Patients often present with unilateral dorsal foot pain accompanied by swelling. The pain may be of insidious onset or it may follow an injury. It is often described as aching or tenderness at the navicular region. Patients may also have limited weight bearing ability. With continued activity, the onset of pain occurs sooner during the activity and lasts longer after cessation of activity [1] [2] [3] [4]. Swelling is often present at the dorsomedial midfoot; it may be present diffusely as well. The clinician should bear in mind that foot injuries, in addition to navicular fracture, may be present [5].

• Wrist Arthritis

  Figure 1: Scaphoid non-union with Wrist arthritis Figure 1: Scaphoid non-union Figure 2 Figure 3 Figure 4: CT scan showing a scaphoid fracture Figure 5: MRI showing an occult fracture fracture Figure 6 [centraljerseyhand.com]

  Symptoms of arthritis in the wrist may include: Aching Stiffness Decreased range of motion in the wrist Pain with activities such as lifting, gripping, or weight bearing Treatment for arthritis focuses on improving symptoms. [orthoinfo.aaos.org]

• Osteopenia

  Despite anatomic reduction of the navicular and initiation of early weight bearing, diffuse osteopenia is evident throughout the foot. Due to the patient’s other injuries, her mobility was significantly limited during the initial recovery period. [healio.com]

Workup begins with a history and physical exam. Physical exam consists of a comparison of the arch between the affected and the uninvolved foot. Asymmetry (e.g., loss of longitudinal height of the arch during full weight-bearing) may reveal injuries such as rupture of the navicular ligament or the posterior tibialis tendon. Palpation of the medial arch often elicits pain at the proximal dorsal portion of the navicular (the "N spot"), directly over the navicular body in the superior medial arch alongside the anterior tibialis tendon [6]. This is a key physical finding and highly suggestive of a navicular fracture [7]. During the physical exam, passive eversion, active inversion, and/or hopping while standing on tip-toes will cause pain. In addition to a musculoskeletal exam, a neurovascular examination should be performed. Compartment syndrome should be considered when there is a significant degree of swelling.

X-rays are the most commonly used imaging modality for diagnosis; a computed tomography (CT) scan and/or magnetic resonance imaging (MRI) are more sensitive imaging modalities and may reveal subtle injuries. If a navicular fracture is suspected based on the patient’s history and physical exam findings, and X-rays do not demonstrate a fracture, a CT or MRI should be performed for a more thorough evaluation.

X-rays of both feet are recommended (i.e., the affected foot as well as the opposite foot for purposes of comparison). Foot X-rays consisting of anteroposterior (AP), lateral, and oblique views should be obtained. An external oblique view permits optimal imaging of the navicular tuberosity [10]. Stress views can help rule out acute ligamentous injury. In patients with high-energy injuries, ankle X-rays can help identify any concomitant injuries. X-rays of the contralateral foot may be obtained for comparison of the accessory navicular [8]. Avulsion fractures are characterized by a fleck of cortical bone. Tuberosity fractures should be differentiated from the injury of the accessory navicular [9].

CT scan permits identification of any subtle injuries and/or intra-articular fracture [10]. MRI may be used to identify injuries to the posterior tibial tendon, spring ligament, and/or accessory navicular [11].

• Joint Space Narrowing

  It leads to collapse of the navicular and joint space narrowing, which is most appropriately managed with fusion. Nonunion can also occur due to the bone’s limited blood supply. [healio.com]

There was a statistical trend towards NWB as a more favourable initial treatment option. Both of these treatments were significantly superior to either NWB for less than 6 weeks or LWA. [ncbi.nlm.nih.gov]

Several authors have confirmed the efficacy of this treatment protocol.5,12,15 Even in patients who have failed treatment in a weightbearing cast, the use of a non-weightbearing cast treatment compares favorably with surgical treatment.12 Khan and colleagues [podiatrytoday.com]

Evaluation and treatment of navicular stress fractures, including nonunions, revision surgery, and persistent pain after treatment. Foot Ankle Clin. 2009 Jun. 14(2):187-204. [Medline]. Gillespie WJ, Grant I. [emedicine.medscape.com]

Surgical repair by lag screw has been described to have a better prognosis. © 2018 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA) [merckvetmanual.com]

Treatment and prognosis Acute pain can be managed can be achieved by corticosteroid injection and immobilization of the foot for 2-3 weeks. For refractory cases, surgical management can be considered. [radiopaedia.org]

Google Scholar Simon LC, Schulz AP, Faschingbaker M, Morlock M, Jurgens C: Basketball foot-long-time prognosis after peritalar dislocation. Sportverlatz Sportschaden. 2008, 22: 31-37. 10.1055/s-2008-1027208. [casesjournal.biomedcentral.com]

Prognosis of a navicular stress fracture With appropriate physiotherapy management, most patients with a stress fracture of the navicular can make a full recovery (return to sport or full activities) in a period of 3 – 9 months. [physioadvisor.com.au]

[…] subsequent encounter for fracture with delayed healing K- subsequent encounter for fracture with nonunion P- subsequent encounter for fracture with malunion S- sequela Navicular Fracture ICD-9 825.22 Fracture of navicular (scaphoid), foot Navicular Fracture Etiology [eorif.com]

[…] scan has a high sensitivity, it is also non-specific and requires additional diagnostic testing in the event of a positive test, further delaying the definitive diagnosis.11 Bone scans are unable to differentiate navicular pathology from other possible etiologies [podiatrytoday.com]

[…] resorption requires 10 days to three weeks to allow visualization of these fractures on plain radiographs, even complete fractures are often not seen on initial films. 26 However, plain films are useful if positive, and they also assist in ruling out other etiologies [aafp.org]

[…] encounter for fracture with delayed healing K- subsequent encounter for fracture with nonunion P- subsequent encounter for fracture with malunion S- sequela Navicular Fracture ICD-9 825.22 Fracture of navicular (scaphoid), foot Navicular Fracture Etiology / Epidemiology [eorif.com]

Epidemiology 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. [emedicine.medscape.com]

During this procedure, slight excavation of the edge of the trapezium bone may be necessary to reach the scaphoid as 80% of this bone is covered with articular cartilage, which makes it difficult to gain access to the scaphoid. [12] Epidemiology [ edit [en.wikipedia.org]

Stress Fractures: Pathophysiology, Epidemiology, and Risk Factors. Current Osteoporosis Reports, 4(3), 103-109. Wohl, G. R., Towler, D. A., & Silva, M. J. (2009). [raynersmale.com]

Tarsal navicular stress fracture in a young athlete: Case report with clinical, radiologic and pathophysiologic correlations. J Am Board Fam Pract 2001;14:381-5. [ PUBMED ] 13. Torg JS, Pavlov H, Torg E. Overuse injuries in sport: The foot. [ijoonline.com]

Tarsal navicular stress fracture in a young athlete: Case report with clinical, radiologic, and pathophysiologic correlations. J Am Board Fam Pract. 2001 Sep-Oct;14(5):381-5. 17. Alfred RH, Belhobek G, Bergfeld JA. [podiatrytoday.com]

Prevention The ultimate key to reduce the chances of navicular stress fractures is prevention. [newhealthadvisor.com]

Build strong muscles and practice balancing exercises to prevent falls. [winchesterhospital.org]

Prevention There is some evidence that Calcium and Vitamin D supplements decrease the incidence of stress fractures, particularly in females. [emedicine.medscape.com]

Even if the first X-rays do not show a fracture, your doctor still may treat you to prevent possible problems with healing. Right after the injury, you may wear a splint because your wrist is too swollen to put a cast on. [northshore.org]

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