Navicular fractures in elite athletes—2025 International Foot and Ankle Sports Consensus and systematic review

Abstract

Purpose

Navicular injuries are a significant concern in athletics, often leading to prolonged recovery periods and risks of further complications. Navicular stress fractures, in particular, have gained recognition as common injuries among athletes, especially in high‐impact sports. The management of navicular injuries remains controversial, lacking standardised treatment protocols. The purpose of the present systematic review and consensus process was to provide up‐to‐date recommendations on workup and diagnosis, operative and nonoperative treatments, and the return‐to‐sport (RTS) for elite athletes with navicular fractures.

Methods

A consensus process was conducted using a modified Delphi technique with two rounds of questionnaires. ‘General consensus’ was defined as 75%–85% agreement, ‘strong consensus’ as 86%–99% agreement, and ‘unanimous consensus’ as 100% agreement. In addition, a systematic review was conducted evaluating the workup, treatment and postoperative management of Navicular injuries in athletes.

Results

Thirty‐four consensus statements were established regarding the diagnosis, management and RTS following navicular fractures in elite athletes; 10 achieved unanimous consensus, 21 reached strong consensus and 2 did not reach consensus. Across 319 athletes identified in the systematic review, those treated surgically returned to sport at a mean of 8.2 weeks postoperatively, with 98.7% resuming competition. The panel reached a strong consensus that athletes should remain nonweightbearing for 4–6 weeks following surgery and may expect to return to full sport within 4–6 months, supported by corresponding timelines in the literature.

Conclusion

Athletes sustaining navicular fractures can typically expect a functional recovery, with most returning to play within 4–6 months after surgery. The consensus recommendations provide the first standardised, evidence‐based framework for postoperative progression, including a 4–6 week nonweightbearing phase and structured rehabilitation milestones. These findings guide clinicians in optimising recovery and RTS outcomes in elite athletes.

Level of Evidence

Level V.

Abbreviations

BMAC

bone marrow aspirate concentrate

CBMA

concentrated bone marrow aspirate

DVT

deep vein thrombosis

IFASC

International Foot and Ankle Sports Consensus

MINORS

Methodological Index for Non‐Randomised Studies

NF

navicular fracture

NSF

navicular stress fracture

NWB

nonweightbearing

ORIF

open reduction internal fixation

PRISMA

Preferred Reporting Items for Systematic reviews and Meta‐Analyses

PRP

platelet‐rich plasma

RTP

return to play

TMT

tarsometataral

INTRODUCTION

Tarsal navicular fractures, while relatively rare in the general population, are increasingly recognised as a significant issue among high‐level athletes. Chronic incomplete navicular fractures, commonly referred to as navicular stress fractures (NSF), arise from chronic overuse and account for up to 35% of all stress‐related injuries [13, 27]. The challenges associated with accurate diagnosis [5], compounded by the frequent occurrence of concomitant midfoot fractures [28], contribute to the morbidity of these injuries, particularly within the elite athlete demographic. In contrast, acute navicular fractures are significantly less prevalent and typically occur as a result of traumatic injury [9]. Given the variable aetiological factors, diagnostic approaches and management strategies for these injuries, this discussion will primarily concentrate on NSFs in elite athletes.

Navicular stress fractures are most commonly classified according to Saxena et al., based on the fracture morphology on computed tomography (CT) scan (Table 1) [35].

Table 1.

Saxena classification of navicular stress fractures. ^a

Type	Imaging	Description
0.5	MRI	Stress reaction and bone oedema. Negative CT.
1	CT	Unicortical dorsal fracture
2	CT	Dorsal fracture propagating into the body
3	CT	Bicortical fracture; dorsal + plantar, medial, or lateral

Modifiers
A: avascular necrosis
C: cystic degeneration
S: sclerosis of fracture line(s)

Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.

^a Adapted from Saxena et al. [35, 36].

In 2010, the classification was expanded to include Type 0.5, which specifically addresses magnetic resonance imaging (MRI) findings such as bone oedema that are not visible on CT [36]. It is widely accepted that more severe fractures, Types 2 and 3, necessitate surgical intervention. Initially, nonsurgical treatment was deemed appropriate for Type 1 fractures in the general population; however, debate still exists regarding the management of Type 0.5 and 1 fractures in the athlete population.

Certain athletes are more predisposed to NSFs due to the chronic repetitive forces endured by the tarsal navicular bone in activities such as running and high‐impact sports, including track, football and basketball. A case series evaluating 180 elite athletes revealed that competitors in track and field accounted for 59% of the identified NSFs, highlighting a concerning trend within this demographic [6]. It is hypothesised that the unique biomechanics of the midfoot contribute to the aetiology of these injuries. Distal forces are asymmetrically propagated through the 1st and 2nd tarsometatarsal (TMT) joints and their respective cuneiform, resulting in uneven loading of the medial and lateral aspects of the navicular. This asymmetric loading, in conjunction with the medialized distribution of weight through the proximal talonavicular joint, generates a shear force in the central navicular, predisposing the area to microfractures [2]. Additionally, the attenuated vascular supply of the central navicular perpetuates the risk of stress fracture, nonunion and osteonecrosis [27, 30]. The risk of these complications is inherently worsened by missed or delayed diagnosis, which occurs in approximately 30% of NSFs [1].

The subtle nature of chronic incomplete fractures adds to the complexity of their diagnosis. Previous studies have recommended an initial workup including a thorough history and physical, followed by plain radiographs and a CT scan. MRI is subsequently reserved for cases that maintain a high clinical suspicion despite negative preliminary imaging studies [19]. Following the successful diagnosis of NSFs, management will depend on the severity of the injury and the individual needs of the athlete. Nonsurgical treatment historically involves a nonweightbearing period between 6 and 8 weeks [40], while the recommended surgical treatment in athletes is ORIF [37]. Fixation of severe fracture types aims to decrease the time to healing and return to play (RTP), although some studies suggest there is no evidence that RTP is hastened with surgery [3]. A 2021 meta‐analysis by Attia et al. reported an overall RTP rate of 82%, with no difference between surgically or nonsurgically managed navicular fractures [3].

