What is a Stress Fracture?

For many dancers, the fear of getting a stress fracture is a major worry, especially if they start developing foot pain. Many dancers avoid consulting a therapist when they have foot pain for fear of being diagnosed with a Stress Fracture, however catching them early can make the difference between it resolving quickly or becoming a chronic issue. So what is a Stress Fracture? How do you know if you have one? And what should you do if you get one?

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What Is A Stress Fracture?

A “fracture” is a disruption, or break in a bone.

Some fractures, called stress fractures, are microscopic, and develop more over a period of time, rather than with one big incident. Our bodies are amazing and adapt remarkably well to the things we demand of them. However, if too much load is placed through a bone, in a particular direction, and it does not have the strength to endure such forces, a stress fracture may develop. Over time tiny faults will appear within the bone, and unless the forces imposed in that bone are changed, they will accumulate and develop into a more major fault in the bone.

Stress fractures often follow a progression of three stages…

A) Bone Strain – Re-modelling of bone, or increased activity of the cells that build bone is the first sign of an issue with loading in the bone. This stage is very rarely picked up as the dancer does not feel much pain at all. The remodeling may sometimes be picked up by a bone scan looking for other issues.

B) Stress Reaction – Once there is a tender portion of bone, but before the bone shows signs of a fracture, it is called a stress reaction. This stage is often seen in dancers who are increasing hours or changing styles of dance. If problems with technique or footwear are picked up at this stage, it is possible to avoid the development of a stress fracture. Many dancers avoid reporting pain at this stage as they are scared of "Having an injury" however, if it is caught early, and dealt with appropriately, then more severe injury and disability can often be avoided.

C) Stress Fracture – Once there is a development of an actual fault in the bone, it is classed as a stress fracture, and usually, a period of non-weight-bearing is needed to resolve the symptoms. Depending on the risk factors of that particular dancer, treatment may vary considerably, so it is important to be guided by your therapist on any time off, use of a boot, and a gradual build back into class.

Types of Stress Fracture:

There are two common types of Stress Fracture

Fatigue Fracture. This is the most common form of stress fracture found in dancers and is caused when a normal bone is exposed to repeated abnormal stresses e.g. Jumping, Landing, Balancing on demi Pointe e.t.c. with poor alignment or insufficient control.
Insufficiency Fracture. This type of fracture occurs when a normal amount of stress is applied to an abnormal bone e.g. bone with Osteopenia, especially in the case of eating disorders.

Locations most susceptible to getting a Stress Fracture:

There are several areas of the foot that are most susceptible to Stress Fractures in dancers and athletes alike; the Metatarsal Bones (Especially the first and second MT in Dancers) and the Navicular Bone (More common in athletes, usually caused by running). Stress fractures may also occur in the Tibia (Shinbone), the Calcaneus (Heel bone), and the 5th MT (Outer part of the foot)

Navicular Stress Fracture - Skeletal Foot Anatomy - Anatomy Diagram - Lisa Howell - The Ballet Blog

Causes of a Stress Fracture:

Causes of a stress fracture include anything that creates load through one part of the bone over another.

Errors in Technique (in Dancers) such as incorrect posture, poor weight dispersion across the foot e.t.c.
"Fishing" the foot en pointe, or the foot twisting in the shoe.
Impact of an unfamiliar surface, such as dancing on an unfamiliar stage, or jumping on concrete for a photoshoot.
Training errors such as too rapid an increase in the number of hours training, such as when a dancer starts full-time training.
Stress caused by another foot problem. I.e. Walking on the outer border of the foot to avoid pain under the big toe joint.
Wearing poorly cushioned shoes while dancing or walking on hard surfaces. This includes the frequent use of "UGG Boots" in winter and Thongs/flip flops/Sandals in summer. This is a huge problem for dancers as ballet shoes tend to lack essential support.
Poorly fitted pointe shoes can also add a tremendous amount of unnecessary stress to particular parts of the foot.
Abnormal foot structures, such as flat feet or extremely high arches can cause the load to be focused on certain parts of the foot.
Restricted range in one part of the foot, often due to a previous injury, can cause more load in the more mobile areas.
Repetitive pounding on the ground, without appropriate control of the landing phase, or striking the foot too hard during Battements Frappé e.t.c.
Rapidly increased levels of activity without correct conditioning, often during rehearsals for shows and exams.
Obesity, or a sudden increase in body weight in a short period of time.
Eating Disorders - Malnutrition causes bone density to decrease.
Rapid decrease in bone density e.g. Osteoporosis or Osteopenia.

Symptoms of a Stress Fracture:

General symptoms of a stress fracture include:

Sharp pain while walking and mild swelling, in the affected area.
A stress fracture will often ache at night, even when there is no load on the foot.
It may be uncomfortable or painful when pressure is applied directly to the small area around the fracture.
Acute fractures may result in an inability to put weight on the foot, swelling, and more severe pain. Even acute fractures usually have little displacement when they occur in a metatarsal bone.

Diagnosis of a Stress Fracture:

In analysing your injury, your therapist or doctor may be able to diagnose your injury strictly on the basis of a physical exam. The therapist will assess the injured area, comparing it to the uninjured leg or knee. He or she will evaluate visible signs of injury such as tender skin, swelling, and differences in joint mobility or appearance.

