Navicular Stress Fracture: Symptoms, Causes & Treatment
Navicular Stress Fracture: Why That Midfoot Pain Could End Your Season
If you’ve been feeling a nagging ache across the top or inside of your midfoot during running, and someone has told you it’s “just tightness” or an angry tendon — I implore you: think again.
Many athletes come to SportsFit Physio and Health for a second opinion after weeks of worsening tightness, discomfort and eventually pain across the top of their midfoot, only to discover it’s a navicular bone stress injury — one of the highest-risk stress fractures in the entire body.
Left untreated, this isn’t just a niggle. It can mean surgery, months off running, and in some cases an inability to return to running at all. The good news? Early diagnosis and proper management can literally save your season — and your running or sporting career.
At SportsFit Physio and Health, we regularly assess and manage navicular and other bone stress injuries in runners and athletes from Glen Iris, Malvern East, Ashburton and surrounds.
What On Earth Is a Bone Stress Injury?
A ‘Normal’ Fracture vs a Bone Stress Injury
When people hear the word “fracture”, they typically think of acute fractures that happen instantly in response to trauma — twisting an ankle, or falling down the stairs. These injuries sometimes require surgery and time away from sport, and come with their own distinct challenges.
Bone stress injuries (BSIs) are completely different. They develop gradually, over a period of time, in response to changes in bone loading and physiology. Let’s explain how.
How Bone Stress Injuries Happen
To understand bone stress injuries, it helps to know a little about bone physiology.
Your bones aren’t just solid scaffolding — they’re living tissue, constantly broken down and rebuilt in a process called bone remodelling. There are two main bone cell types involved in this process:
- Osteoclasts — the demolition crew, clearing out old or micro-damaged bone.
- Osteoblasts — the builders, laying down fresh bone.
When this process is balanced, bones adapt beautifully to running and other loads. When it isn’t, you can tip into what’s known as the bone stress injury continuum:
- Microcrack formation — normal, and needed to stimulate the bone’s remodelling pathways.
- Excessive microcrack accumulation — starting to tip towards greater bony breakdown.
- Bone stress reaction/response — early swelling, inflammation and irritation inside the bone without a visible fracture line. May show as bone marrow oedema or a periosteal reaction on MRI. May or may not be symptomatic. Usually visible only on MRI — not X-ray.
- Stress fracture — an actual, visible crack forming in the bone once loading outpaces repair. Usually accompanied by some bone marrow oedema/stress reaction findings as well.
- Complete fracture — the worst-case scenario if ignored. When a stress fracture progresses to a complete fracture, it can displace and become unstable enough to affect nearby blood vessels and nerves, leading to permanent disability and requiring surgical treatment for bony stability.
Factors That Tip the Balance
Several key factors push the balance toward breakdown:
- Training spikes — sudden jumps in mileage, intensity, hills or speed, typically within the 4–6 weeks before symptom onset. These increase bone load immensely, and without enough emphasis on recovery, our bone-building cells simply don’t get enough time to do their job.
- Energy availability — under-fuelling, very low-carb diets, or Relative Energy Deficiency in Sport (RED-S) can have an enormous impact on normal bone remodelling and turnover.
- Hormonal imbalances — oestrogen, testosterone, thyroid and cortisol levels, vitamin D status, and irregular or absent menstrual cycles are all necessary for proper bone health and physiology.
- Bone mineral density — low bone mineral density or a history of stress fractures increases vulnerability.
- Recovery issues — poor sleep, illness, or certain medications such as corticosteroids (common in people with asthma).
Put simply: your demolition crew (osteoclasts) can outpace your builders (osteoblasts) if your bone, energy, activity and hormonal environment isn’t supporting repair and positive adaptation.
So, bone stress injuries are injuries anywhere along that spectrum that gradually develop due to imbalances in the bone remodelling cycle — most commonly from doing too much, too soon. This is very different to the “standard” acute fracture that happens instantly in response to a specific trauma.
