From the Guidelines
Navicular pain should be initially evaluated with radiography, as it is the most appropriate first-line imaging study, according to the American College of Radiology Appropriateness Criteria 1. This is because radiography can help distinguish among different causes of chronic foot pain, including tarsal coalitions, stress fractures, and osteoarthritis.
Causes and Diagnosis
Navicular pain can result from various causes, including overuse, structural foot issues like flat feet, or traumatic injuries. The diagnosis of navicular pain involves a combination of clinical evaluation and imaging studies. The Ottawa Ankle Rules, which include point bone tenderness of the navicular, can help guide the decision to obtain radiographs in patients with acute foot trauma 1.
Treatment
Treatment of navicular pain typically involves conservative measures, such as:
- Rest, ice, and non-weight bearing activities for 4-6 weeks
- NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (500mg twice daily) to reduce inflammation and pain
- Supportive footwear with arch support or custom orthotics
- Physical therapy focusing on foot strengthening and flexibility
Severe Cases
For severe cases, a walking boot or cast may be necessary for 6-8 weeks. If conservative treatments fail after 3-6 months, corticosteroid injections or surgery might be considered. It is essential to note that the navicular bone has limited blood supply, making healing slower than other bones. Returning to normal activities should be gradual to prevent reinjury.
Imaging Studies
While radiography is the initial imaging study of choice, other modalities like MRI or CT may be necessary in certain cases, such as suspected fractures or soft tissue injuries. MRI, in particular, allows for optimal visualization of the bone marrow within the ossicle and visualization of the synchondrosis, making it useful in the evaluation of symptomatic accessory ossicles 1. Ultrasound may also be used to evaluate conditions like plantar fasciitis, Morton's neuroma, or intermetatarsal bursitis, especially when there is a high clinical suspicion of these conditions 1.
From the Research
Navicular Pain Causes
- Navicular stress fractures are a common cause of navicular pain, particularly in young athletes 2
- These fractures are multifactorial injuries due to chronic overload on the navicular 2
- The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion 2
Diagnosis of Navicular Pain
- Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome 2
- Advanced imaging is essential in making the diagnosis and monitoring healing 2
- A thorough history and physical, plain radiographs of the foot and ankle, followed by a CT scan can be used to fully characterize any fracture of the navicular and to rule out other etiologies of foot pain 3
- If a CT scan is negative, and a high clinical suspicion persists, an MRI scan can be obtained to rule out a stress reaction 3
Treatment of Navicular Pain
- Both nonsurgical and surgical treatments have demonstrated good results for navicular stress fractures 2
- Nonsurgical management consists of a period of immobilization and nonweight bearing 2
- Surgical management typically involves open reduction and internal fixation 2
- Surgical intervention for appropriately selected patients can result in full symptom resolution and a return to the desired level of athletic participation 3