The goal of this consensus initiative is to enhance the current body of literature by providing detailed consensus statements derived from the insights of 35 international foot and ankle experts. These recommendations address critical aspects of managing NSFs in elite athletes, including comprehensive evaluation, accurate diagnosis, effective treatment strategies and guidelines for RTP. Additionally, the study presents an in‐depth systematic review of all tarsal navicular fractures (NF), ensuring the recommendations are informed by the latest research and grounded in evidence‐based practices.

METHODS

Consensus working group

Thirty‐five global orthopaedic foot and ankle experts who treat elite athletes were invited to participate on an expert panel to develop these general consensus statements on Navicular sports injuries. The participants were invited to be founding members of the International Foot and Ankle Sports Consensus. Surgeons from 26 countries (six continents) were selected based on a grid system and scores were assigned by three independent physicians based on the following criteria: (1) academic position, (2) number of academic publications, (3) number of national/international presentations and lectures, (4) professional sports team coverage and (5) leadership role in professional foot and ankle/sports medicine society. A minimum total score of 8 points was required for individuals to be eligible for participation. The grid classification criteria used for the selection of the experts are detailed in Table 2. The number of representatives was organised based on continent so that a minimum of 6 continents had adequate representation. Continents with a larger proportion of research output and professional sport involvement were allotted additional positions. Once the expert board was created, experts were also given the opportunity to provide recommended individuals to be evaluated and assessed based on the aforementioned criteria to be included in the second round of screening.

Table 2.

Point system used for selection of expert panel.

Criteria evaluated	Grid system
Academic position	… Assistant professor: 1 point … Associate professor: 2 points … Full Professor: 3 points
Number of academic publications	… 1–10 publications: 1 point … 11–20 publications: 2 points … 21 or more publications: 3 points
Number of national/international presentations and lectures	… 1–5 presentations/lectures: 1 point … 6–10 presentations/lectures: 2 points … 11 or more presentations/lectures: 3 points
Professional sports team coverage	… No coverage: 0 points … Local/regional coverage: 1 point … National/international coverage: 2 points
Leadership role in professional foot and ankle/sports medicine society	… No leadership role: 0 points … Member: 1 point … Officer/Board Member: 2 points

Consensus survey

The questions were generated by an initial survey sent to the expert panel focusing on Navicular workup and diagnosis, nonoperative/operative intervention and post‐operative rehabilitation. A standard Delphi method approach was used to generate consensus statements, with the experts completing two rounds of electronic questionnaires [11]. Participant identities were recorded alongside their responses. The first survey included categories focused on workup, nonsurgical treatment, operative management and return‐to‐sport (RTS). The questions were structured as either ‘yes/no’ responses or open‐ended free‐text responses. The second survey was formulated based on the prior responses and consisted only of ‘agree/disagree’ statements. The resulting data was analysed to determine the percentage of agreement for each individual question.

Consensus criteria

For each survey question, the degree of agreement was expressed as a percentage rounded to the nearest whole number. General consensus was defined as 75%–85%, strong consensus as 86%–99%, and unanimous consensus was indicated by 100%. Questions with significant response variation were chosen for a live debate with the expert panel.

Systematic review

In December 2024, a systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) guidelines on PubMed, EMBASE and The Cochrane Library databases (Figure 1) [24]. The purpose of this systematic review was to establish the current understanding and approach to diagnosis, treatment and follow‐up of Navicular sport injuries. The search terms that were utilised were: (navicular or tarsal or midfoot) and (stress or fracture). The inclusion and exclusion criteria are listed in Table 3. The titles, abstracts and full‐text articles of all of the searched studies were screened by two independent reviewers by applying the inclusion and exclusion criteria. The senior author of this paper was consulted to arbitrate any discrepancies that arose.

Figure 1.

PRISMA flowchart outlining the study selection process. PRISMA, preferred reporting items for systematic reviews and meta‐analyses.

Table 3.

Inclusion and exclusion criteria of systematic review.

Inclusion criteria	Exclusion criteria
Clinical studies reporting outcomes following the treatment of sport‐related Navicular injuries in the athletic population	Review articles
Follow up ≥3 months	Case reports
Published in a peer‐reviewed journal in the past 15 years	Cadaveric studies
Article written in English	In vivo studies
	Paediatric studies
	Failed to evaluate outcomes

Assessment of level of evidence and methodological quality

Fourteen articles included in this study were graded via the Methodological Index for Non‐Randomised Studies (MINORS) scale due to their observational nature [38]. The MINORS scale categorises studies into comparative or noncomparative groups, with the comparative studies graded from 0 to 24 points and the noncomparative groups graded from 0 to 16 points, with each item worth 0–2 points.

Data extraction and evaluation

All articles populated by the study search terms were retrieved from their respective databases and uploaded to Rayyan, a public software program designed to assist with abstract and title screening. Duplicates were removed by hand. Once complete, selected articles underwent further full‐text screening. Articles that met the inclusion criteria were selected for analysis. All studies were assessed by two independent reviewers. The senior author of this paper was consulted to arbitrate any discrepancies that arose.

Topic examined

This manuscript provides a comprehensive evaluation of the diagnosis, workup, surgical and nonsurgical management of NSFs in elite athletes. Recommendations and guidelines regarding these athletes′ RTS are also discussed.

