In this video, we're gonna look at navicular stress fractures, which is a tiny little bone
in the bridge of your foot. Now, we're going to look at: Why does this bone get injured so
easily in certain types of sport? Why doesn't it heal that well? And why is it seen as a high-risk
stress fracture? Then, we're going to take a look at what's the most common causes of this. And then
finally, we’ll also look at what treatment options you have, either conservative and surgical,
and what are the arguments for which, and how long you can expect your recovery time to take.
So, for those of you who don't know me, my name is Maryke. I'm one of the physiotherapists from
sports-injury-physio.com, where you can get online physiotherapy assessment as well as treatment for
your injuries. Have a look at the description of this video if you want a link to our website.
Okay, so where is the navicular bone and what does it do? If you look at your little bones in your
foot, the navicular bone is right on the bridge, right on the inside there, and it's quite a large
little bone compared to the rest of them. It takes a lot of strain, and it's kind of in the centre of
all the weight transferring movements when you play your sports. And navicular stress fractures
are very common in people who play sports that have a lot of changing of direction in it,
or jumping sports and quite fast push-off, but it's also common in long distance runners.
Now, if you look at the blood supply of the navicular bone, you have good blood supply on the
one side, good blood supply on the other side, but then you have a zone in the middle that doesn't
quite have such good blood supply, and it's that area that's vulnerable to overuse injuries. And
the reason for that is, it takes a bit longer for that part of the bone to recover. So, if you're
not … If you're doing high volumes of training and you're not allowing enough recovery time,
that's the bit that's gonna strain the most. And also, if you do ... It won't have the strength
to deal with really sudden increases or large increases in volumes, if you do not build it over
time. So, what's the main causes of this? I've touched on it, basically, that overuse is that the
major cause of that. So, you're not giving it enough time to recover, or there's something,
you've changed your shoes and there's for some reason, now you've suddenly inverting a
lot .... ah ... pronating a lot more and putting more strain on there. So, there's some change in
your normal environment that makes that part work harder and not allowing it to recover enough. Now,
certain things like over-pronation can predispose you to it. Also, there's some research to show
that if you've got a stiff ankle joint that doesn't want to dorsiflex so much,
that can predispose you to it. Now, on that note, some people just have feet – especially guys with,
or people with really high arches – they have an anatomical reason for their foot being stiff,
and they can't really improve that range of motion. So, it can be useful
if the clinician you're working with thinks that that's part of the cause of yours,
it could be useful to see a podiatrist, because they can help adjust your footwear
that it takes some strain off that, but that's just one part. Then, other things you want to
be thinking about are vitamin D levels as well as the food you take in. So, vitamin D is really
important for us to … in our bodies to have strong bones, because you can take in all the calcium
you want, but you can't actually absorb it from your gut if you don't have enough vitamin D. Now,
we get vitamin D naturally from the sun; it gets produced in your skin. But if you wear sunblock
every time you go out in the sun or you live in areas that you don't really see much sunshine,
especially in the wintertime; there's quite a lot of research to show that athletes in Europe
are vitamin D deficient in the wintertime. Even athletes in places like Israel, where there's
a lot of sun, because they don't train in direct sunshine or they cover themselves up when they're
in the sun, they can be vitamin D deficient. So, it's something that your doctor can test for you.
Have a look … If you've got a stress fracture, it’s always good to look at vitamin D levels.
The other thing that's really important, and especially for people who do endurance sports,
is that you check that you're actually getting enough energy into your diet. So, there's strong
research now to show that for both males and females, if you have what we call a relative
energy deficiency (the acronym for it is Red-S), all it means is that over a long period of time,
you're taking in fewer calories than what you burn; your body thinks that you're in a starvation
phase. So, what it then does is, it shuts off processes that it doesn't see as essential
for survival. And one of those processes is the process of renewing your bones. So, every time
you train, you're getting little bits of micro damage in all your tissue, including your bones,
but your body's going to repair that then. But now your body’s thinking you're starving, so it's not
repairing the damage from exercise. And that's when you ... one of the main reasons why people
do end up with stress fractures. So, if you think you may possibly not have been taking
in enough energy, it's worth consulting somebody who works with sports nutrition and just checking
how can you adapt your diet to, first of all, help your recovery from the stress fracture,
but secondly, to avoid it in the future. Good! So let me see what I'm leaving out.
