Stress Reactions of the Foot


What are stress reactions of the foot?

Stress reactions of the foot are overuse issues that arise from repetitive and excessive stress on the bone, with limited rest. They are classified in severity from grade I to IV, with a grade IV stress reaction being a stress fracture (an actual crack of a bone). The most common locations of stress reactions of the foot are the second and third metatarsal (long bone of the midfoot), the calcaneus (heelbone) and the navicular, a bone at the base of the midfoot.

How can they occur?

Stress reactions of the foot are overuse issues from intense ballet training and are most often related to a number of different functional problems. Their direct underlying cause is a failure of proper active foot and ankle stabilization. Muscle dysfunction can seriously affect foot and ankle stabilization and is an important contributing factor.
The psoas muscle is probably the most important muscle involved with dance injuries and overuse issues. Psoas dysfunction leads to tightness of the rectus femoris muscle (a part of the quadriceps) and deactivation 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 peroneals – a group of two active foot stabilizers on the lower leg – are often affected. Active foot stabilization thus can be seriously affected and overuse can occur in the foot.
Poor bone quality due to osteoporosis is another important contributing factor. It is referred to as bone insufficiency and is often related to eating disorders in dancers. Reduced bone density immensely elevates the risk of a stress fracture.

What are the typical symptoms of a stress reaction?

Symptoms of a stress reaction of the foot usually develop gradually, but may also occur acutely if it comes to a fracture. Pain often increases with weight-bearing activities and diminishes with rest. You may notice some swelling on the top of the foot or the outside of the ankle, tenderness at the site of the fracture and possibly bruising.

How can a stress Reaction be diagnosed?

Your doctor will examine your foot and ankle 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 underlying causes of stress reactions is often challenging and your doctor may ask a specialist in manual medicine for his opinion. Stress fractures are difficult to see on X-rays until they have actually started to heal. Your doctor may therefor recommend a bone scan or MRI scan, that can detect stress reactions at an earlier stage.


This MRI scan of the back foot shows a severe stress reaction of the heel bone (calcaneus). You can spot that the bone shows white in the area of the stress reaction. The white color indicates a higher amount of liquid due to an ongoing inflammation. A fracture line has occurred on the bottom of the bone.

What treatment options are there?

Stress fractures of the foot demand instant medical care and sometimes need surgical treatment if the injury involves a displaced bone, multiple breaks, or has failed to heal adequately. Symptoms of lower grade stress reactions rather 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 6-12 weeks, depending on the severity of the problem. Immobilization of the foot will often be necessary. You may be given a cast, a special cast boot or a stiff-soled shoe and sometimes crutches.
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.

Next steps

Do you think that you might have a stress reaction of your foot 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

There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:

Flexibility training: Foot release (if no fracture), Professional calf and foot release (if no fracture), Deep back release, Rectus femoris release, Psoas release, Piriformis release, Compex “DECONTRACTURE” program (peroneal muscles)

Strength training: Compex “DISUSE ATROPHY” program (peroneal muscles), “The clamshell” – Piriformis training,“The monster walk” – Piriformis training

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.



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