Statistical analysis

All other statistical analyses were performed using RStudio software (version 4.2.0). Descriptive statistics were calculated for all continuous and categorical variables. Continuous variables were reported as weighted mean and estimated standard deviation, whereas categorical variables were reported as frequencies with percentages.

RESULTS

Overall consensus

A total of 34 statements were established regarding the diagnostic evaluation, nonsurgical management, surgical treatment and RTS considerations for navicular fractures in the elite athletic population. Of these, 10 achieved unanimous consensus, 21 had a strong consensus, and 2 did not reach consensus. The consensus statements are shown below.

Consensus statements

Workup and diagnosis

• 1.
  The most common mechanism of injury for chronic incomplete navicular fractures in athletes is overuse and overload, where traumatic fractures occur due to axial loading, twisting, rotational forces and high‐impact trauma.

  • a.
    Strong consensus
• 2.
  For fractures of the navicular, plain radiographs are the first‐line imaging study.

  • a.
    Unanimous consensus
• 3.
  For fractures of the navicular in athletes, a CT scan is routinely performed to assess fracture displacement or complexity.

  • a.
    Unanimous consensus
• 4.
  For nondisplaced fractures of the navicular, a bone scan is not routinely recommended to rule out an occult chronic incomplete fracture if initial X‐rays are negative.

  • a.
    Strong consensus
• 5.
  In an athlete with navicular fracture(s), it is important to assess the athlete′s gait and mechanical alignment to evaluate potential contributing factors such as poor biomechanics or footwear.

  • a.
    Strong consensus
• 6.
  NSAIDs (e.g., ibuprofen) are not routinely recommended to manage pain or inflammation in athletes with fractures of the navicular during the initial treatment phase.

  • a.
    Strong consensus

Nonsurgical treatment

• 7.
  Indications for nonsurgical management of a navicular fracture in athletes may include nondisplaced or incomplete fractures and the presence of isolated bone oedema on MRI without positive findings on CT.

  • a.
    Strong consensus
• 8.
  In nonsurgically treated navicular fractures a nonweightbearing period of at least 4–6 weeks is recommended.

  • a.
    Unanimous consensus
• 9.
  In nonsurgically treated navicular fractures, return to partial weight bearing at 6 weeks is typically appropriate.

  • a.
    Unanimous consensus
• 10.
  In the nonsurgical management of navicular fractures, custom inserts are utilised to correct biomechanical abnormalities contributing to the injury.

  • a.
    Unanimous consensus
• 11.
  For nonsurgically managed fractures of the navicular, immobilisation in a boot, with or without the use of custom inserts, is preferred over a cast or splint for initial management.

  • a.
    Strong consensus
• 12.
  DVT prophylaxis is not recommended during the nonweightbearing phase of treatment for navicular fractures treated nonsurgically in the absence of risk factors or hospital policies that require this therapy.

  • a.
    Strong consensus

Surgical treatment

• 13.
  Indicators for surgical treatment of navicular fractures include: complete displaced fractures, nonunion, failure of nonsurgical treatment and all athletes.

  • a.
    Strong consensus
• 14.
  Minimally invasive techniques (e.g., percutaneous screw fixation) are preferred for surgical treatment of nondisplaced or minimally displaced navicular fractures.

  • a.
    Strong consensus
• 15.
  An open approach is preferred for the fixation of displaced navicular fractures.

  • a.
    Unanimous consensus
• 16.
  The fixation construct for a nondisplaced fracture of the navicular typically involves 1–2 compression screws.

  • a.
    Unanimous consensus
• 17.
  The fixation construct for a displaced navicular fracture typically involves open reduction and internal fixation (ORIF) with screws or a plate.

  • a.
    Strong consensus
• 18.
  The fixation construct for a nonunion of the navicular typically involves open reduction with bone grafting, screw fixation, or vascularises bone grafting.

  • a.
    Strong consensus
• 19.
  In athletes with nonunion fractures of the navicular that had been treated nonsurgically initially, bone grafting is recommended in conjunction with fixation during surgery.

  • a.
    Strong consensus
• 20.
  Specific fluoroscopic views, including AP, lateral, oblique and Canale, are utilised intraoperatively to assess the reduction and fixation of navicular fractures.

  • a.
    Strong consensus
• 21.
  Bone grafting (e.g., autograft, allograft) is recommended as a possible adjunct to fixation during surgery for navicular fractures.

  • a.
    Strong consensus
• 22.
  Surgical treatment of navicular fractures may involve the use of biologics (e.g., CBMA, PRP, etc.) depending on the fracture.

  • a.
    Strong consensus
• 23.
  Surgical treatment of navicular fractures does not routinely include the use of a bone stimulator postoperatively.

  • a.
    Unanimous consensus

RTS and other considerations

• 24.
  An athlete should remain nonweight bearing for 4–6 weeks following surgical intervention for a navicular fracture.

  • a.
    Strong consensus
• 25.
  Vitamin D, at a dose of 2000–5000 IU daily or 50,000 IU weekly, and calcium supplementation are recommended for athletes with navicular fractures to aid bone healing.

  • a.
    Strong consensus
• 26.
  Custom insoles, rehabilitation exercises, consolidation and healing and sport‐specific management are appropriate considerations when considering postoperative return‐to‐play recommendations after surgical or nonsurgical treatment of navicular fractures.

  • a.
    Strong consensus
• 27.
  For athletes with fractures of the navicular, cross‐training in low‐impact activities, such as swimming, low‐impact cycling, hydrotherapy and deep water running, is recommended as early as 3–6 weeks after beginning nonsurgical treatment.

  • a.
    Unanimous consensus
• 28.
  In the case of navicular fractures treated nonsurgically, physical therapy may be started at 6 weeks for strengthening.

  • a.
    Unanimous consensus
• 29.
  An athlete undergoing nonsurgical treatment for a navicular fracture can expect to return to light training in their sport within 2–4 months.