What are the symptoms of a navicular stress fracture? So, the first thing that you'll feel is,
you'll feel pain over the bridge of your foot, more towards the inner part of the foot,
and sometimes even along the inside of it; it can be underneath as well. But it's not a pain that
you can easily say, ‘Here it is!’ or, you know, that you really clearly know. It can just feel
like this dull ache that you don't know where is. Sometimes, it can be a bit sharp when you push on
this or step on it as well. It can sometimes get confused with plantar fasciitis if it gives you
pain underneath the foot. It can be confused with things like tib post tendinopathy, because both
of them can give you pain on the inside of your of your ankle, or tib ant tendinopathy, which is
a tendonitis or tendinopathy that you get in the tendons that run over the bridge of the foot.
So, those are things that a clinician can help you identify and differentiate between. Now ... What
was I going to say? Oh, yes! The other important thing is, the pain doesn't start with a sudden
thing. So, it's not that you step on your foot and suddenly you feel a sharp pain.
This ache or pain you feel with the activity usually builds slowly over time. And it's
usually at the beginning, just when you do your sports or just when you stand a lot or walk a lot.
But as it progresses, it can become painful when you're just sitting or sleeping. So,
it comes in various forms, depending on how long you've had the injury for. How to diagnose it?
Well, a skilled clinician should be able to listen to the history you're telling them, plus do some
tests to check that it's not the other things we've just spoken about, like the tendinopathies.
And then there's a test where, if you press directly on the navicular bone from the top,
if that's painful, what the research is showing is that it's very likely that you've got a stress
fracture then. However, if it's not painful, it doesn't rule it out; it just means that you've got
to do further investigations then. But if it is painful when you press directly on the navicular
bone, it’s likely that you've got a stress fracture then. Then, the first step is to get
an X-ray. Now, X-rays aren't that sensitive for stress fractures; they can easily be missed on it.
Why do we do an X-ray? Because it can pick up other things. So, it can pick up coalition of
the tarsal bones, which means that you've got an anatomical reason why there's differences
in bones that's kind of pressing on each other. Or it can pick up things like growths, it can pick up
osteophytes. So, even though you can't rule out a stress fracture if it comes back not showing one,
it can show you other things that are useful. But then, an MRI scan is the gold standard
to pick up stress fractures. Because also, you've got to remember that actually, before you get
to the stage where the bone fractures, you get what we call a stress reaction in the bone. And
if you look on an MRI scan, it's if a bone has a stress reaction in it, it's just going to show you
a really angry part in that bone, and it's not going to show a fracture line at that point.
And only MRI scans can really pick that up. So, an X-ray can't show that for you.
And then also, MRI scans are better at ... Sometimes, depending on how the fracture lies,
it's just lying in a position where the X-ray doesn't pick it up, whereas MRI scans can do
that. So, that's really the gold standard to be diagnosing it with this. Good! So now you've got
the unfortunate diagnosis of, it is a navicular stress fracture. What are your treatment options?
The researchers are having a little bit … or clinicians are having a little bit of argument
between whether you should go conservative first and then surgery, or surgery in all cases.
So, I'm going to talk about both, because I think it's important for everybody to make
their own informed decision about this. So, let's talk about conservative management first.
The first step in that is that you get immobilized in a boot for at least six
weeks, but often actually eight weeks, with absolutely no weight bearing through that foot.
