Navicular Stress Fractures in Runners: A Physiotherapist’s Guide to Diagnosis, Management, and Return to Sport

Learn how to recognise, treat, and prevent navicular stress fractures in runners. A physiotherapist’s evidence-based guide to managing this high-risk injury.

Introduction

Running is a fantastic way to stay fit, but it’s not without its risks—especially for the bones of the foot. One of the most serious and frequently overlooked injuries in runners is the navicular stress fracture (NSF). Often dubbed the “Achilles heel” of the midfoot, the navicular is a high-risk site for stress injury due to its poor blood supply and central role in load-bearing.

As physiotherapists, recognising the early signs, facilitating appropriate diagnosis, and guiding safe return to running are crucial in preventing long-term complications.

What Is a Navicular Stress Fracture?

The navicular bone is a small, wedge-shaped bone located in the midfoot, articulating with the talus and cuneiform bones. It plays a key role in maintaining the medial longitudinal arch and absorbing impact during gait.

A stress fracture occurs when repetitive loading exceeds the bone’s ability to repair, leading to microfractures. In the navicular, this typically affects the central third of the bone, an area with limited vascularity—making healing more difficult.

Who Is at Risk?

Runners—particularly those increasing volume or intensity rapidly—are most at risk. Contributing factors include:

High training loads
Poor shock absorption (e.g., rigid feet, poor footwear)
Biomechanical abnormalities (e.g., overpronation or cavus foot posture)
Previous history of stress fractures

Studies suggest navicular stress fractures are more common in track and field athletes, with incidence rates estimated between 15-35% of all tarsal stress fractures (Khan et al., 1994; Torg et al., 1982).

Symptoms and Clinical Presentation

Early diagnosis is critical. Classic signs include:

Dorsal midfoot pain – usually vague and poorly localised
Pain aggravated by activity and relieved by rest
Tenderness over the "N spot" – dorsal navicular palpation
Occasional swelling
Pain with hopping or single-leg heel raise

Unfortunately, NSFs often present insidiously and are missed without high clinical suspicion.

Diagnosis

Imaging is essential. Plain X-rays often miss navicular stress fractures, especially early on.

The gold standard includes:

MRI – sensitive for bone marrow edema
CT scan – best for assessing fracture lines and cortical involvement

The Torg classification system (I–III) helps grade severity and guides treatment (Torg et al., 1982).

Physiotherapy Management

Initial Management: Offloading Is Key

Rehabilitation Goals

Maintain cardiovascular fitness with non-impact activities (e.g., swimming, cycling)
Address contributing factors:
- Biomechanics (e.g., orthotics for overpronation)
- Running technique
- Strength deficits (especially gluteal, calf, and intrinsic foot muscles)
Progressive loading and impact reintroduction

A graded return-to-running program should only begin after full pain resolution and radiological healing confirmation.

Prevention Strategies

Gradual training progression (10% rule)
Ensure proper footwear with adequate support
Strengthen the kinetic chain (hips, calves, feet)
Consider bone health and dietary intake (vitamin D, calcium, energy availability)

Return to Sport

Most runners return to pre-injury levels within 4–6 months, though this varies with fracture severity and compliance. A phased return guided by pain, function, and imaging is critical.

Reinjury is possible without addressing underlying biomechanical or systemic issues, so the physiotherapist plays a key role in both rehab and long-term prevention.

Key Takeaways

Navicular stress fractures are high-risk injuries requiring early detection and proper management.
Physiotherapists are essential in recognising subtle signs, facilitating referral for imaging, and guiding rehabilitation.
Evidence-based rehab involves offloading, strengthening, biomechanical correction, and gradual return to sport.
Prevention is possible with load management, proper footwear, strength training, and nutrition.

References

Khan, K. M., Fuller, P. J., Brukner, P. D., Kearney, C. E., Burry, H. C., & Bradshaw, C. J. (1994). Outcome of conservative and surgical management of navicular stress fracture in athletes: 18 cases. The American Journal of Sports Medicine, 22(6), 810-818.
Torg, J. S., Moyer, R. A., Gaughan, J. P., & Boden, B. P. (1982). Management of tarsal navicular stress fractures: conservative versus surgical treatment: a retrospective study. The American Journal of Sports Medicine, 10(5), 345-355.
Nattiv, A., Loucks, A. B., Manore, M. M., Sanborn, C. F., Sundgot-Borgen, J., & Warren, M. P. (2007). The Female Athlete Triad. Medicine & Science in Sports & Exercise, 39(10), 1867–1882.

Need help managing a navicular stress fracture or recurrent foot pain? Reach out for a physiotherapy assessment—early intervention makes all the difference.