Navicular and Midfoot Anatomy & Biomechanics Basics
The navicular sits on the inside of your midfoot. It joins with the talus (one of the ankle bones) and the three cuneiforms (which lead to your first three toes), and sits beside the cuboid on the outer midfoot.
A simple way to understand its role is to picture the foot split into two “columns”:
- Medial column (inside of the foot): navicular, cuneiforms, and the first three metatarsals/toes. This side is built to be stronger and stiffer, helping the foot transfer force from the ground up through the body, and vice versa.
- Lateral column (outside of the foot): cuboid, and the 4th and 5th metatarsals/toes. This side is more flexible, helping the foot adapt to uneven ground.
The navicular is often called the “keystone of the midfoot” because it’s the central bone that helps support the entire medial arch. When you go up onto your toes — like at the top of a calf raise, or during push-off in walking or running — your big toe bends and tightens the band under your foot (the plantar fascia). This lifts and stiffens your arch.
As this happens, the navicular becomes the main stabiliser. It’s the bone everything pulls toward, helping lock the arch into a strong, load-bearing position.
In everyday terms: whenever your arch tightens and lifts, the navicular is the key bone holding your midfoot steady and supporting your body weight. The navicular is subjected to high amounts of compressive force as the surrounding bones push into it (as part of its keystone role), while also being subjected to high tensile loads from the pull of the tibialis posterior tendon.
The navicular also articulates (forms joints) with five other bones in the ankle and foot:
- The talus — the closest joint to the ankle
- The cuboid — right next to the navicular, laterally
- The medial cuneiform
- The middle/intermediate cuneiform
- The lateral cuneiform
As a result, there’s a high concentration of joint structures around the navicular — hyaline cartilage, synovial membrane, and ligaments such as the important deltoid ligament complex and spring ligament. There are also several important muscles and tendons in the area, particularly the tibialis posterior tendon, which attaches onto the navicular tuberosity, and the tibialis anterior tendon, which inserts just past the navicular on the medial cuneiform. On top of this, we have all of the small intrinsic foot muscles and the plantar fascia running through the same region.
Why the Navicular Bone Stress Injury Is So Dangerous
1. High Biomechanical Forces
As mentioned above, the forces and loads placed on the navicular are incredibly high and complex — to the point where we probably don’t fully understand them yet.
What we do know is that it’s not only subjected to a high amount of force, but many different types of force, including compressive, bending and tensile forces.
The main reason this is dangerous is that it’s incredibly hard to truly rest this bone enough to allow it to heal. And even once it has healed and we start to reload with calf raises, running and jumping, we’re again subjecting it to that same combination of forces. There’s unfortunately no getting around it if we want to return to those activities.
2. Blood Flow and Supply
In addition to the sheer amount of force and pressure put through the navicular, it also has a notably poor blood supply. Proper bony remodelling — and, in the case of a BSI, healing — relies heavily on good blood supply and perfusion to deliver oxygen, nutrients and hormones.
The navicular’s blood supply comes from two arteries:
- The tibial artery supplies the inner/medial aspect
- The dorsalis pedis artery supplies the outer/lateral aspect
Frustratingly, there’s a “watershed” area on the dorsal (top) and central aspect of the navicular that receives very little blood supply, which slows healing and makes it less predictable. This is made worse by the fact that this same watershed area is the part of the bone believed to be subjected to the highest forces.
3. Symptoms: Why These Injuries Are Often Missed
Navicular bone stress injuries creep in slowly and behave in a vague, hard-to-pin-down way, which means they can easily be mistaken for something far less serious in their earlier stages. Early symptoms often include:
- Gradual, vague pain and tightness at the top and inner aspect of the midfoot, often described as a low-level ache
- Pain that eases during warm-up but returns after sport (which, from a physio’s perspective, can sound more like tendon pain)
- Pain that’s hard to pinpoint — more diffuse or vague than a typical sharp injury
- A slight, vague, achy pain at the top of a calf raise
- A slight, vague, achy pain with the push-off phase of a hop or jump
- A history of training spikes, energy deficits, poor sleep, or hormonal changes
As the injury progresses along the bone stress injury continuum, symptoms tend to become more severe:
- Pain that worsens during running and forces you to stop
- Pain with any weightbearing, including walking
- Limping
- Pain at rest
- Stiffness getting up from a chair or out of bed
- Night pain
- Stiffness and increased pain first thing in the morning
- Overall worsening pain severity and irritability
- Worsening pain at the top of a calf raise
- Worsening pain on the push-off phase of a hop or jump, with or without pain on landing
If this sounds familiar, it’s time to take action before it progresses.
