Out of Harm's Way

Help students prevent painful foot and lower-leg stress fractures.

Stress fractures in the shinbone or ball of the foot are the most common dancer injuries.

If one of your dancers points to a spot on her foot or leg and says it hurts, pay close attention. She may have the start of a stress fracture, an incomplete break in the bone caused by repetitive trauma or an abrupt twist or torque. “When a dancer complains of pinpointed pain, don’t ignore it, especially when it is near a joint surface, like the side of the leg, the dome of the foot or under a toe,” says Glenna Batson, associate professor of physical therapy at Winston-Salem State University.

According to a study published in the January 2010 issue of International Orthopaedics, 50 percent of all activity-related injuries are due to overuse, and the most common overuse issues are stress fractures and soft-tissue problems in the feet. For dancers, stress fractures often involve the shinbone or the ball of the foot—specifically the second or third metatarsal, which are among the five long foot bones located between the toes and ankle.

One of the biggest problems for dancers, however, is recognizing the warning signs before the injury escalates. “Dancers, like athletes, operate at higher pain thresholds and tend to wait longer than they should,” says podiatrist James Ludden. “They should be evaluated if they have a sudden onset of pain, or within a day or two if they complain of the symptoms. If you leave it unattended, you can get a through-and-through fracture.”

Unfortunately, diagnosis is often delayed because there is minimal swelling and physical examinations and X-rays are often inconclusive, according to the study, which examined 150 pre-professional ballet dancers for two years and followed 19 students with stress fractures. A bone scan or MRI may be necessary if X-rays fail to illuminate the cause of discomfort. The study found that “initially, the pain occurred only during activity and resolved with rest. Continuation of activity is associated with a progression of pain that becomes constant. This usually occurs 7 to 20 days after the first onset of pain.”

So what actions should you take to help students recover from and prevent stress fractures? Read on for tips on properly guiding injured students back into class and ways to help them prevent these fractures from the start.

Patience During Healing

Those most at-risk for developing stress fractures are girls ages 15 and older, and boys ages 18 and older, because their bones have matured. Depending on the student’s age, it can take four to five weeks of healing before the dancer can be (carefully) active again. Expect 8 to 10 weeks for full bone healing. If the fracture is severe, a physician may ban the dancer from any weight-bearing activity for eight weeks.

But this doesn’t mean that a dancer has to stay away from the studio. “They can come to class to learn the combinations from a static position, use their arms and backs and visualize performing the exercises,” says Batson. Ludden agrees: “They can work on their upper-body motions to keep themselves intact. For five or six weeks, I recommend light, weight-bearing activity before they are back to full swing.” This includes swimming, yoga, bicycling or limited class participation with no rélevés or jumps.

It’s also important for teachers to acknowledge the emotional impact an injury like this can cause, says Kathryn Daniels, dance department chair at Cornish College of the Arts in Seattle. “Injured dancers, particularly those experiencing their first injury, often don’t realize that the fear, anger and sadness they experience are normal,” she says. “I try to provide an empathetic ear so that they have an opportunity to talk about their emotions at this time of stress. I remind them that this is a temporary situation, and I encourage them to make it a time for learning and growing.”

When a dancer does get the OK to return to regular training, Daniels recommends conditioning and somatic classes to aid in recovery, as well as starting students at a lower-level class because it “serves the dual goal of diminishing physical demands while facilitating attention to good mechanics.” Batson adds that injured students should be under the guidance of a physical therapist throughout the course of healing, because “once you’ve had one stress fracture, your risk goes up for getting another one.”

Preventing the Injury

So, how do you make sure students safeguard themselves from stress fractures? First, consider whether there are sprung floors, which help absorb the shock and impact of jump landings. How many hours a week does the dancer train? Does the dancer have extremely high arches? If so, her risk for stress fractures increases, since high-arched dancers experience an unusual amount of stress on the ball of the foot, instep and heel, especially when landing from jumps.

“From a training standpoint, there is an amazing amount of high-impact repetition, especially from landing a jump over and over again,” Batson says. “A dancer should land to bring the heels down as close to the floor as possible, otherwise she is more likely to be injured.” Daniels agrees and says that it’s important to emphasize good mechanics to minimize the stress on any part of the body.

Reduce overuse by giving students an appropriate rest-to-activity ratio—for example, a 30-second rest between jump combinations—and alternate exercises, like going from a petite allegro to turns to jumps.

Teachers should also give students exercises that stretch the back of the leg and strengthen the front. “Most studios should have some sort of stretching board, where the dancer stands on an incline with the heel lower than the toes, feeling the stretch in the back of the legs,” says Batson. Thera-Bands can aid in strengthening the fronts of legs—loop the band around a sturdy object, put the band around the top of the foot and pull the foot and toes toward the body in a flexed position. (Place a bag of rice on top of the foot for added resistance.)

Poor nutrition also plays a role in stress fracture risk, as does a lack of dance-shoe support. Custom-made, sports-friendly, prescription orthotic inserts can help support the foot—even in the thinnest dance shoes. Another way to ensure dancers stay healthy is to encourage annual orthopedic screenings, writes Linda H. Hamilton in her book, The Dancer’s Way: The New York City Ballet Guide to Mind, Body, and Nutrition. With routine screenings, doctors can identify problem areas—before an injury occurs. DT

Hannah Maria Hayes is a freelance writer with an MA in dance education from New York University.

Photo copyright iStockphoto.com/carlo dapino

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