In part 1 of CSSM Physio Kelsey Thomas’s ballet blog series, we looked at how to tell if you have a stress fracture and the best way to manage it. In part 2, we look at why stress fractures are a problem for young dancers.
While the section below talks a lot about the intrinsic factors that may lead to a stress fracture, there are still many extrinsic factors that an athlete and team need to consider to reduce the likelihood and incidence of a stress fracture. It’s important to make sure you, your coaching team and health team are communicating and are on the same page when it comes to your performance and health. Extrinsic factors, or outside influences, can include:
Young dancers as they are going through growth spurts in pre-puberty (particularly female dancers), will have issues where height development and mineral accumulation in the bone don’t happen at the same time, leading to less bone density. Think of it like spreading the same amount of butter over a larger piece of bread, you won’t have as much coverage. Paired with higher training loads and large forces going through the lower limbs, this can lead to stress fractures and other tendon and ligament injuries. Stress fractures in skeletal immature populations are a cause of concern when the growth plate is involved. A period of complete rest would be required, sometimes up to 6-months, and missed growth plate fractures may lead to future deformities, poor alignment and arthritis in the joints (Beck & Drysdale, 2021; Zhou, 2021)
Relative energy deficiency in sport (RED-S), previously known as the female athlete triad, occurs with a myriad of symptoms that pre-dispose a dancer to not only stress fractures, but other physiological and psychological injuries and ailments. RED-S is mainly caused by low-energy availability, whereby the dancer’s dietary energy intake is insufficient to support their normal health functions and day to day living once the rigorous training has been considered. Basically, there’s more output than input. The potential health impacts of RED-S can include altered menstrual function in female dancers, which we’ll talk more about below, immunological and gastrointestinal issues, impacts to bone health, psychological affects and growth and development delays (Mountjoy M, Sundgot-Borgen J, Burke l, et al., 2015).
The effects of RED-S can take their toll on the dancer’s performance in other ways than just stress fractures. Some of the symptoms a dancer or other high-performance athlete might notice as their energy deficiency progresses include performance deficits such as decreased training response, lower concentration and coordination, issues with muscle strength and energy, and psychological affects like irritability and depression (Mountjoy M, Sundgot-Borgen J, Burke l, et al., 2014).
Due to the high aesthetic component of ballet, many dancers may feel pressured to look a certain way and restrict their dietary intake or focus on more low-calorie options. For dancers that are training quite heavily, this may lead the RED-S development. If you are concerned in any way about your dietary intake or would like some advice, a session with a sports dietitian is highly recommended to keep you on track and limit the possibility of injury development.
Did you know that if you have not had your first menstrual cycle by the age of 15, you are automatically in a moderate risk category for not only RED-S but stress fractures? For athletes that are amenorrhoeic, that is, have not experienced a period by the age 15 or have not experienced a period for one or more cycles, will have lower bone mineral density, decreased trabecular bone, and decreased cortical bone thickness (Akerman et al., 2011).
The good news is that when we see resumption of regular menses, we also see an increase bone mineral density. However, this is not to be confused with an artificial menstrual cycle that is created with the use of an oral contraceptive pill. The absence of a menstrual cycle is a symptom of RED-S and not a cause of reduced bone mineral density. Therefore, the cycle may appear to be stable, but the underlying RED-S is still affecting the rest of the system. There is a role for the pill, but it’s not the only answer.
While we manage the stress fracture from a physical perspective, we will need to consider the other factors discussed. We will likely complete an assessment to determine if RED-S is involved in your fracture. These may sometimes feel like uncomfortable questions, however when your health, athletic or dancing career and participation is on the line, it will be important to discuss these things with us to the best of your ability and comfort.
We may look at further investigations and getting your General Practitioner (local Doctor) and/or Sports Doctor involved. Additional team members may include a Dietitian and Sports Psychologist.
Generally, we will see stress fractures appear from too much load and not enough relative rest. Management will include resting, strengthening and addressing contributing factors such as footwear and training surface.
For more on how to tell if you have a stress fracture and the best way to manage this injury, read Part 1, Understanding Bone Stress Injury.
Kelsey is a Physiotherapist, dance injury program 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 athletics 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!
In addition to her clinical role, she currently works 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.
If you or your dance school are interested in a pre-pointe or mid-pointe assessment, please contact our dance injury coordinator and Physiotherapist, Kelsey at Kelsey.Thomas@cssm.com.au or make a booking online. We also have information packs available for dance schools.
Find a copy of the full RED-S clinical assessment tool here.
Ackerman, K. E., Nazem, T., Chapko, D., Russell, M., Mendes, N., Taylor, A. P., . . . Misra, M. (2011). Bone microarchitecture is impaired in adolescent amenorrheic athletes compared with eumenorrheic athletes and nonathletic controls. The Journal of Clinical Endocrinology & Metabolism, 96(10), 3123-3133.
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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