Because the symptoms seem so mild, it’s very common for both the person experiencing them and health professionals to write them off as nothing more than tightness or a minor sprain.
This is part of what makes a navicular stress fracture so dangerous — it’s genuinely hard to pick up clinically, and hard to diagnose correctly. If we don’t get the diagnosis right, we’re very unlikely to build the right treatment plan. In fact, the average time to diagnosis for these high-risk bone stress injuries is nine months (Attia et al., 2021), and one study included a participant whose injury went undiagnosed for ten years (Potter et al., 2006).
The most common “incorrect” diagnosis health practitioners make is tibialis posterior tendinopathy — and honestly, it’s easy to see why. The symptoms and onset are remarkably similar, the loads through both the tendon and the bone are extremely high during the activities that bring on symptoms, the pain location is nearly identical, and particularly in the earlier stages people can often still hop and jump with only minor symptoms, which can point away from a bony injury.
But here’s where the inverted commas come in. We often do see genuine tibialis posterior tendon changes on MRI in these patients — but it’s usually secondary to something far bigger: a navicular bone stress injury. If that bone is angry, inflamed and swollen, the tib post tendon gets caught in the crossfire and becomes painful too. So the tibialis posterior tendinopathy can often be a red herring — or more accurately, a red flag for something bigger going on. In that sense, those “incorrect” diagnoses aren’t always entirely wrong.
4. Long Return-to-Sport Times, Lower Return Rates and High Complication Rates
Given the factors above, the impact of these injuries on individuals is generally significant. They take a lot longer to heal, often require surgical fixation to stabilise the fracture, and take a long time to return to sport — usually around six months, but sometimes far longer. They also carry higher rates of avascular necrosis (bone death) and persistent disability and pain, higher rates of non-union (failed bony healing), and higher rates of re-fracture (Attia et al., 2021; Torg et al., 2010). This combination often leads to a poor treatment outcome and rehab “failure”.
5. Likelihood of Fracture Progression
Perhaps the most important reason this type of BSI is so dangerous: when you combine the factors above — poor blood flow, high biomechanical forces, long return-to-sport times and vague clinical symptoms — the risk of fracture progression is high. The chance of this type of BSI progressing along the continuum toward a complete, displaced fracture is significantly higher than at other sites in the body.
Defining and Classifying A Navicular Stress Fracture: The Saxena Classification System
If there’s even the slightest suspicion of a navicular bone stress injury, it’s essential that it’s appropriately imaged so we can grade the injury and select the right management strategy. There are two main management pathways — surgical and non-surgical — and the imaging findings (along with your goals, preferences and overall clinical presentation) tell us a great deal about which is likely to be the best fit.
We’ll usually refer you for an MRI, sometimes alongside a CT scan. An MRI is best for picking up early bone changes — known as a stress reaction — which sit at the early end of the bone stress injury spectrum and may not show up on a CT. Catching an injury at this stage is ideal, since earlier diagnosis almost always means a smoother, quicker recovery. That said, in bones like the navicular, it’s quite rare to detect a stress reaction alone, because symptoms are often so mild that people don’t seek treatment until the injury has already progressed.
A CT scan is often added to get a clearer picture of the bone itself. While MRI is excellent for early changes, small fracture lines can sometimes be hard to see on MRI — and this is where CT is particularly helpful, as it’s highly sensitive for detecting fractures. Using both scans together helps avoid missed diagnoses and ensures we choose the right treatment pathway from the start. A CT scan can also be especially useful in more chronic cases, where MRI false negatives are a bit more common.