Now, it doesn't help to cheat, because it may not be painful to weight-bear through it. But what the
research is showing … Remember that blood supply isn't great in there. If you want the conservative
treatment to be successful and avoid surgery, you have to put absolutely no weight through
that foot for at least six weeks, but likely up to eight. Then, once you come out of that boot,
you've now had six to eight weeks of no weight through it. So, you would have lost muscle
strength in your foot, you would have lost muscle strength around your ankle, and perhaps … Well,
ideally, your physio will help you with exercises that you can do to strengthen the rest of your
body but doesn't put weight through that. But you have got to improve the strength and control
in those muscles first, otherwise you will end up injuring your foot and ankle again.
So, the first step is then to do exercises that strengthen the intrinsic muscles of your foot
as well as the muscles that control your ankle. So, strength is one aspect. The other aspect is,
you've got to do proprioceptive exercises. Now, although it's a mouthful, all it means is it's
balancing type exercise, exercises that help your brain to connect to your foot and ankle again.
Proprioception is that ability that, when you close your eyes,
you know exactly where your fingers are, your toes are, where your feet are, everything. Now,
what we don't actually realize is, every step we give, our brain has to calculate exactly at what
speed you're moving at, what position your foot is, what position you're going to hit the ground,
so that it can activate the muscles in the perfect rhythm, as well as with the perfect intensity
for that job. So, it's really complicated. Now, when you've had an injury like this,
and especially if you've been immobilized in a boot or plaster cast for a while, your brain loses
a little bit of that connection to that body part, and you've got to restimulate it and rebuild it.
It’s really easy to do if you're very diligent with your balancing exercises. So,
you would start with easy, simple things. Just … I despair sometimes, because as soon as people hear
‘balancing exercise’, they think, ‘Ah, balance board! Let's get on really unstable surfaces!’
No. You start on a stable surface. Can I keep my balance on one foot on the floor
without wobbling and looking like this? If you can't do that, there's no ways that you should be
progressing to anything unstable, because you'll just injure yourself. You've got to master the
easy things first. Again, a physio will help to guide you through that. So then, the other thing
to remember is that while it's immobilized and while you're not putting weight through the foot,
your bones and everything will also just go, ‘Nah, we don't have to be that strong at the moment,
and we're not used to weight bearing anymore.’ Little bit like an astronaut coming back from
space; not that severe. But you will have to load it slowly over the next few weeks to get it used
to load bearing and get those bones to recover and rebuild themselves nice and strongly again.
This whole process will take you about 12 weeks from the moment you come out of the boot to the
moment that you're ready to return to your full sport. And an important thing to remember is,
12 weeks may sound long, but that's the regular time that people will take when
they go from totally unfit to really ready for sport if they don't want to get injured. So,
we're looking for conservative treatment to take you around five months if you take that you've
got to be in the boot for two months – well, one-and-a-half to two months – and then you've got
to take your time with your rehab to ensure that you don't just end up overloading the bone again
and that you get all your strength back. At the same time, remember to think about supplements,
think about your energy deficiency; all of those elements feed into this. Now, why may some people
consider surgery to be a better option than conservative treatment? The reason being that
the conservative treatment takes such a long time. So, some people argue that, ‘No, no, no! If we've
got a top-level athlete who can't take that much time out, bang them into surgery and the recovery
time is a bit shorter.’ Now, it's important to realize that it's not shorter by much. It's not to
get you back to training full on and competition within six weeks; it's usually about … I think the
research showed that it's about three-and-a-half months versus five months recovery time. So,
you're saving roughly about six weeks. And the typical surgery they'll do is, they'll go in and
put a pin in – small pins or screws – sometimes do a bone graft as well. Now, whenever you do
surgery, there can be complications, and we don't quite know what the long term – so, several years
even after you stop competition – what the effect on your foot will be from that. So,
that's why some clinicians reckon that it's better to try the conservative treatment first and allow
your body to heal itself in the natural way. And then, only if that fails do you consider surgery.
But this is something you've got to decide for yourself and discuss with your doctor,
which route you want to take. Hope you found this useful! Let me know if you've got any questions.
And remember, if you need more help with an injury, you’re welcome to consult one of the
team via video call; the link to our website’s in the description of this video. Take care!