  • a.
    Consensus not reached
• 30.
  In athletes with navicular fractures, the radiographic criteria that allow for return to play are difficult to assess, but should focus on improvement across the fracture line on CT. Complete radiographic union is often not necessary.

  • a.
    Consensus not reached
• 31.
  An athlete undergoing nonsurgical treatment for a navicular fracture can expect to return to full sport (i.e., gameplay) within 4–6 months.

  • a.
    Strong consensus
• 32.
  An athlete is recommended to start physical therapy at 2 weeks following surgical intervention for a navicular fracture.

  • a.
    Strong consensus
• 33.
  An athlete undergoing surgical intervention for a navicular fracture can expect to return to light training in their sport within 3–4 months.

  • a.
    Unanimous consensus
• 34.
  An athlete undergoing surgical intervention for a navicular fracture can expect to return to full sport (i.e., game play) within 4–6 months.

  • a.
    Strong consensus

Systematic review

Study characteristics and patient demographics

A total of 74 studies were identified during the initial search. After the omission of duplicates, 70 were screened, 26 were assessed for eligibility, and 14 were ultimately included in this review (2 prospective studies, 2 retrospective studies and 10 case series) [7, 8, 17, 20, 21, 22, 23, 25, 26, 29, 31, 33, 34, 42]. Across all studies, 319 patients and 328 isolated injuries met the inclusion criteria. The PRISMA diagram in Figure 1 depicts the full literature search and screening process. The results of bias and quality assessment according to MINORS criteria can be found in Table 4. The average age of patients included in these studies was 22 years, and the mean follow‐up period was 26 months. The most common sports among athletes who experienced NFs included running (25%), soccer (10%) and basketball (5.3%). The participants′ levels of play varied, with 30% engaged in recreational activities and 3%, 0.6% and 18% competing at the high school, college, and professional levels, respectively. The injuries were categorised by treatment type into groups of ORIF [21, 22, 23, 29, 31, 33, 34, 42], percutaneous fixation [8, 22, 26] and nonsurgical management [7, 17, 20, 23, 25, 29, 31, 33, 34, 42], which included 165, 51 and 112 fractures, respectively. The study characteristics for all included articles are summarised in Table 5.

Table 4.

Evaluation of study bias using MINORS criteria.

Author, year	Total bias score	Total possible bias scorea
Maquirriain and Ghisi, 2006	12	16
Saxena, 2017	19	24
Saxena, 2006	12	16
Vopat, 2017	13	16
Burne, 2005	14	16
Egger, 2022	13	16
Malliaropoulos, 2017	12	16
Mehta, 2022	8	16
McCormick, 2011	11	16
Murray, 2005	10	16
Nunley, 2022	14	24
Potter, 2006	13	24
Rizzi, 2022	11	16
Yamaguchi, 2016	10	16

^aTotal possible bias score is 16 for noncomparative studies and 24 for comparative studies.

Table 5.

Study characteristics and patient demographics.

Author, year	LOE	N Patients	N feet	Follow‐up (months)	Age (years)	M/F	Sports	Level of play	Military activity
Maquirrain, 2006	3	3	5	6	22	1/2	Tennis (n = 3)	Professional (n = 3)	0
Saxena, 2017	3	59	59	nr	29.6	24/38	Track & Field Runners (n = 38) Ballistic sports (n = 10) Other (n = 14)	Professional (n = 21)	0
Saxena, 2006	3	19	19	24	27.2	9/10	Running (n = 1) Other (n = 18)	nr	nr
Volpat, 2017	3	11	12	nr	nr	11/0	American Football (n = 11)	Professional (n = 11)	0
Burne, 2005	4	11	11	44.4	24.6	3/8	nr	Elite (n = 6) College (n = 2) Recreational (n = 3)	0
Egger, 2022	4	5	5	7.1	15.8	4/1	Baseball (n = 3) Soccer (n = 1) Basketball (n = 1)	High School (n = 5)	nr
Malliaropolous, 2017	4	10	10	58.2	14.7	nr	Track and field (n = 10)	Professional (n = 10)	0
Mehta, 2023	4	110	110	7.1	14.7	38/72	Cross‐country (n = 15) Track and field (n = 14) Gymnastics (n = 13) Dance (n = 12) Soccer (n = 12) Basketball (n = 10) Other (n = 34)	Recreational (n = 94)	0
McCormick, 2011	4	10	10	42.4	28.7	3/7	American Football (n = 3) Baseball (n = 2) Basketball (n = 1) Cross‐country (n = 1) Other (n = 3)	nr	nr
Murray, 2005	4	2	2	nr	17	0/2	Running (n = 2)	High School (n = 2)	nr
Nunley, 2022	4	43	43	12	19	23/20	nr	nr	0
Potter, 2006	4	26	32	nr	33.5	13/13	nr	nr	0
Rizzi, 2022	4	8	8	nr	25.4	5/0	Basketball (n = 5)	Professional (n = 5)	0
Yamaguchi, 2016	4	2	2	36	14	2/0	Soccer (n = 2)	High School (n = 2)	0

Abbreviations: LOE, level of evidence; M/F, male/female; N, number; nr, not recorded.

Surgical technique

The ORIF group predominantly employed 4.0 mm partially threaded cannulated or noncannulated screws [22, 33], while the percutaneous group utilised both 4.0 and 3.5 mm screws [22, 26]. In the ORIF group, all studies that mentioned bone grafting did so for the majority or all of the included patients [21, 22, 33, 34]. Notably, no studies in the ORIF group reported the use of bone marrow aspirate concentrate (BMAC) in athletes undergoing ORIF. In contrast, the percutaneous group indicated that bone grafting was applied in 20%–65% of cases, with only one study documenting the use of BMAC [8, 22, 26]. Surgical techniques and hardware specifications are detailed in Table 6.