Saxena et al. (2000) looked at classifying and grading navicular bone stress injuries using CT, aiming to better quantify diagnosis and guide treatment decisions. They classified navicular stress fractures into three grades describing the extent of the fracture line, plus additional modifiers. A further grade, based on MRI, was added later (Saxena et al., 2010).
- Grade 0.5 — Bone stress reaction only. Early bone marrow oedema on MRI, with no fracture line seen on either MRI or CT.
- Grade I — A confirmed, smaller stress fracture on CT, isolated to the dorsum (top) of the navicular and not extending into the centre of the bone.
- Grade II — A confirmed fracture on CT extending from the dorsum of the navicular into the central aspect/body of the bone.
- Grade III — A confirmed fracture on CT extending all the way from the dorsum through to the plantar aspect of the bone — essentially, right through the bone.
The modifiers include:
- A — signs of avascular necrosis (bone death)
- C — cystic changes within the bone, indicating a more chronic injury and potentially failed bone repair
- S — signs of sclerosis around the fracture line, indicating impaired healing or bony repair
Saxena et al. (2000; 2010) found that Grade I injuries were typically treated non-operatively, while Grade II and Grade III injuries tended to be treated operatively, particularly in the presence of any modifiers. They also found that return-to-activity timeframes differed significantly between grades, with higher-grade injuries leading to longer time away from activity.
So What’s Better: Surgical or Non-Surgical?
This is genuinely hard to answer. As always, it depends.
The first thing to remember is that the overall aim of bone stress injury management is to reduce the chance of fracture progression and, where possible, prevent re-fracture down the line. In some cases, non-surgical management achieves this. In others, surgery is needed.
The other thing that makes this question difficult is how sparse the evidence is. Because this is a relatively rare injury, there isn’t a huge amount of scientific data to guide management decisions — the answer genuinely requires a lot of nuance.
Still, with the limited data available (both in numbers and methodology), we can try to answer it as best we can. A review of the overall evidence was performed by Torg et al. (2010), comparing the two approaches across a sample of 313 navicular bone stress injuries.
The most successful intervention in that review was non-surgical management, where people were placed in cast immobilisation (a tall moon boot) and made non-weightbearing for six weeks using crutches. When this strategy was followed for the full six weeks, the treatment success rate was 96% — and, interestingly, this didn’t change between partial and full fractures (Grade I vs Grade III). The success rate for surgical management was 82%.
Importantly, if people deviated from the protocol even slightly — say, non-weightbearing for four weeks instead of six — the success rate dropped to 77%. Is that extra two weeks worth a 19% increase in risk of failure? If people were allowed to partially weightbear at all, the success rate dropped to 47%. One limitation of this review is that it didn’t specifically look at return-to-sport rates or time to return to sport — “success” was defined as being pain-free, able to return to previous activities, and free of re-fracture.
The other major review comes from Attia et al. (2021), which added to the available sample size while broadly comparing surgical versus non-surgical management. They found the surgical pathway had a notably higher treatment success rate — 97.9% versus 78.1% in the non-surgical group.
A limitation of this study is that it grouped all non-operative management together as one strategy, rather than separating out, for example, six weeks of strict non-weightbearing versus four weeks. This means some patients in the non-operative group may have been allowed to weightbear throughout their recovery, which could have worsened outcomes for that group. The statistical analysis is also somewhat underpowered, meaning we likely can’t draw particularly strong conclusions, and one included study heavily skewed the overall results.
A strength of this study, however, is that it compared several outcomes between the non-operative and surgical groups:
- Return-to-sport rate: 98.98% in the surgical group vs 73.43% in the non-operative group
- Time to return to play: 4.17 months in the surgical group vs 4.67 months in the non-operative group
- Re-fracture rate: 20 of the 21 total re-fractures in the review occurred in the non-operative group
- Non-union (failed bone healing): a 14.56% rate overall across studies reporting on this — 3% (3 of 94) in the surgical groups vs 21% (33 of 154) in the non-operative groups
Frustratingly, the literature isn’t consistent. One study concludes that surgical fixation should be the first-line treatment for all navicular bone stress injuries, while another suggests that six weeks of strict non-weightbearing in a tall boot offers the best outcomes with non-operative management. This low-level, conflicting evidence is exactly why management needs to be individualised rather than based on a single blanket approach.
