Friday, June 21, 2024

Navicular bone stress accidents in runners

Bone Stress

Navicular bone stress accidents are accidents to not be missed. Navicular bone stress accidents (BSI) carry a substantive larger threat of non union for stress fractures and frank fractures, and delayed therapeutic for bony stress reactions of the navicular. 

Navicular bone stress accidents account for 14-35% of all foot and ankle bone stress accidents, with the harm being widespread to trace and area, and leaping sports activities corresponding to basketball. 

Clinically I’ve seen athletes throughout quite a lot of sports activities current with navicular bone stress accidents, nonetheless with my medical bias being in direction of the working primarily based endurance athlete that’s the place my best expertise within the prognosis of and subsequent remedy of navicular BSI has been garnered.  

Anatomy of the navicular

The navicular articulates with the talus, cuboid, and cuneiforms (see beneath). The navicular, talus, cuboid, and calcaneus make up the transverse tarsal joint. The transverse tarsal joint (also referred to as chopart’s joint) is made up of the talonavicular and calcaneocuboid joints, serving to separate the rearfoot from the midfoot.

Navicular bone stress

Navicular bone stress

Biomechanics of the navicular

The mechanics of the navicular bone present an perception into the potential threat of BSI for this area of the runner’s skeleton. The navicular and transverse tarsal joint play vital roles in permitting the foot to transition from a versatile construction -that permits the foot to soak up impression forces because it strikes the bottom, to the inflexible construction required for environment friendly toe off with gait (1).

Likewise the medial arch of the foot is supported by talonavicular buildings. There’s a delicate interaction between the passive assist buildings and muscle management throughout the transverse tarsal joint. In forefoot pronation the navicular has larger mobility. When the  forefoot is in supination the navicular is in a closed pack place. When the heel is inverted because of the pull of the tibialis posterior and its related tendon (ie hindfoot is supinated) the transverse tarsal joint turns into inflexible in preparation for toe off, leading to compression of the navicular. It’s throughout this toe off section when the interior bone a great deal of the navicular bone are the best, with a zone of tensile loading via the center one -third of the navicular physique and doming of the navicular superiorly.

Along side this excessive area of loading within the central third of the navicular it is usually recognized that the central third of the navicular is a watershed space with poor arterial blood provide, heightening this area’s threat of growing a bone stress harm. This area corresponds to the most typical website of stress fracture within the navicular. This watershed space of the navicular physique makes the danger of nonunion or delayed union a threat for navicular stress fractures and bone stress accidents. Because of this the bone stress accidents to the navicular are thought-about excessive threat, making astute medical administration of the situation important.

Navicular bone stress

Threat elements for navicular bone stress harm

As with all working associated bone stress accidents, threat elements will be divided into two classes: organic and biomechanical threat elements. Organic threat elements decide the well being and skill of a runner’s skeleton to be loaded, whereas biomechanical threat elements embrace these elements that reasonable the loading utilized to the runner’s skeletal system. Organic and biomechanical threat elements are depicted beneath.

Navicular bone stress

Particularly for the navicular Mandell et. al. (8) outlined patho-anatomical threat elements for navicular bone stress accidents to be: lowered ankle dorsi-flexion, cavus foot construction, and a morton foot construction. Corticosteroid use, Vitamin D insufficiency, and Relative Vitality Deficiency in Sport (RED-S) had been additionally listed as navicular bone stress harm threat elements.

Particularly consideration must be given to coaching patterns of the runner who develops a navicular BSI. Coaching errors are usually concerned whereby the error will happen roughly 4 weeks earlier than signs could also be skilled. This is because of a 3 week resorption section of osteoclasts following bone loading in contrast with 3 months of bone formation time,  which creates a window of ‘vulnerability’ for bone harm. If a runner has accrued microdamage (out paced regular bone focused remodelling attributable to a rise in bone workload) and related porosity round a microcrack that area could also be vulnerable to heightened bone stress/pressure and subsequent pathology. Therefore reviewing the coaching diary of a runner who presents with a navicular BSI, 4 weeks earlier than symptom onset can usually reveal a change in bone workload that will have contributed to harm onset. Preserve a selected eye out for the quantity/ or change in depth working which carries with it heightened BSI threat.

Navicular bone stress

Biologically one of the crucial vital threat elements to not miss is the injured athlete’s vitality availability (EA). It’s nicely established that states of low vitality availability (LEA) heighten the danger of BSI via the resultant direct and oblique down regulatory results on skeletal well being. LEA is the important thing driver for relative vitality deficiency in sports activities (RED-S) whereby athletes expertise heightened BSI threat. Within the presence of 2-3 threat elements for RED-S (menstrual dysfunction oligo-amenorrhea, elevated dietary restraint, participation in leanness sport, low BM1 < 21 kg/msq, ) feminine athletes who practice > 12 hours week 3x threat of BSI unbiased of bone well being.However when 3-4 threat elements are mixed w low bone well being (BMD<1.0)  15.6x extra probably BSI (2).

