What is a stress fracture of the femoral neck?
Stress fractures of the femoral neck are overuse injuries that result in a crack in the upper part of the thighbone (femur). They are acute emergencies and demand instant medical care. Stress fractures of the femoral neck are not as common as other overuse issues, but they can occur in dancers under certain conditions.
Prior to a fracture, a stress reaction will build up inside the bone. Stress reactions are classified from grade I to IV; a grade IV stress reaction shows a crack of the bone and is referred to as a stress fracture. Groin pain that is dependent on physical activity is a strong indication of femoral stress reactions.
How can it occur?
Stress fractures are injuries that occur when repetitive and excessive stress on the bone is combined with limited rest. Dancers’ stress syndromes are overuse injuries from intense ballet training and most often relate to a number of different problems. Muscle dysfunction can seriously affect hip stabilization and alignment and is an important contributing factor to hip joint dysfunction and overuse. Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
The psoas muscle is probably the most important muscle involved with overuse issues concerning the hip. Psoas dysfunction leads to tightness of the rectus femoris (a part of the quadriceps) and deactivation of the piriformis (one of the smaller pelvic muscles inserting on the sacrum). This causes pelvic torsion and functional leg length discrepancy. The increased amount of stabilization work needed to compensate for leg length discrepancy will overcharge different groups of muscles. The adductors and other small hip muscles that insert on the inside of the femur are often affected. As a result, mechanical stress to the femoral neck can raise and can cause a stress fracture. Poor bone quality due to osteoporosis is another contributing factor. It is referred to as bone insufficiency and is often related to eating disorders. With a bone insufficiency present, the risk of a bony stress reaction is immensely elevated.
What are the typical symptoms of a femoral neck stress reaction or fracture?
Symptoms of a femoral neck stress reaction usually develop gradually, but may also occur acute if it comes to a sudden fracture. Pain often increases with weight-bearing activity especially with jumping and diminishes with rest. With an acute fracture, weight bearing of the leg may not be possible at all. The pain is specifically located in the groin area.
How can a stress reactions of the femoral neck be diagnosed?
Your doctor will examine your hip and review your symptoms as well as your current training activities. Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of hip overuse syndroms is often challenging and your doctor may ask a specialist in manual medicine for his opinion. Definite stress fractures can usually be diagnosed with an X-ray. Lower grade stress reactions in contrast are difficult to see on X-rays until they have actually started to heal. Your doctor may recommend a bone scan or MRI-scan, which can detect stress reactions at an earlier stage.
This MRI scan of the hip shows a stress reaction (bone bruise) of the femoral neck. You can see that the bone marrow is coloured white in the area of the stress reaction. The white color indicates a higher amount of liquid due to an ongoing inflammation.
What treatment options are there?
Stress fractures of the femoral neck are acute emergencies and demand instant medical care and sometimes need surgical treatment. Symptoms of lower grade stress reactions build up slowly and are often not very acute. However, if you suspect a stress reaction, stop your ballet training immediately! Ignoring the pain can have serious consequences. Even if no fracture has occurred yet, this overuse injury will need time and rest to heal. You should not attend ballet training for at least 8-12 weeks, depending on the severity of the problem. Using crutches will sometimes be necessary to protect your injured leg.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers.
In order to handle an overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine.
Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Do you think that you might have a hip overuse problem and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
As far as the fracture allows, there is a lot that you can do to work on your problem. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.