The best approach is careful, shared decision-making that takes into account your goals and timelines, personal preferences, imaging findings, past injury history, and current clinical presentation. This decision is typically made collaboratively between you, your physio, a sports medicine physician, and sometimes an orthopaedic surgeon, to ensure the chosen pathway best fits your situation.
Rehab & Recovery
Our core treatment goals in bone stress injury management are to:
- Reduce the chance of progression to a complete, displaced fracture
- Safely return to your chosen endeavour or sport
- Decrease the risk of bone stress injury recurrence, either in the same spot or elsewhere in the body
- Reduce and address the risk factors associated with recurrence
- Improve overall bone health
Early, guided management can genuinely save your midfoot — and your running.
Strict Load Management
This typically means an initial period of non-weightbearing, followed by gradual, guided reloading. How long you need to be non-weightbearing is generally guided by an orthopaedic surgeon or sports medicine physician experienced in this area — this decision isn’t usually made by a physio alone.
Targeted Strength & Conditioning
We know athletes who undertake regular, consistent resistance training are up to four times less likely to develop a bone stress injury (Kobayashi et al., 2025), highlighting just how important muscle strength is for bone health. We also know that bone mineral density typically declines globally for more than 12 months after a bone stress injury (Alway et al., 2022; Popp et al., 2021), and that activities like slow, continuous running place very high muscular forces through the body — the capacity of these muscles to produce and tolerate that force takes real, dedicated work to rebuild.
A targeted, individualised and gradual strength and conditioning program is essential, both for returning safely to your chosen activity and for improving overall bone strength to reduce the risk of recurrence. This matters even more given that the single biggest risk factor for developing a bone stress injury is having had one before, anywhere in the body (Wright et al., 2015).
Addressing the ‘Why’
A key part of managing these injuries is trying to prevent recurrence and complications as effectively as possible. To do that well, we need to look at the individual risk factors that may have contributed to the injury in the first place — things like energy balance and availability, hormonal and menstrual health, and overall bone health.
In my own clinical practice, I routinely refer bone stress injury clients for blood tests and other investigations to look into these areas, and regularly involve one of our Sports Dietitians, Alex or Paige, to assess the role diet and nutrition might be playing in bone health. In some cases, further referrals may be needed — such as a DEXA scan to assess bone mineral density (looking for osteopenia or osteoporosis), or referral to a women’s health specialist and/or an endocrinologist. Without looking into these things, we risk missing an important part of the picture — potentially affecting bone healing, bone strength after recovery, and the risk of recurrence.
Running Re-education and a Gradual Return-to-Run Program
One of the key reasons bone stress injuries happen in the first place is a spike in training volume. Since ongoing prevention is such a critical part of managing these injuries, we need to make absolutely sure we don’t repeat the same mistakes. This is particularly important for navicular bone stress injuries, given the extended non-weightbearing period and associated deconditioning involved.
Criteria-Based Rehabilitation
Most protocols allow a return to running at around 12 weeks post-injury, provided a follow-up CT scan shows good bony healing. But is the rest of your body ready for it? Will you have enough strength to tolerate the huge forces going through the foot during running? The bone itself might be ready, but if your joints, muscles and tendons aren’t, you’re setting yourself up to re-fracture on return to running and dynamic sport.
This is why it’s so important to use physical performance criteria — strength, jump and hop testing, such as the AxIT strength testing equipment we use at SportsFit Physio and Health — alongside imaging results and surgical clearance, before returning to run. Assess, don’t guess.
