Tag: stress fractures in shin

Stress Fracture in the Dancer

What is a stress fracture?

Stress fractures are one of the most common sports injuries that typically occur as a result of repetitive overuse that exceeds the ability of the bone to repair itself. High-impact activities like jumping can fatigue muscles and cause an inability to absorb additional shock or stress, which eventually transfers to the bone and causes microfractures, which without adequate rest can lead to a stress reaction and eventually fracture. The most common lower extremity stress fractures involve the tibia (approx. ½ of all stress fractures in children and adults) or metatarsal bones (25% of stress fractures). Less common stress fractures include the fibula, navicular tarsal bone, pelvis, and femur. 

Specifically, in the dancer population, the most prevalent stress fractures occur in the feet, particularly the second and third metatarsals, fifth metatarsal (Jones fracture), or sesamoid bones. Tibial stress fractures are the most common stress fractures that occur in the leg. 

Common Symptoms:

– Localized tenderness with palpation at the pain site, sometimes with swelling around the area

– Dull pain with a gradual onset that worsens during weight-bearing activity
– Pain that diminishes with rest
– Possible bruising around painful site

Differential Diagnoses:

Tibia
    1. “Shin Splints” (medial tibial stress syndrome)
    2. Compartment Syndrome 
Foot
     1. Plantar fasciitis
     2. Metatarsalgia
     3. Morton’s neuroma
     4. Posterior Tibialis Tendon Dysfunction
     5. Lisfranc Injury 
Pelvis
     1. Pathologic fracture
     2. Rectus femoris strain 
     3. Iliopsoas Syndrome

How Does it Happen?

Bone adapts to increased load in weight bearing through a process of remodeling, which speeds up as the load increases. Some bone tissue is destroyed (resorption) and then rebuilt during this process. However, when bone is unaccustomed to sustained forces without enough time to recover, resorption of bone occurs faster than the body can naturally replace it, leading the body more susceptible to a stress fracture.

Risk Factors:

– Dancers who dance > 5 hours per day (Ballet) 
– Hormonal or menstrual disturbances (long duration of amenorrhea) (Ballet) 
– Participation in running and jumping sports
– Rapid increase in physical training program
– Excessive physical activity with limited rest periods
– Poor pre-participation physical condition
– Female sex
– Hormonal or menstrual disturbances (long duration of amenorrhea) 
– Low bone turnover rate
– Decreased bone density
– Decreased thickness of cortical bone
– Nutritional deficiencies (including dieting)
– Extremes of body size/composition
– Running on irregular or angled surface
– Inappropriate footwear
– Inadequate muscle strength
– Poor flexibility
– Low levels of Vitamin D
– “Type A” behavior 

When to Seek Medical Attention:

– Contact your doctor if pain becomes severe or you begin to feel pain at rest or at night
– If you have had a history of stress fractures you should consult your doctor to rule out an unhealed stress fracture
– Particular attention to the signs of Female Athlete Triad/RED-S (disordered eating, irregular or absent menstrual cycle, and low bone mineral density) in female and male athletes should be considered and managed with a multidisciplinary approach (sports psychologist or counselor, nutritionist, registered dietician, physician, PT, etc)

If You Suspect You May Have a Stress Fracture:

Modified activity
     1. Cross-training with swimming and cycling to maintain aerobic fitness while avoiding weight bearing stress
     2. Avoid continuous activity that provokes symptoms
     3. Seated exercises during dance class (prescribed from PT) 
Protective Footwear
    1. Stiff-soled shoe for walking 
    2. Removable brace
    3. Taping 
NSAIDS, cryotherapy 
Decrease weight bearing on painful area
    1. May need to use crutches to offload stress through injured area

How To Treat Stress Fracture:

– Maintain weight bearing restrictions as prescribed by physician 
– Active rest/modified activity without decreasing fitness
– Seated range of motion/strengthening: 
    1. Ankle exercises: ankle alphabets, seated plantarflexion/dorsiflexion/inversion/eversion with resistance
         – Foot intrinsic: marble pickups, towel scrunches, toe curls
    2. Knee exercises: eccentric hamstring and quad strengthening 
    3. Hip exercises: side lying abduction/clamshells, prone hip extension
    4. Core: Crunches, modified planks 
– Progress from isolated muscle strengthening to strength and form correction during routine 
– VIDEO TAPE MOVEMENT! Record self dancing and work with PT to identify areas to improve body mechanics  

Return to Sport:

– In most cases it takes 6-8 weeks for a stress fracture to heal
     1. DO NOT return to activity sooner than this! You increase your risk for larger, harder to heal stress fractures and chronic problems with a stress fracture that never healed properly
– More serious stress fractures take longer due to extended non-weight bearing status 
     1. Femur: 8-14 weeks
     2. Navicular: 16-20 weeks
– Doctor may confirm that the stress fracture has healed with X-rays and follow-up examination
– Weight bearing during single leg hopping (landing a jump) should be completely pain free 
– Gradual return to activity: alternate days of activity with days of rest
– Consider biomechanical analysis of dance movement pattern for long-term health and modifiable positioning to put less stress through joints

Prevention:

– Eat a healthy diet rich in calcium and vitamin D. Ensure adequate calories to replace energy expenditure. 
– Use proper footwear and replace worn out shoes (typically every 8-12 months). Avoid wearing flip flops and high heels frequently due to lack of support/stability
– Start new activity slowly and gradually increase time and intensity back in studio 
– Cross-train or rest at least once a week to avoid overstressing one area of your body 
– Add strength training to prevent early muscle fatigue and bone loss: use resistance bands, weights, or your own body weight 
– Proper warm ups and cool downs every practice! 
– If pain or swelling occurs, immediately stop and rest for a few days and consult doctor or orthopedic specialist if pain persists

Contributor: Erin Gentile, SPT 
Former Professional Irish Dancer 
PREP Performance Center Student Intern 

References:

– Sanderlin BW, Raspa RF. Common stress fractures. Am Fam Physician. 2003;68(8):1527-1532.
– Kadel NJ, Teitz CC, Kronmal RA. Stress fractures in ballet dancers. Am J Sports Med. 1992;20(4):445-449.
– Schoene L. A guide to diagnosing and treating common dance injuries. Podiatry Today. 2013; 26(4):48-54.
– Laid JC, Kruse DW. Assessing readiness for en pointe in young ballet dancers. Pediatr Ann. 2016 45(1):e21-25.
– Tosi M, Maslyanskaya S, Dodson NA, Coupey SM. The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters, Dancers, and Runners. Journal of Pediatric and Adolescent Gynecology. 2019;32(2):165-169.
– Noon M, Hoch AZ, Mcnamara L, Schimke J. Injury Patterns in Female Irish Dancers. Pm&r. 2010;2(11):1030-1034. doi:10.1016/j.pmrj.2010.05.013.
– Albisetti W, Perugia D, De Bartolomeo O, Tagliabue L, Camerucci E, Calori GM. Stress fractures of the base of the metatarsal bones in young trainee ballet dancers. Int Orthop. 2010;34(1):51–55. doi:10.1007/s00264-009-0784-3

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