They should also look at the rest of the body, especially the trunk, spine, and pelvis, looking for weaknesses or asymmetries that may have led to the injury occurring. Correctly identifying any contributing factors early will help in devising the most correct, and effective rehab program to help ensure that the injury does not reoccur.

Often people ask whether they should have an X-ray to check for stress fractures. Because they are rarely ‘displaced’ (when the bone has shifted its position), or appear all of the way through the bone (this can happen in very severe cases) Stress Fractures cannot initially be seen on regular x-rays. In addition, many people think that if their x-ray is ‘clear’ then they are fine, however, this is not necessarily the case.

Sometimes the doctor or therapist may request a bone scan, an MRI (Magnetic Resonance Imaging), or CT (Computed Tomography) scans to confirm the diagnosis, however, these are often not needed.

IMPORTANT! Correctly diagnosing a stress fracture is very important to ensure that you get the correct treatment. Many different injuries can give pain in similar areas, so this step is extremely important.

Treatment for Stress Fractures of the Lower Leg and Foot:

Stress fractures are usually treated conservatively, without surgery. Treatment of the stress fracture will depend on the individual dancer's risk factors and contributing factors, but may include the following:

Rest of the injured area is essential and usually requires suspending the activity that caused the injury for six to eight weeks.
This should always be "Relative Rest" to avoid reconditioning in the rest of the body.
Possible use of an orthopedic boot to offload the area - this should make the foot pain free
Some specialists do not advocate the use of an orthopedic boot and believe that gentle weight-bearing will encourage blood flow, so walking on the foot may be allowed, depending on your injury.
Avoidance of high-impact activities (Such as dance or gymnastics).
Use of contrast bathing, involving alternate hot and cold water baths, to encourage blood flow to the area.

NB - we now tend to avoid the traditional R.I.C.E treatment as this can actually reduce blood flow to the area and may delay healing.

A major component of the treatment for a stress fracture must always be in identifying and correcting any contributing factors that led to the injury developing in the first case. This may include, but is certainly not limited to:

Pelvic and core stability exercises
A modified class or Floor Barre to maintain condition in the rest of the body
Specific manual therapy techniques to mobilise stiff areas of the foot
Specific strengthening and re-patterning exercises for the foot and ankle
Fascial Mobility exercises to ensure balance and mobility in the body
Mirror therapy to maintain muscle patterning in the foot while not using it
Dietary and lifestyle changes including monitoring sleep habits and ceasing smoking if this is an issue

Floor barre is an extremely effective way of maintaining dance fitness and technique while enabling the dancer to retrain certain areas of their technique. The absence of gravity in some positions allows dancers to find and activate muscles that are easily overpowered by larger muscles. Often utilising these muscles over the more powerful muscles achieves better control of the movement and a nicer line. A good example is during développés; often the deep core muscles are not used while the quadriceps work strongly. Our video taken from the "Will I Ever Dance Again?" program showcases how effective floor barre can be.

Returning To Dance After A Stress Fracture:

Once the stress fracture heals, normal activities should be gradually incorporated. A dancer should employ the 10% policy – workload should not be increased by more than 10% per week after the treatment period. With this type of injury, it is extremely important that the dancer does not start working at full capacity immediately, as the injury could reoccur. It is important to slowly work yourself back to full-time training.

It is essential that you are well-conditioned and that equal time is given to work and rest to prevent fatigue. Make sure to start each day with warm-up exercises and cool down at the end of the exercise period. A balanced diet including vitamin D and calcium-rich foods is important in maintaining bone density and health.

Replace any old or ill-fitting ballet or athletic shoes, and ideally have an individual fitting with an experienced fitter, as the style and size of shoe that is most suitable for you may have changed following your rehab (often strengthen the foot can cause a change in shape)

If you experience pain or swelling in the injury site as you resume dancing, please stop all exercise immediately and seek the advice of your health professional.

Prevention of Stress Fractures:

Due to the extended recovery time (6-10 weeks) for a stress fracture to fully heal, and the effect that this has on a dancer's training, preventing stress fractures is of major importance. Gradually increasing workloads at a rate of no more than 10% a week and varying the training by using cross-training techniques will help to offset the overload and repetition often associated with stress fractures.

Warming up properly and preparing the body for the workout will help to keep the muscles from fatiguing as quickly. This will also prevent injuries to the muscles and tendons, which could lead to further weakening of the bones. Injuries to the muscles, tendons, or ligaments that support the skeletal system could lead to excess, and awkward, pressure on the bones.

Flexibility is essential for dancers and athletes as well. Muscles that are flexible will provide more support and, due to their elasticity, absorb more shock. They are also less susceptible to injury, which could lead to an imbalance or improper gait. Stiff muscles will also lead to incorrect running and landing patterns that could lead to extra stress.

Injury & Foot Resources

If you are looking to delve deeper into this topic, check out the following programs:

Will I Ever Dance Again: The “Will I Ever Dance Again?” program is perfect if you are unable to train at full capacity, whether this is due to a foot injury, surgery, an accident or illness outside of the studio. It helps you build back to full capacity gradually, while maintaining strength, flexibility and control in the rest of the body.
Level One Dance Teacher and Therapist Training: This unique course covers a multitude of assessment and treatment techniques to individualise a dancer's training. With special focuses on Postural Control, Core Stability, Flexibility, Basic Classical Technique, The Dancers Hip, Allegro, Spinal Mobility and Arabesques, it is suitable for anyone working closely with dancers.