Navicular bone stress

Navicular particular threat elements might embrace a log 2nd ray, discount in ankle dorsiflexion, a cavus foot, and stiffness within the subtalar joint (3). 

Analysis of Navicular BSI

Runners with navicular bone stress harm will current with ache over the dorsum of the foot within the area of the navicular. The ache tends to be distributed and obscure versus a pin level location. The N-spot could also be tender to palpate nonetheless the diagnostic worth of this has not been scientifically decided. The N-spot is lateral to the tibialis anterior tendon however medial to the extensor hallucis tendon within the central area of the dorsum of the navicular (see beneath).

Navicular bone stress

Loading the foot with working or hopping will usually produce ache. Single leg calf raises can also elicit ache within the area of the navicular

Imaging for suspected navicular bone stress imaging is essential. Plain movie radiographs (x-rays) have low sensitivity for detecting navicular bone stress harm, therefore an MRI is essential. Whereas MRI is nice at detecting bone stress MR is probably not delicate sufficient to detect cortical fractures. The sensitivity of MR imaging for navicular fracture has been reported as being 71.4% (4). A CT scan needs to be carried out if there’s suspicion of a navicular stress fracture following MR imaging. Repeat CT imaging could also be indicated to judge fracture therapeutic and union.

Navicular bone stress

Classification of navicular stress fractures

In 2000 Saxena and colleagues (5) proposed a 3 tiered classification system of navicular stress fractures: 

  • Sort I fractures happen on the dorsal aspect of the navicular. 
  • Sort II fractures propagate into the navicular physique
  • Sort III fractures lengthen to the alternative cortex 


Navicular bone stress

These three fracture varieties additionally contain modifiers together with avascular necrosis (A), cystic adjustments to the fracture line (C) , and sclerosis of the fracture line (S). 

Saxena et al (4) reported that Sort I had been most definitely to obtain conservative administration, whereas Sort III fractures took a larger time to heal than fracture varieties I & II. Sort I fractures has a mean return to exercise of three months whereas Sort II’s return to exercise was 3.6 months. In the meantime Sort III fractures has a return to exercise timeline of 6.8months. Surgical procedure is indicated for Sort II and III fractures notably if modifiers are current. 


Conservative pathway 

So as to optimise therapeutic and reduce the danger of nonunion or related doable sequelae, non weight bearing (NWB) for at least 6 weeks is advisable. Excessive CAM walker use can be strictly recommended-as they infer extra stiffness for the decrease leg, whereas preserving the talo-crural joint in impartial.

Partial weight bearing is related to a excessive price of nonunion or delayed bone union. 

Analysis was carried out in 2010 by Torg et al. which highlighted that lower than 50% who had been handled with partial weight bearing had profitable returns to sport (6). The return to play timelines being 5.7months. This partial weight bearing method was inferior in contrast with intervention that comprised 6 weeks of strictly no weight bearing in a solid, whereby the return to sport timelines had been a lot shorter 3.7months and the success price a lot larger 96% in contrast with the partial weight bearing group. 

Surgical pathway 

A surgical method will be indicated when there’s proof of a displaced fracture, or avascular necrosis of the navicular. In the meantime surgical intervention might moreover  be indicated when there’s a recurrence of the fracture, non union, or an entire fracture (Sort 3), or within the occasion of an elite athlete who must minimise time loss. 

Surgically percutaneous screw fixation will be carried out for partial and non displaced fractures. Bone grafts could also be required the place there’s sclerotic bone or fracture displacement, or avascular necrosis {Hardware} could also be eliminated in some sufferers at or round 12 months publish surgical procedure. 

Torg’s meta evaluation (6) reported that 82% of sufferers had a profitable final result publish surgical procedure. 

Publish surgically rehabilitation requires 6 weeks non weight bearing in a tall CAM walker boot. Weight bearing as tolerated can start from 6 weeks publish surgical procedure, with progressive power and conditioning progressing from 6 weeks publish surgical procedure additionally. 

Consideration and remedy of all doable BSI drivers (biomechanical and organic) is essential whereas the athlete is recovering within the boot. This may increasingly embrace an evaluation with a sports activities dietitian to determine and guarantee adequate vitality and vitamins can be found to the athlete. 