A Word of Advice: Patience, My Friend — Go Slow to Go Fast
If you’ve made it this far, you’ll have a good sense that this is a big, nasty, and genuinely dangerous injury. Honestly, that might be putting it lightly.
Recovery from this injury is long, complex, and often full of ups and downs — healing complications, surgical risks, pain flares and deconditioning are all common, and the impact extends well beyond the physical to your mental and emotional wellbeing.
In my opinion, these higher-risk bone stress injuries are still poorly understood globally, and that lack of understanding likely contributes to their poor prognosis and high recurrence rates. Because of this, rehab should be far longer and more comprehensive than it typically is — addressing not just the bone, but strength, plyometric capacity, energy availability and the psychological load of the injury.
Too often, a patient is “cleared” to run as soon as pain has settled and follow-up imaging looks better — and in my view, that approach sets people up to fail. At that point, most people haven’t rebuilt enough muscle strength, jump and landing (plyometric) capacity, or bone resilience to tolerate running safely.
Rehabilitation for this type of high-risk BSI is a marathon, not a sprint. Be patient, be diligent, and remember: go slow, to go fast.
The Take-Home Message
Don’t ignore pain at the top of the midfoot. The navicular is one of the highest-risk sites in the body for a stress injury, and missing it can mean a complete fracture, surgery, and months off running — or, in some cases, an inability to return to running at all.
At SportsFit Physio and Health, we recognise the signs early, guide appropriate imaging, and manage your recovery safely. Catch it early — it could save your season, and your running career.
If you’ve had this sort of pain with running, or it’s worsening despite rest, stretching or foam rolling, book an assessment immediately. Better safe than sorry.
Todd Grbac
Physiotherapist
References
Alway, P., Peirce, N., Johnson, W., King, M., Kerslake, R., & Brooke-Wavell, K. (2022). Activity specific areal bone mineral density is reduced in athletes with stress fracture and requires profound recovery time: A study of lumbar stress fracture in elite cricket fast bowlers. Journal of Science and Medicine in Sport, 25(10), 828–833. https://doi.org/10.1016/j.jsams.2022.08.006
Attia, A. K., Mahmoud, K., Bariteau, J. T., Labib, S. A., DiGiovanni, C. W., & D’Hooghe, P. (2021). Return to sport following navicular stress fracture: A systematic review and meta-analysis of three hundred and fifteen fractures. International Orthopaedics, 45(7), 2699–2710. https://doi.org/10.1007/s00264-021-05147-6
Kobayashi, T., Seki, S., Liu, M., Chiba, I., Oguro, T., Makino, Y., Kobayashi, Y., Matsumoto, H., & Hwang, I. (2025). Effects of resistance training experience on bone mineral density and stress fractures in female college athletes: A retrospective cohort study. Sports, 13(7), 227. https://doi.org/10.3390/sports13070227
Popp, K. L., Ackerman, K. E., Rudolph, S. E., Johannesdottir, F., Hughes, J. M., Tenforde, A. S., Bredella, M. A., Xu, C., Unnikrishnan, G., Reifman, J., & Bouxsein, M. L. (2021). Changes in volumetric bone mineral density over 12 months after a tibial bone stress injury diagnosis: Implications for return to sports and military duty. The American Journal of Sports Medicine, 49(1), 226–235. https://doi.org/10.1177/0363546520971782
Saxena, A., Behan, S. A., Valerio, D. L., & Frosch, D. L. (2017). Navicular stress fracture outcomes in athletes: Analysis of 62 injuries. The Journal of Foot and Ankle Surgery, 56(5), 943–948.
Saxena, A., Fullem, B., & Hannaford, D. (2000). Results of treatment of 22 navicular stress fractures and a new proposed radiographic classification system. Journal of Foot and Ankle Surgery, 39, 96–103.
Torg, J. S., Moyer, J., Gaughan, J. P., & Boden, B. P. (2010). Management of tarsal navicular stress fractures: Conservative versus surgical treatment: A meta-analysis. The American Journal of Sports Medicine, 38(5), 1048–1053. https://doi.org/10.1177/0363546509355408
