The majority of stress fractures in dancers are to the metatarsals, but they may also occur in the fibula, tibia, spine and hip. Especially of concern are stress fractures to the femoral neck, anterior cortex (front side) of the tibia, and proximal fifth metatarsal. These locations carry the highest risk of complications, and should be referred to a sports medicine physician or orthopedist as soon as possible.
Causes & Symptoms:
Female dancers are subject to an increased risk for stress fractures due to a high incidence of the female athlete triad: amenorrhea (cessation of menstruation), disordered eating, and low bone density. Additionally, dancers with high arches may be at an increased risk for stress fractures of the foot. Serious infections and cancer may also weaken the bones, increasing risk of fractures (Cosca & Novazio, 2007).
Types of Stress Fractures:
- Proximal fifth metatarsal stress fractures are most common in modern dancers who perform repeated cutting and pivoting movements, frequently without shoes.
- Second metatarsal stress fractures occur more commonly in female ballet dancers who do pointe work. Dancers with improperly fit pointe shoes are at a greater risk for second metatarsal stress fractures. MRI is the best diagnostic tool for this injury. Diagnosis should be taken seriously, as there is a high risk for fracture without adequate rest.
- The first sign of fibular stress fractures is tenderness on the fibular shaft (lateral or outside part of the lower leg). Poor balance and fatigue while initiating a pirouette are implicated in fibular stress fractures. Fibular stress fractures often do not appear on traditional x-rays. Ask for a bone scan if symptoms persist. Rest and immobilization almost always work, but the recovery period can take up to 1 year.
- Stress fractures of the femoral neck are characterized by pain in the groin area while dancing (especially jumping). A stress fracture on the inferior surface of the bone is more stable than on the superior surface of the bone. Tension fractures (superior surface) carry a high risk of separation and are often treated surgically.
- Anterior tibial stress fractures are not entirely common (experienced by less than 5% of athletes), but nonetheless can occur in dancers from repeated loading on the tibial shaft. At the Harkness Center for Dance Injuries, 24 of the 1757 dancers seen between 1992 and 2006 experienced tibial stress fractures. Seven of those dancers required surgical intervention, either through drilling and bone grafting, or intermedullary nailing. Although the average recovery time was well over six months, 6 out of 7 returned to dance with very few problems.
Diagnosis & Treatment:
According to Cosca & Novazio (2007), stress fractures typically present the following symptoms:
- Pain that worsens with weight-bearing activity
- Localized pain that is sometimes present while at rest
- Localized swelling around the area of pain
Stress fractures are difficult to diagnose, and difficult to treat. If a dancer suspects a stress fracture, s/he should seek medical attention immediately.
Not all stress fractures can be detected with x-rays or MRI scans. However, a callus forms around the bone 2-3 weeks after the initial injury that usually appears on x-rays. If immobilization (such as a cast or boot) is recommended, it should be removed no later than 3 weeks after the initial injury to prevent weakness and atrophy of the surrounding muscles. Healing time varies anywhere from 3-12 weeks, up to 12 months to full recovery, depending on the location and age/bone health of the individual. In the foot, fifth and first metatarsal fractures typically take longer to heal than the middle toes.
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