Table 6.

Injury and surgical characteristics.

Author, year	N Patients	N Feet	Incomplete, nondisplaced Fx	Complete, nondisplaced Fx	Complete, displaced Fx	Saxena type I	Saxena type II	Saxena type III	Surgical technique	BMAC (n)	Bone graft (n)
Open reduction internal fixation (ORIF)
Rizzi, 2022	5	5	nr	nr	nr	nr	nr	nr	nr	nr	nr
Saxena, 2017	47	47	nr	nr	nr	5	25	17	4.0‐mm partially threaded solid cancellous screw, Kirschner Wire	nr	47
Yamaguchi, 2016	2	2	0	0	2	nr	nr	nr	Variable‐threaded screws or two tapered variable‐threaded screws	nr	2
Saxena, 2006	13	13	nr	nr	nr	0	7	6	nr	nr	9
Mehta, 2023	16	16	nr	nr	nr	nr	nr	nr	nr	nr	nr
Volpat, 2017	8	9	nr	nr	nr	0	2	7	nr	nr	nr
Potter, 2006	13	13	nr	nr	nr	nr	nr	nr	nr	nr	nr
McCormick, 2011	7	7	0	3	4	nr	nr	nr	Two partially threaded 4.0‐mm cannulated screws	nr	6
Percutaneous fixation
McCormick, 2011	3	3	3	0	0	nr	nr	nr	Two 4.0‐mm cannulated screws	nr	1
Egger, 2022	5	5	3	2	0	0	2	3	nr	nr	1
Nunley, 2022	43	43	nr	nr	nr	nr	nr	nr	Threaded 3.5 mm screws	1	28
Nonsurgical treatment
Malliaropoulos, 2017	10	10	nr	nr	nr	nr	nr	nr	NWB cast immobilisation	nr	n/a
Mehta, 2023	94	94	nr	nr	nr	nr	nr	nr	Protected weightbearing with either protective boot or a cast	nr	n/a
Rizzi, 2022	3	3	nr	nr	nr	nr	nr	nr	Activity modification and protected weightbearing	nr	n/a
Saxena, 2017	12	12	nr	nr	nr	9	3	0	NWB below‐the‐knee cast or boot	nr	n/a
Murray, 2005	2	2	2	0	0	nr	nr	nr	Immobilisation in NWB case for 6 weeks	nr	n/a
Saxena, 2006	6	6	nr	nr	nr	4	1	1	NWB in below‐knee cast boot	nr	n/a
Volpat, 2017	3	3	nr	nr	nr	nr	nr	nr	NWB boot immobilisation	nr	n/a
Burne, 2005	11	11	nr	nr	nr	nr	nr	nr	NWB with variable duratoin +/− cast immobilisation	nr	n/a
Potter, 2006	19	19	nr	nr	nr	nr	nr	nr	NWB cast immobilisation	nr	n/a
Maquirrain, 2006	3	5	nr	nr	nr	nr	nr	nr	nr	nr	n/a

Abbreviations: BMAC, bone marrow aspirate concentrate; N, number; n/a, not applicable; nr, not recorded; NWB, nonweightbearing; WB, weightbearing.

Length of immobilisation, time to weightbearing and RTS

Patients in the ORIF group underwent a postoperative immobilisation period between 6 and 10 weeks [21, 22, 34]. These patients were allowed to begin partial weightbearing after 4–12 weeks [21, 33, 34], and typically began full weightbearing between 10 and 12 weeks [22, 23, 33, 34]. Four studies in this group reported information regarding RTS, with 98.7% returning to competition at an average of 8.2 ± 11.1 weeks after surgery [21, 23, 33, 34]. Athletes in the percutaneous group were immobilised for 6 and 12 weeks and were allowed to resume full weightbearing at an average of 11 weeks [8, 22, 26]. Eighty‐four percent of these patients achieved full union, and 100% successfully returned to their sport. Only one study reported time to RTS in the percutaneous group, which averaged 24 weeks [8]. In the nonsurgical treatment group, all studies that reported a protocol employed an immobilisation and nonweightbearing (NWB) period of 6 weeks [17, 25, 33, 34]. These patients were then advanced to full weightbearing between 7 and 10 weeks [23, 34]. Time to RTS varied greatly, with reported timeframes between 4 and 22 weeks [20, 23, 33, 34]. Immobilisation, weightbearing and RTS data are included in Table 7.

Table 7.

Length of immobilisation, time to weightbearing, return‐to‐sport.

Author	N Patients	N Feet	Length of immobilisation (weeks)	Time to partial WB (weeks)	Time to full WB (weeks)	Time to union (weeks)	N Full union	N RTS	Time to RT running (weeks)	Time to RTS (weeks)
Open reduction internal fixation (ORIF)
Rizzi, 2022	5	5	nr	nr	nr	nr	nr	4	nr	nr
Saxena, 2017	47	47	nr	4	11	nr	nr	47	nr	4.56
Yamaguchi, 2016	2	2	10	8	nr	21.7	0	nr	nr	26
Saxena, 2006	13	13	6	6	10	nr	8	13	nr	4.1
Mehta, 2023	16	16	nr	nr	10	nr	14	nr	18	20
Volpat, 2017	8	9	nr	nr	nr	nr	5	nr	nr	nr
Potter, 2006	13	13	nr	nr	nr	nr	nr	13	nr	nr
McCormick, 2011	7	7	10	nr	11.7	nr	5	nr	nr	nr
Percutaneous fixation
McCormick, 2011	3	3	10	nr	11.3	nr	3	nr	nr	nr
Egger, 2022	5	5	12	nr	12	12	3	5	nr	24
Nunley, 2022	43	43	6	6	10	34.8	37	40	nr	nr
Nonsurgical treatment
Malliaropoulos, 2017	10	10	6	nr	nr	nr	nr	10	nr	nr
Mehta, 2023	94	94	nr	nr	7	nr	nr	nr	12	14
Rizzi, 2022	3	3	nr	nr	nr	nr	nr	2	nr	nr
Saxena, 2017	12	12	6	nr	nr	nr	nr	nr	nr	3.97
Murray, 2005	2	2	6	6	nr	nr	2	2	nr	8
Saxena, 2006	6	6	6	6	10	nr	6	6	nr	3.7
Volpat, 2017	3	3	nr	nr	nr	nr	nr	nr	nr	nr
Burne, 2005	11	11	nr	nr	nr	nr	3	6	nr	nr
Potter, 2006	19	19	nr	nr	nr	nr	nr	19	nr	nr
Maquirrain, 2006	3	5	nr	nr	nr	nr	nr	2	nr	22.3

