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Navicular Injuries for Football Players

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Introduction

Navicular injuries can be a significant setback for football players, impacting agility, power, and overall performance. The small but crucial navicular bone, located on the inner side of the midfoot, plays a vital role in the foot’s biomechanics. Understanding the nature of these injuries, their causes, and the best management strategies is paramount for a successful return to play. This comprehensive guide aims to equip physiotherapists, players, and sports science staff with the knowledge needed to navigate navicular injuries effectively.

What is a Navicular Injury?

The navicular bone acts as a keystone in the arch of the foot, connecting the talus (ankle bone) to the cuneiforms (bones leading to the toes). It is essential for transmitting forces during activities like running, jumping, and kicking. Navicular injuries in football can range from stress reactions (bone overload without a fracture) to stress fractures (small cracks in the bone) and, in rarer cases, acute fractures due to direct trauma. Due to its relatively poor blood supply compared to other bones in the foot, the navicular has a propensity for delayed healing, making early and accurate management critical.

Causes of Navicular Injuries

Navicular stress injuries are often the result of repetitive microtrauma and cumulative overload, common in the high-impact and high-volume demands of football. Several factors can contribute to their development:

  • High Training Load and Intensity: Sudden increases in training volume or intensity, especially during pre-season or periods of intense competition, can overload the navicular.
  • Biomechanical Factors:
    • Excessive Pronation: Over-rolling of the foot inwards can place increased stress on the navicular as it tries to stabilize the arch.
    • Pes Planus (Flat Feet): Reduced arch support can lead to altered load distribution through the midfoot.
    • Rigid Pes Cavus (High Arches): A lack of shock absorption can transmit higher forces directly to the navicular.
    • Limited Ankle Dorsiflexion: Reduced upward movement of the ankle can compensate with increased midfoot motion, stressing the navicular.
  • Footwear: Inadequate or worn-out footwear that doesn’t provide sufficient support or cushioning can contribute to increased stress on the foot.
  • Playing Surface: Hard or uneven playing surfaces can increase impact forces.
  • Muscle Imbalances: Weakness in the intrinsic foot muscles, calf muscles, or hip stabilisers can alter biomechanics and load distribution.
  • Previous Injury: A history of foot or ankle injuries can predispose players to altered movement patterns and increased stress on other structures, including the navicular.
  • Low Bone Mineral Density: While less common, factors affecting bone health can increase the risk of stress fractures.

Assessment of Navicular Injuries

A thorough assessment is crucial for accurate diagnosis and effective management of suspected navicular injuries. This typically involves:

  • History: Gathering information about the onset of symptoms (gradual vs. sudden), pain location and characteristics (deep ache on the dorsal (top) inner aspect of the midfoot), aggravating and relieving factors (pain often worsens with activity and improves with rest), training history, footwear, and any previous injuries.
  • Physical Examination:
    • Palpation: Tenderness directly over the navicular tuberosity (the bony prominence on the inner side of the midfoot) is a key finding. This is often referred to as the “N spot“.
    • Weight-Bearing Assessment: Observing the player’s stance and gait for any biomechanical abnormalities like excessive pronation or a flattened arch.
    • Range of Motion: Assessing ankle dorsiflexion, plantarflexion, inversion, and eversion, as well as midfoot mobility.
    • Strength Testing: Evaluating the strength of the ankle plantarflexors, dorsiflexors, invertors, and evertors, as well as intrinsic foot muscle strength.
    • Functional Tests: Assessing pain and limitations during hopping, single-leg stance, and sport-specific movements (e.g., agility drills, kicking). The “navicular stress test” involves palpating the navicular while passively inverting and everting the forefoot, which can elicit pain.
  • Imaging:
    • X-rays: Initial radiographs may be negative, especially in the early stages of a stress reaction or stress fracture. However, they are important to rule out acute fractures or other bony abnormalities.
    • MRI (Magnetic Resonance Imaging): Provides detailed images of both bone and soft tissues, allowing for accurate diagnosis of stress fractures (including the extent and location), bone marrow edema (a sign of stress reaction), and any associated soft tissue injuries. MRI is often the preferred imaging modality for definitive diagnosis.
    • CT Scan (Computed Tomography): Can be useful for visualising the fracture line in more detail, particularly if surgical intervention is being considered.

Treatment Options for Navicular Injury

The primary goal of treatment is to reduce pain, promote healing, and safely return the player to full activity. Treatment options vary depending on the severity of the injury:

  • Non-Operative Management: This is the mainstay of treatment for navicular stress reactions and most stress fractures.
    • Rest and Offloading: Complete cessation of weight-bearing activities is often necessary initially. This may involve the use of crutches. The duration of non-weight bearing depends on the severity and can range from 4-8 weeks or longer.
    • Immobilisation: A walking boot is typically used to immobilise the foot and reduce stress on the navicular. The duration of immobilisation is guided by pain levels and imaging findings, often lasting 6 weeks.
    • Pain Management: Over-the-counter or prescription pain relievers (NSAIDs) may be used to manage pain and inflammation in the initial stages.
    • Biomechanical Correction: Addressing any underlying biomechanical issues is crucial for long-term management and prevention. This may involve:
      • Orthotics: Custom or prefabricated orthotic insoles can help to support the arch, control excessive pronation, and redistribute load away from the navicular.
      • Footwear Advice: Recommending appropriate footwear with good support and cushioning for both training and daily activities.

  • Surgical Management: Surgery may be considered in cases of:
    • Displaced Fractures: If the fracture fragments are significantly out of alignment.
    • Non-Union: If the fracture fails to heal with conservative management after an adequate period.
    • High-Level Athletes: In some elite athletes with certain types of stress fractures, surgery may be considered to potentially expedite the return to play, although this is a complex decision with potential risks and benefits that need careful consideration.
    • Surgical options typically involve internal fixation using screws to stabilise the fracture fragments and promote healing.

