity is often difficult.

  • Some factors that have been implicated as causes of stress fractures include the following:
    • Starting athletic activity at a high level without a gradual increase in activity over time
    • Starting a second sport and assuming that the body is conditioned to participate at that sport immediately and at a high level. The navicular is at particular risk when runners participate in sports that require jumping and do not take the time for proper conditioning in their new sport.
    • Ill-fitting and/or old, worn equipment
    • Change in running or field surfaces
    • Relative osteopenia
    • Biomechanical abnormality
  • Some risk factors for stress fracture include the following:

Related eMedicine topics:
Female Athlete Triad
Nutrition for the Female Athlete

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Osteoporosis

More on Navicular Fracture

Overview: Navicular Fracture
Differential Diagnoses & Workup: Navicular Fracture
Treatment & Medication: Navicular Fracture
Follow-up: Navicular Fracture
Multimedia: Navicular Fracture
References
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Further Reading

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Keywords

tarsal navicular fracture, midfoot fracture, mid-foot fracture, navicular stress fracture, navicular stress fractures, navicular cortical avulsion fracture, navicular tuberosity fracture, navicular body fracture, heel fracture, foot fracture, broken foot, navicular bone fracture, foot pain, N-spot, N spot

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Contributor Information and Disclosures

Author

Michael J Ameres, MD, Consulting Staff, Department of Emergency Medicine, Southampton Hospital
Michael J Ameres, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Greg Montalbano, MD, Assistant Clinical Professor, Department of Orthopaedics, New York University Medical School
Greg Montalbano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Sierra Cascade Trauma Society
Disclosure: Nothing to disclose.

Rafat Farouqui, MBBS, Consulting Staff, Department of Orthopedic Surgery, Brooklyn Hospital Center
Disclosure: Nothing to disclose.

Benson Yeh, MD, Assistant Program Director, Department of Emergency Medicine, Brooklyn Hospital Center; Clinical Instructor, Department of Medicine, Division of Emergency Medicine, Cornell University
Benson Yeh, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, Assistant Professor, Departments of Neurological Surgery, Orthopedics, and Rehabilitation, University of Miami
Andrew L Sherman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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