Abbreviations: N, number; n/a, not applicable; nr, not recorded; RT return to; RTS, return‐to‐sport; WB, weightbearing; wks, weeks.

Complications, failures and secondary surgical procedures

The most common complications observed in patients with NSFs across all treatment groups included nonunion or delayed union, osteonecrosis and refracture. An overall complication rate of 22.5% was noted among athletes who underwent ORIF. Refracture rates, reported by two studies in this group, ranged from 13% to 15% [33, 42]. The failure rate for the ORIF group was 11%, with 12.6% of individuals requiring at least one secondary procedure. Among athletes undergoing percutaneous fixation, the failure rate was 16%, and secondary procedures were needed in 12%. Notably, none of the studies in this group reported instances of refracture following percutaneous fixation. Hardware removal was required in 14% of athletes treated percutaneously. Among those treated nonsurgically, 4% experienced complications, while 20% failed this treatment option. Furthermore, secondary surgical procedures were necessary for 10% of these patients. Complications, failures and secondary surgical procedures are described in Table 8.

Table 8.

Complications, failures, secondary surgical procedures.

Author	N Patients	N Feet	Nonunion (n)	Partial union (n)	Delayed Union (n)	Refracture (n)	Unable to RTS (n)	Failures	Complications	Secondary Surgical Procedures	Hardware Removal
Open reduction internal fixation (ORIF)
Rizzi, 2022	5	5	nr	nr	nr	nr	1	0	0	0	nr
Saxena, 2017	47	47	nr	nr	nr	7	nr	0	7	7	7
Yamaguchi, 2016	2	2	2	0	0	0	0	2	1	1	1
Saxena, 2006	13	13	0	nr	5	0	nr	5	1	1	1
Mehta, 2023	16	16	1	nr	1	nr	3	2	0	1	1
Vopat, 2017	8	9	1	nr	nr	1	nr	1	10	2	nr
Potter, 2006	13	13	nr	nr	nr	nr	0	0	4	nr	nr
McCormick, 2011	7	7	2	0	0	nr	nr	2	2	2	0
Percutaneous fixation
McCormick, 2011	3	3	0	0	0	nr	nr	0	0	0	0
Egger, 2022	5	5	0	2	0	0	0	2	1	0	0
Nunley, 2022	43	43	6	0	0	nr	3	6	0	6	6
Nonsurgical treatment
Beling, 2023	1	1	1	nr	nr	nr	nr	1	1	1	n/a
Mehta, 2023	94	94	nr	nr	nr	nr	nr	15	0	15	n/a
Rizzi, 2022	3	3	nr	nr	nr	1	1	nr	1	1	n/a
Saxena 2017	12	12	nr	nr	nr	0	nr	nr	0	nr	n/a
Murray, 2005	2	2	nr	nr	nr	nr	0	nr	0	0	n/a
Saxena, 2006	6	6	0	nr	nr	0	1	0	0	nr	n/a
Volpat, 2017	3	3	1	nr	nr	nr	nr	1	0	nr	n/a
Burne, 2005	11	11	8	nr	nr	nr	5	8	0	nr	n/a
Potter, 2006	19	19	nr	nr	nr	nr	0	nr	3	nr	n/a
Maquirrain, 2006	3	5	nr	nr	nr	nr	1	nr	1	nr	n/a

Note: Failures were defined as nonunion, delayed union, partial union, or failed nonsurgical treatment requiring surgery. Complications were defined as refracture, chronic pain, posttraumatic osteoarthritis, hardware breakage or irritation, postoperative infection, or nerve injury.

Abbreviations: N, number; n/a, not applicable; nr, not recorded; RTS, return‐to‐sport.

DISCUSSION

The most important finding of this study is that athletes sustaining navicular fractures may safely return to full sport within 4–6 months following surgery, as supported by expert consensus and systematic evidence. The panel also achieved strong agreement that a 4–6 week nonweightbearing period should be observed postoperatively, establishing a standardised framework for rehabilitation and RTS progression. These findings provide the first evidence‐based timelines to guide management of navicular fractures in elite athletes and reduce variability in clinical practice.

Workup and diagnosis

The diagnosis of navicular stress fractures warrants significant attention due to the high incidence of misdiagnosis and the resultant complications that may occur as a consequence of delayed detection. A high index of suspicion is paramount in athletes with an insidious onset of dorsomedial foot pain that may radiate along the medial arch [10]. In a study by Torg et al., approximately 81% of patients with radiographically‐confirmed NSFs had tenderness to palpation at a nickel‐sized area near the proximal dorsal navicular, deemed the ‘N’ spot (Figure 2) [39].

Figure 2.

Lateral radiograph with arrow signifying the ‘N’ spot.

