We all know our bones support and protect our bodies but did you know that our bones continually changing? Building up and breaking down as part of our normal metabolism? Because our bones are in a constant state of regeneration, it means that when there’s too much demand or load, a fracture can occur. With repeated jumping, landing and running, dancers are prone to stress fractures. This can occur slowly over time, so often a dancer may not even know he or she is at risk until it has progressed to become a more significant injury.
Read on to find out how to tell if you have a stress fracture and the best way to manage this injury.
A fracture is any break in the bone that disrupts the matrix that makes the bone solid, uniform, and whole. Compared to an obvious incidence such as a fall, where a snap or crack might be felt immediately, stress fractures are a common overuse injury caused by repetitive submaximal loading to the bone. These fractures can be partial, where the bone is cracked in one part but not on the other side and may not go all the way through, or complete, where there is a divide in the bone and the fracture has gone all the way through. (Knechtle, Jastrzębski, Hill, & Nikolaidis, 2021) .
There are different levels of severity of bony stress injuries.
Firstly, there are bony stress responses. These are regular bone stressors that usually cannot be felt either when loading or through touching the bone. Bone stress will occur through everyday activities that are typically greater than walking (such as jogging, weights training, or jumping). Bone loading and stress can aid in stimulating new bony turnover and this is why activities that place stress on the bone have been recommended to aid in the prevention of osteopenia and osteoporosis (Drysdale, 2021).
Secondly, there is a bony stress reaction. These bone stress injuries are sometimes tender to the touch and may cause some local swelling. These are usually signs that over-training and overuse has occurred and serve as the perfect warning sign to de-load and take some rest. This has occurred because there has been too much bony turnover where more old bone is being removed through the loading process, however not enough time has been taken to rest, to allow new bone to be laid down. Training can typically be modified to reduce loads without having to take complete rest and technique can be focussed on more readily (Drysdale, 2021).
Lastly there is a bony stress fracture. These cracks or breaks in the bone are a sign that over-training and overuse has occurred and will now require complete offloading (in most cases) and rest from activity. A large discrepancy in bony turnover resulting in more old bone going out than new bone coming in leads to a weak point and the bone cracks when loaded. In the lower limb where these types of fractures typically occur, recovery may mean crutches or a boot depending on the severity and location.
In more severe cases, some injures may require surgical intervention to realign these fractures and aid in healing. Some fractures may reach consolidation (return to normal looking and functioning bone) as early as six weeks, however others may take as long as 24 weeks. Adequate offloading is vital to the resting period and reduction of further bony injury (Beck & Drysdale, 2021).
In our dancing population there are several common sites of stress fractures. Due to the dancer’s position when rising en pointe, the foot and ankle are susceptible at different points of loading and are influenced by the repetitive landing of jumps and releve’s over the long hours and back-to-back days of training.
Common fracture sites include:
In the initial phase, bone stress reactions may present with few physical signs other than some mild pain and local tenderness, so they are often ignored and dismissed.
However, without active management and reduction in load to allow the bone to heal, the progression of a stress reaction to a stress fracture is likely. This can result in more noticeable symptoms such as:
If you experience any of these symptoms, they should not be ignored. it is important to get an assessment to determine proper treatment and reduce the risk of further damage to the affected bone.
What can I do now I have a stress fracture?
Management of your injury will occur in a few different ways. Initially, diagnosis will occur with imaging investigation. Depending on the location of the injury, you may be required to wear a short or long boot and possibly use crutches for a period of time. In some circumstances, surgery may be required to re-align or stabilise higher risk fractures. If a surgeon is not required, consultation with a sports doctor is desired to gain medical perspective and advice around bony healing times and needs for your fracture type.
It will be important to maintain good function in the non-injured limb and undergo range of motion and eventually strength and loading exercises in the injured limb once the initial healing phase is complete. Our Physiotherapist and Dance Program coordinator will work alongside teachers and parents to create the best rehabilitation program possible to allow students the best possible outcomes and enhance participation, even during early injury stages.
The best prevention for a dancer initially entering the world of pointe ballet is to undergo a thorough pre-pointe assessment with an appropriately qualified practitioner. This will ensure that the dancer is physically ready to undergo the stressors placed on the body when rising up en pointe. Pre-pointe analyses are advised to be undertaken following 3 years of dance training and preparation. Additionally, some dancers find a lot of benefit of completing a secondary assessment once beginning dancing en pointe, to maintain their fitness to dance and receive further advice on injury prevention.
Interested in learning more about our pre-pointe assessments? Follow the link here to find out more.
Bone stress reactions and stress fractures are common in all sports and activities that require high levels of loading and are particularly problematic for dancers. The signs and symptoms should not be ignored. Early assessment and prudent management early in the injury cycle provide far superior outcomes. As with all things, prevention is better than cure!
Keep an eye out for Part 2 of Kelsey’s blog – Why are stress fractures particularly a problem for young dancers?
If you or your dance school are interested in a pre-pointe or mid-pointe assessment, please contact our dance team coordinator and Physiotherapist, Kelsey via our contact page or make a booking online. We also have information packs available for dance schools.
Kelsey is a physio, dance team coordinator and Myotherapy team lead at CSSM. She has 17 years of dance training and is no stranger to working within elite sporting environments including the AFL and with independent athletes.
Kelsey has also done her fair share of teaching and coaching, initially choreographing tap and jazz routines for a local school for two years and then taking her talents to a different area and coaching rock-climbing for state and national juniors for five years. Talk about diversity! If you have a chat with her, you may find yourself talking about snowsports too!
She currently has taken on a casual role with LaTrobe University in assisting the first year Masters of Physiotherapy students in their learning during clinical placement. While she has a strong desire to complete further studies, Kelsey is focussing her efforts on her dance athletes and improving her knowledge and skills in this area.
Beck, B., & Drysdale, L. (2021). Risk factors, diagnosis and management of bone stress injuries in adolescent athletes: A narrative review. Sports, 9(4), 52.
Drysdale, L. M. (2021). Does bone-targeted training reduce bone injury-related time loss to dancing in pre-professional classical ballet dancers? BalletMor: A feasibility study. Griffith University,
Knechtle, B., Jastrzębski, Z., Hill, L., & Nikolaidis, P. T. (2021). Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures—A Narrative Review. Medicina, 57(3), 223.
Zhou, Z. (2021). Overuse Injuries of Foot and Ankle and Healthy Training in Young Female Ballet Dancers. Paper presented at the 2021 3rd International Conference on Literature, Art and Human Development (ICLAHD 2021).
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