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].

• Soft Tissue Swelling

  However, if major soft tissue swelling or severe pain is present, a more serious ligamentous injury may have occurred and the patient should be kept non-weight bearing with immobilization for 6 weeks. [healio.com]

• Noncompliance

  In addition, it surely results in frustration and psychological morbidity in these highly motivated individuals, resulting in a high risk of noncompliance. [ijoonline.com]

• 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]

  There are many types of procedures that can be performed for wrist arthritis. [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]

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