Products that may help

Aircast Boot

The Aircast boot is often required to immobilise the ankle during the early stages of a navicular injury. The Aircast boot has air cushions and shock absorption features, which make this boot the gold standard for foot and ankle injuries.

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Ankle Cool Sleeve Ice Pack

This ankle ice pack provides cold therapy and compression for the entire foot ans ankle area, providing pain relief and helping to reduce swelling. The ice pack contains gel to ensure longer lasting cold therapy and the ankle specific design also provides compression to the injured area.

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Insoles

Insoles can provide extra foot padding and shock absorption which can provide some protection for the pain and discomfort from navicular issues.

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Balance Cushion

The balance cushion is a useful piece of equipment to provide challenging proprioception exercises that help to improve stability of the foot and ankle.

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Vitamin D Supplementation

Vitamin D contributes to normal immune, muscle and bone function. The body produces it naturally through exposure to sunlight. However during the autumn and winter months, most footballers Vitamin D levels will drop. It is therefore essential for footballers to supplement their diet during this period to protect their overall health as is it is not present in most foods. All SOCCER SUPPLEMENT products are rigorously batch tested under the Informed-Sport program.

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Rehabilitation for Navicular Injuries

Rehabilitation is a critical phase in the management of navicular injuries, aiming to restore pain-free movement, strength, proprioception, and functional capacity. The rehabilitation program should be progressive and tailored to the individual player’s healing and tolerance. Key components include:

  • Phase 1 (Immobilisation/Early Weight-Bearing):
    • Pain and Swelling Management: Continue with ice and elevation.
    • Maintaining Upper Body and Uninjured Limb Fitness: Implement a program focusing on cardiovascular fitness and strength training of the unaffected areas.
    • Gentle Range of Motion (ROM) Exercises: Once pain allows and as directed by the physiotherapist, begin gentle ROM exercises of the ankle and toes within the limits of immobilisation.

  • Phase 2 (Protected Weight-Bearing and Early Mobilization):
    • Gradual Weight-Bearing Progression: Slowly increase weight-bearing as tolerated, using crutches initially and progressing to full weight-bearing with or without the walking boot.
    • Active ROM Exercises: Begin active ROM exercises of the ankle and midfoot, focusing on dorsiflexion, plantarflexion, inversion, and eversion.
    • Isometric Strengthening: Initiate isometric strengthening exercises for the ankle and foot muscles (e.g., pushing against a wall).
    • Proprioceptive Exercises: Introduce basic balance exercises in a stable environment (e.g., double-leg stance).
    • Introduction to Low-Impact Activity: Begin with short periods of pain-free walking on a flat surface, gradually increasing duration and distance.

  • Phase 3 (Progressive Loading and Strengthening):
    • Increasing Strength: Progress to isotonic strengthening exercises using resistance bands, light weights, and bodyweight (e.g., calf raises, heel raises, toe raises, resisted inversion/eversion).
    • Improving Flexibility: Continue with stretching exercises for the calf muscles, plantar fascia, and other relevant structures.
    • Enhancing Proprioception: Progress to more challenging balance exercises on uneven surfaces (e.g., wobble board, balance disc), single-leg stance, and dynamic balance activities.
    • Gradual Return to Running Program: Implement a structured return-to-run program, starting with walk-jog intervals and progressively increasing running duration and intensity (as outlined in a return-to-run protocol).

  • Phase 4 (Return to Running and Agility):
    • Football Conditioning: Gradually incorporate football-specific movements including backpedalling, sidestepping, accelerations and decelerations. Begin to introduce passing, dribbling, and light kicking, ensuring no pain exacerbation.
    • Speed & Agility Drills: Introduce low-impact agility drills (e.g., cone drills, shuttle runs) focusing on controlled movements and pain-free execution.
    • Sport-Specific Exercises: Gradually incorporate football-specific movements, such as passing, dribbling, and light kicking, ensuring no pain exacerbation.

  • Phase 5 (Return to Training and Competition):
    • Progressive Integration into Training: Gradually increase participation in team training drills, starting with non-contact activities and progressing to full contact.
    • Increasing Training Load: Monitor the player’s response to training and gradually increase the intensity and volume.
    • Return to Competition: Return to competitive play should be a gradual decision based on pain-free participation in full training and successful completion of functional testing.

Conclusion

Navigating navicular injuries in football requires a thorough understanding of the injury’s nature, aetiology, and the importance of accurate assessment and comprehensive management. Early diagnosis and appropriate offloading are crucial for promoting healing. A well-structured and progressive rehabilitation program, addressing strength, flexibility, proprioception, and biomechanical factors, is essential for a safe and successful return to play. Close collaboration between the player, physiotherapist, sports science staff, and medical team is paramount to optimise outcomes and minimize the risk of re-injury, allowing these athletes to once again showcase their talent on the field.

Further Reading

Attia et al, (2021) – Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures

Mehta et al, (2023) – Tarsal navicular bone stress injuries: a multicenter case series investigating clinical presentation, diagnostic approach, treatment, and return to sport in adolescent athletes

Egger et al, (2022) – Navicular Stress Fractures in Adolescent Athletes: Injury Characteristics and Outcomes of Surgical Fixation

Disclaimer

The information provided in this article is for educational purposes only and should not substitute professional medical advice. Always consult with a qualified healthcare professional for diagnosis, treatment, and personalised recommendations based on your specific condition. Some affiliate links may also be used in this article, these are from products we have specifically selected to display based on our own experience.

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