Palpation of this area, along with other provocative manoeuvres such as inversion and eversion of the forefoot, may reproduce the pain and aid in diagnosis. Previous research indicates that NSFs are typically not diagnosed until more than six months after the initial onset of pain, leading to an increased risk of nonunion, functional impairments and chronic pain [18]. A standard algorithm to evaluate for navicular fractures is not widely accepted, as some authors propose radiographs followed by MRI to optimise sensitivity [18], while others suggest radiographs followed by CT to allow for the most accurate characterisation/classification [33, 41]. The expert committee proposes a stepwise imaging approach to suspected NFs in elite athletes, always beginning with plain radiographs, followed by CT to allow for accurate characterisation and treatment planning. There was a strong consensus amongst the expert panel that, even in cases of nondisplaced fractures negative on X‐ray, a bone scan is not recommended. If the CT results are negative or inconclusive, an MRI should be obtained to evaluate for Type 0.5 fractures. A comprehensive clinical exam, including an assessment of the athlete′s gait and mechanical alignment, should always supplement these imaging modalities to evaluate for potential contributing factors.

Nonsurgical management

The role of nonsurgical versus surgical management of navicular fractures in elite athletes is highly debatable, depending on the severity of the fracture and physical requirements of the athlete. Historically, Saxena types 0.5, 1 and 2 are treated nonoperatively [10, 41], with some authors electing for nonsurgical management of Type 3 fractures in the general population [32, 40]. Athletes, however, rely on the expertise of their physicians to create treatment plans that prioritise a safe and effective RTS while also minimising potential long‐term complications. With the athlete patient in mind, Saxena et al. recommend that Type 2 or 3 fractures undergo surgical fixation, especially when accompanied by cystic changes, sclerosis, or osteonecrosis [19, 33, 34]. Many agree that, even in elite athletes, stress reactions only observable on MRI (Type 0.5) may be treated nonsurgically to prevent progression and propagation [33, 41]. The least consensus lies with Type 1 fractures in athletes, which may be treated with or without surgery. Limited evidence suggests surgical fixation decreases the time to RTS and complications such as delayed union and refracture [16, 33, 35]. Based on the cumulative experience and expertise of the IFASC committee, the authors agree with the implication of this evidence and recommend that, in most scenarios, surgical treatment of Type 1 NSFs is appropriate.

In examining the trajectory of weightbearing in patients undergoing nonsurgical treatment, the present review reveals a mean duration of nonweightbearing lasting approximately six weeks. The transition to full weightbearing was found to occur between the seventh and tenth weeks. The experts′ statement suggests a slightly more aggressive course, with a recommended NWB period of 4–6 weeks in most cases. Progression to partial weightbearing at this point aims to facilitate early physical therapy and expedite the athlete′s RTS. Although previous studies have debated the risk/benefit ratio of chemoprophylaxis against deep vein thrombosis (DVT) during the nonweightbearing period following foot and ankle surgery [4], the expert panel recommends against prophylaxis in patients without significant risk factors for coagulation. At the onset of weightbearing, the use of a custom orthotic is recommended to correct for biomechanical factors that may contribute to the injury and prolonged pain. Although previous studies endorse the use of a boot or short‐leg cast relatively equally, a removable boot is recommended to allow for the use of inserts and to encourage early rehabilitation. Low‐impact therapeutic activities such as swimming, cycling, hydrotherapy and deep‐water running are recommended as early as 3–6 weeks after treatment begins, with formal physical therapy suggested at the 6‐week mark. Failure of nonsurgical treatment is not uncommon in individuals who sustain NFs, as over 20% of the athletes in this group experienced unsuccessful initial outcomes. In such instances, surgical fixation is generally deemed the most appropriate next step.

Surgical management

Surgical management is a valid option in nearly all navicular fractures in elite athletes, with Type 0.5 fractures being a common exception. Per the experts′ recommendation, indications for surgical fixation include: complete displaced fractures, nonunion and failure of nonsurgical treatment. To aid the intraoperative reduction and fixation of NFs, specific fluoroscopic views, including AP, lateral, oblique and Canale, are used.

Regardless of surgical technique, the experts also recommend bone grafting (e.g., autograft, allograft) and/or biologics (e.g., CBMA, PRP) to aid in bone healing. Preclinical studies support the use of these compounds in stress fractures due to the positive osteogenic upregulation of bone‐forming growth factors and proteins [12]. With this knowledge, the routine use of a bone stimulator postoperatively is not unanimously recommended, but this decision remains at the discretion of the surgeon.

In the present review, surgical candidates were separated into ORIF and percutaneous fixation groups. There was a strong consensus amongst the committee that percutaneous fixation is favoured in nondisplaced NFs and ORIF is favoured in the case of displaced NFs in elite athletes.

Further, it is recommended that nondisplaced fractures be treated with 1–2 compression screws, and displaced fractures be treated with multiple screws and/or a plate. Figure 3 demonstrates pre‐ and post‐operative radiographs of a minimally displaced NSF treated with two compression screws.

Figure 3.

AP radiograph of the right foot demonstrating a navicular stress fracture pre‐operatively (left); Postoperative AP radiograph of the right foot with fixation of a navicular stress fracture (right).

Of the 112 included fractures that underwent ORIF, multiple hardware combinations were used, although screws were employed more often than plates. Among the 51 athletes who underwent percutaneous fixation of their navicular fracture, the most common screw sizes used were 3.5 and 4.0 mm. In both studies that detailed their percutaneous surgical technique, the choice was made to employ multiple screws instead of a single screw. This stands in contrast to earlier research that has advocated for an algorithmic approach, which recommends the use of one percutaneous 3.5 mm screw for Type 1 fractures while suggesting ORIF with one or two screws for Types 2 and 3 fractures [37]. In cases of NF nonunion, surgical management, encompassing ORIF and bone grafting, is recommended. Following surgical intervention, the expert panel recommends the athlete begin physical therapy at 2 weeks, but remain NWB for 4–6 weeks. These parameters aim to lower the risk of complications and failure, which were observed in 22.5% and 12.6% of athletes in the ORIF group, respectively. In the percutaneous fixation group, postoperative complications occurred in 2% of athletes, whereas almost 16% of these patients failed this treatment.