Train remedy ought to concentrate on a progressive return to plantar flexor loading on the symptomatic aspect as soon as the athlete is ready to weight bear with out a moon boot with nil aide. Plantar flexors (calf) workouts needs to be listed up step by step from seated deload single leg calf raises , via till heavy loaded single leg calf raises which can start as soon as satisfaction of the bone stress harm or fracture has been arrived at (medical indicators and /or imaging outcomes as indicated). Along with calf train work, the rest of the working kinetic chain will be focused in a house and fitness center primarily based train program. Workout routines for the kinetic chain might embrace contralateral leg work whereas the athlete is therapeutic their navicular BSI (this could embrace above and beneath knee single leg workouts), forward of progressive programming for compound actions corresponding to loaded barbell again squats and deadlifts, and eventually progressive plyometric train prescription all through mid-late stage rehabilitation. Standing calf raises might start at round 8 weeks publish harm. Return to working might start at round 12 weeks if the athlete is void of ache on single leg hopping and has passable therapeutic on repeat CT imaging. 

It is very important incorporate some single leg hopping (of varied types eg forwards, aspect to aspect, up onto a step and many others) for the asymptomatic leg to be able to improve bone mineral density/ bone well being within the unaffected leg. One of many recognized corollaries of great deload intervals for the skeleton will be regional bone density losses of as much as 33% when an harm and subsequent deloading happens, corresponding to with navicular BSI. Incorporating single leg hopping over the therapeutic months might serve to offset/cut back some bone well being deficits within the reverse leg of the athlete.

Return to Run rules to notice embrace: 

  • Start with a stroll/jog program and set up as much as 30 minutes accrued regular state jogging  for instance of a 4-6 week interval.
  • Utilise physique weight supported working choices if obtainable such because the AlterG anti-gravity treadmill. (Rehabilitating working accidents with physique weight supported treadmills-blog)
  • Re-establish working minutes /quantity/loading cycles first forward of introducing depth working later within the rehabilitation journey. Depth working indexes larger threat for BSI, notably a bone just like the navicular. 
  • Load monitoring with return to run packages needs to be ache free. Warden et al paper (2021) (7)  outlines that with BSI return to run programming the goal is to not expertise any soreness within the bone on return. If there’s any soreness Warden et al advocate ceasing working for 3 days, after which resuming by regressing 1 week on the progressive return to run program.

Navicular bone stress



Brad Beer

APA Titled Sports activities & Train Physiotherapist (APAM), POGO Founder

Ebook an Appointment with Brad right here.

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  1. Sammarco VJ. The talonavicular and calcaneocuboid joints: anatomy, biomechanics, and medical administration of the transverse tarsal joint. Foot Ankle Clin. 2004 Mar;9(1):127-45. doi: 10.1016/S1083-7515(03)00152-9. PMID: 15062218.
  2. Barrack MT, Gibbs JC, De Souza MJ, Williams NI, Nichols JF, Rauh MJ, Nattiv A. Larger incidence of bone stress accidents with growing feminine athlete triad-related threat elements: a potential multisite examine of exercising women and girls. Am J Sports activities Med. 2014 Apr;42(4):949-58. doi: 10.1177/0363546513520295. Epub 2014 Feb 24. PMID: 24567250.
  3. Pavlov, H., Torg, J. S., & Freiberger, R. H. (1983). Tarsal navicular stress fractures: radiographic analysis. Radiology, 148(3), 641-645.
  4. Saxena, A., Behan, S. A., Valerio, D. L., & Frosch, D. L. (2017). Navicular stress fracture outcomes in athletes: evaluation of 62 accidents. The Journal of Foot and Ankle Surgical procedure, 56(5), 943-948.
  5. Saxena A, Fullem B, Hannaford D. Outcomes of remedy of twenty-two navicular stress fractures and a brand new proposed radiographic classification system. J Foot Ankle Surg. 2000;39:96–103.
  6. Torg JS, Moyer J, Gaughan JP, Boden BP. Administration of tarsal navicular stress fractures: conservative versus surgical remedy: a meta-analysis. Am Journal Sports activities Med. 2010; 38:1048-1053.
  7. Warden SJ, Edwards WB, Willy RW. Optimum Load for Managing Low-Threat Tibial and Metatarsal Bone Stress Accidents in Runners: The Science Behind the Scientific Reasoning. J Orthop Sports activities Phys Ther. 2021 Jul;51(7):322-330. doi: 10.2519/jospt.
  8. 2021.9982. Epub 2021 Might 7. PMID: 33962529.
  9. Mandell JC, Khurana B, Smith SE. Stress fractures of the foot and ankle, half 2: site-specific etiology, imaging, and remedy, and differential prognosis. Skeletal Radiol. 2017 Sep;46(9):1165-1186. doi: 10.1007/s00256-017-2632-7. Epub 2017 Mar 25. PMID: 28343329.

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