Stress Fractures

A stress fracture is a bone injury that occurs at a spot in the bone that is exposed to high or repetitive forces. These forces either come from external sources (like impact with the ground when you walk, run, or jump) or from internal sources (like muscles/tendons pulling on the bone). Specific spots of bones may be more susceptible to stress fractures than others due to mechanics/form while performing specific tasks or due to cyclical weaknesses that occur naturally as a part of the bone’s remodeling process.

Sudden increases in physical activity, changing ground surfaces used during activity (like going from grass to a wood floor), and using poor landing mechanics during jumping activities are common causes of stress fractures. Fatigue, overtraining, poor physical conditioning, and improper footwear can also contribute to the onset of a stress fracture.

The two most common causes of stress fractures in the performing arts are related to doing too much too soon. This happens at the start of the season and when a performer is returning to full rehearsals and performances after taking time off due to an injury or illness (or school/company break).

Locations of Stress Fractures in Performing Artists

Dancers commonly have stress fractures in the foot (primarily the 2nd-4th metatarsals), the lower leg (the middle of the tibia and the lower portion of the fibula), and the low back. Dancers are especially prone to fibular stress fractures due to their tendency to have pronated feet (the position replicated by rolling in while standing in 1st position).

Marchers may develop metatarsal stress fractures, especially in the 2nd metatarsal. These fractures are actually called “march fractures” due to the proclivity for military cadets to develop them at basic training. Depending on their marching technique, footwear, and surfaces, marching band members may also develop a stress fracture in the heel (calcaneus).

Signs and Symptoms

Stress fractures can be difficult to diagnose early on because their symptoms are rather generic, and they can appear to be musculotendinous overuse injuries (like tendinitis).

However, there are a set of symptoms that most stress fractures present with, including:

• Tenderness focused over one specific location
• Pain.  Early on, pain will only be present with activity. Later, the pain will be constant and often becomes more intense at night.
• Increased pain at the site of the injury with vibration or percussion of the bone
• Swelling may be present

Stress fractures will not appear on x-rays until the injury:

1. Has rested long enough for the body to increase bone cell (healing) activity in the area (the extra healing cells in the area of the injury are actually what shows up on the x-ray)  - OR -
2. Progresses to the point of becoming a full fracture (a black line will appear on the x-ray, indicating a fracture in the bone; at this point the injury will be treated as a fracture).

Treatment

REST!!!!

The best way to treat a suspected stress fracture is to seek out a medical professional to guide you through the process.

Recognizing a stress fracture as early as possible – and taking appropriate steps to stop further damage – is critical. Untreated and unhealed stress fractures will eventually develop into complete fractures that could even displace (the two ends of the bone are move out of place and are not abutted right up against each other). It is possible for an advanced stress fracture to progress to a full fracture in a rather dramatic fashion when exposed to a sudden large force, like when landing from a jump. College basketball fans: this is what happened to Louisville’s Kevin Ware in the 2013 NCAA tournament. If you don’t know or remember what this is in reference to and you’re queasy, do yourself a favor – don’t look it up.

When a stress fracture is being treated by a medical professional, the course of treatment and amount of allowable physical activity will vary based on the individual who is injured, the site of the injury, and the extent of the injury at the initiation of treatment. If you are unable to work directly with a medical professional, always err on the side of caution. For managing a stress fracture, this means resting.

Taking care of your overall health (eating nutritiously, staying hydrated, sleeping well, etc) will facilitate healing.

When you are treating a potential stress fracture, avoid taking anti-inflammatory drugs (Ibuprofen, Advil, Aleve) as these mask your pain and can interfere with bone healing on the cellular level.

A note about terminology: A “stress reaction” is a term that has become popular over the last several years. This term doesn’t really have a specific medical definition, but it typically is used to identify an injury that is on the road to becoming a stress fracture. A diagnosis of “stress reaction” should not be viewed as ‘no big deal’ because it’s not a stress fracture. Depending on the intensity of your symptoms, you may be able to successfully resolve your stress reaction symptoms while still doing modified participation in rehearsals. However, make no mistake – stress reactions will become stress fractures if the level of activity that initially caused the damage is not reduced or stopped altogether.