RTS and other considerations

Across all treatment groups, ORIF, percutaneous fixation and nonsurgical management, 95.2% of athletes successfully returned to their sport. In the ORIF group, an impressive 98.7% of athletes resumed their activities, averaging a return at 8.2 ± 11.1 weeks. All athletes treated with percutaneous fixation successfully returned to sport, although specific timeframes could not be extracted. Despite the wide variability in RTS timelines following ORIF, the panel suggest that athletes engage in light training between 12 and 16 weeks post‐treatment, followed by a full RTS between 16 and 24 weeks after any surgical intervention. In the nonsurgical treatment group, the mean time to RTS was 14.8 ± 7.9 weeks, with 87% of these athletes being able to return to their sport. This data supports the recommendation that elite athletes can expect to return to light training in their sport between 8 and 16 weeks, with full RTS expected between 16 to 24 weeks if following a nonsurgical treatment plan.

Readiness for return can be difficult to assess, as refracture can be a significant concern. The committee recommends evaluating the injury via CT prior to RTS, with the primary focus of this tool being signs of healing and improvement rather than complete resolution of the fracture line. Some long‐term follow‐up studies have observed asymptomatic patients with persistent fracture lines on CT up to 6 years after treatment [7]. To mitigate delays in RTS for elite athletes, the decision regarding the appropriate timing for resuming training should be based on a multifactorial approach. The progression in clinical evaluation and imaging studies should be prioritised over the attainment of complete radiographic union. When providing recommendations regarding RTS, it is important to consider contributing factors that may facilitate a smooth transition. Custom inserts, rehabilitation exercises, consolidation and healing and sport‐specific management should all be evaluated and/or utilised in this pivotal transition period.

Additional considerations during the treatment and rehabilitation periods include the use of Vitamin D and calcium supplementation. Previous literature supports the use of these supplements to aid in bone healing and prevent delays in achieving union. Given that Vitamin D insufficiency is a well‐recognised risk factor for stress fractures, it is reasonable to perform screening tests in athletes who sustain NFs and are suspected to be Vitamin D deficient [14]. A study conducted by Lappe et al. found that a combination of calcium and Vitamin D therapy, dosed at 2000 mg and 800 IU, respectively, resulted in a 20% decrease in stress fractures in female navy recruits [15]. Per these guidelines and the combined experience of the committee, the panel recommends all athletes with NFs be treated with calcium and Vitamin D, with the latter being dosed aggressively at 2000–5000 IU daily, or 50,000 IU weekly.

This study presents several potential limitations that should be acknowledged when interpreting the findings. The systematic review is constrained by the level of evidence, the sample sizes of the included studies, and the heterogeneity of the data, which complicates statistical analysis and cross‐comparison. The consensus statements represent level V data, as they are based on expert opinion and may be subject to inherent biases. To mitigate this, we aimed to include a diverse group of surgeons with a strong interest and proven expertise, as evidenced by their clinical and academic accomplishments. Furthermore, the questions posed were selected by group leaders, introducing a potential source of bias due to the absence of a standardised question‐generation process. To counter this issue, all authors involved were given the opportunity to review the manuscript and raise points for discussion.

CONCLUSION

Athletes sustaining navicular fractures can typically expect a functional recovery, with most returning to play within 4–6 months after surgery. The consensus recommendations provide the first standardised, evidence‐based framework for postoperative progression, including a 4–6 week nonweightbearing phase and structured rehabilitation milestones. These findings guide clinicians in optimising recovery and RTS outcomes in elite athletes.

AUTHOR CONTRIBUTIONS

Kassidy J. Webber: Methodology; writing—original draft preparation. Vanessa J. Boggiano: Methodology. Julia M. Balboni: Formal analysis and investigation. Scott D. Semelsberger: Writing—review and editing. Jay Moran: Writing—review and editing. Paul Mast: Systematic review data collection; manuscript draft. Alberto Vasquez: Formal analysis and investigation. Arianna L. Gianakos: Conceptualisation; methodology; formal analysis and investigation; writing—review and editing; supervision. IFASC Committee Members: Conceptualisation; formal analysis and investigation; writing—review and editing.

IFASC COMMITTEE MEMBERS

Kini Abhishek MD, Robert Anderson MD, Mette Andersen MD, Jorge Batista MD, James Calder MD, Christel Charpail MD, Choon Chiet Hong MD, Tim Clough MD, Ben Forster MD, Eric Ferkel MD, Richard Ferkel MD, Stéphane Guillo MD, Bryan Den Hartog MD, Pieter D'Hooghe MD, John G. Kennedy MD, Gino Kerkhoffs MD, Jin Woo Lee MD, Jeff Ling MD, Graham McCollum MD, Kirk McCullough MD, Martin O'Malley MD, Cristian Ortiz MD, Chris Pearce MD, David Porter MD, Marcelo Prado MD, Damien Richardson MD, Elena Samaila MD, Lew Schon MD, Pietro Spennacchio MD, Jim Stone MD, Fransceca Vannini MD, Jordi Vega MD, Monika Volesky MD, J. Turner Vosseller MD, Gregory Waryasz MD, Youichi Yasui MD, Alastair Younger MD, Urszula Zdanowicz MD.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

No Institutional Review Board or Ethics Committee approval was required due to the retrospective collection of publicly available data. All expert recommendations provided here are intended for interprofessional guidance and should not be interpreted as implying any liability.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.