Musculo-skeletal   [back to the Category]

Stress fractures of the foot   [read the french version]

Author :   Docteur Anne Thiescé

Stress fractures of the foot are often multiple.

They can affect all the bones of the foot. They are especially common amongst the metatarsals since they represent 63% of stress fractures in female ballet dancers. They are also to be found in sesamoid, tarsal and external malleolus bones.Fig stress fracture of the talus.

The diagnosis must be considered for any instep pain, especially one that increases with exertion. An osseous scintigraphy must be carried out which will reveal lesions that are often multiple and bilateral.

Stress fractures of the metatarsals

The study of metatarsal geometry shows that performing "pointes" and "demi-pointes" in ballet puts the 2nd metatarsal bone under maximum pressure. Its base is situated in a fairly rigid area but is solicited during arch development and forms an articular side in Lisfranc's articulation. Stress fractures usually occur in the diaphysis and neck of the 2nd and 3rd metatarsal bones and most often in the base of the 2nd metatarsal bone. Fig 2.
Clinical history usually finds a seat of chronic pain that did not warrant a consultation, followed by an exacerbation of the pain during a jump landing or a wrongly performed pirouette. The pain is localised, pedal, sometimes resulting in complete disability or the inability to go up on "pointe" or "demi-pointe" and to jump. Sometimes, there is a dorsal œdema of the foot, a bruise and / or an increase in local heat. There is a point of exquisite pain. Moving the metatarsal bones is painful as they are the seat of the fracture. Percussion on the toe, in the axis of the relevant column, triggers pain.

X-rays are usually negative in the early stages or they show a slight solution of transversal continuity, necessitating rapid recourse to scintigraphy. At a later stage, there are two clear X-ray pictures: the resulting osteoporosis which reveals the fracture line and the periosteal apposition which locally deforms the contour of the bone with a limited and not very dense outline. It is necessary to use scintigraphy when faced with an early affection. It often reveals non-symptomatic, multiple or bilateral lesions.
A MRI might be necessary, when the affection is situated at the base of the 2nd metatarsal in order to differentiate between an arthropathy of the tarso-metatarsal joint (Lisfranc) and a stress fracture. Fig.3.
Rest, with total or partial stoppage from weight-bearing depending on the pain, is obligatory in order to avoid pseudarthrosis. Ballet can be resumed between 6 weeks and several months. It often depends on how quickly the diagnosis was made. Dancing must be resumed progressively in order to reduce the risk of a relapse, sequelae pains can hamper recovery and necessitate a control scintigraphy in order to determine their nature.
Stress fractures of the base of the 2nd metatarsal bone can often suffer from pseudarthrosis and sometimes require surgical treatment in the form of arthrodesis in which case, dancing can only be resumed after long months of stoppage.

Bibliography:

Daniel F., Heuleu J N., Fracture de fatigue du 2° métatarsien, Médecine et Sciences de la danse IV° congrès international 18/6/94.

Kadel N. J., MD, Teitz C. C., MD and Kronhal R. A., PhD., Stress fractures in Ballet dancers, The Am. J Sports Med, 1992 Vol. 20, No. 4 1992 pp 445-449.

Quirck R., Common foot and ankle injuries in Dance. Foot Ankle injuries in sports 1994; 25; 1: 123-133.

Thiescé A., Le geste dansé et ses conséquences en rhumatologie. Ed Laboratoires Ciba-Geigy 1996.

Thiescé A., Les fractures de fatigue en danse, Médecine des Arts N° 20 juin 1997.


Stress fractures of the sesamoids

The sesamoids of the big toe are to be found under the head of the first metatarsal. Descriptions of the fractures of these bones are, above all, to be found in ballet pathology. They occur mainly in dancers of both sexes who do not use point shoes. It is, in fact, in the "demi-pointe" position that the support is born on the anterior arch and the toes, this increases even more over the sesamoids, under the head of the first metatarsal, so that there exists a pronate posture. This area is also responsible for pivots and for taking the worst of the shock during jump landings. Furthermore, by giving their insertions to the big toe flexor muscles, the sesamoids are expressly solicited by the impetus demanded in jump practise.

Pain is localised under the first metatarsal head, it makes the performance of "demi-pointes" and jumps impossible. Dancers avoid the pain by bearing an external support of the forefoot. Palpation is painful, passive relaxed movement of the first metatarsophalangeal bones can be painless.

X-rays, especially the incidence of the sesamoids or a Walter Muller Weiss photograph, Fig 4, show a change in the sesamoid concerned. Usually, it is a fragmentation of the internal sesamoid. The irregularity and the spaces between the fragments allow them to be differentiated from a bipartite sesamoid. The diagnosis can be confirmed, in case of doubt, by a scintigraphy punctiform hyperfixation or a MRI. Treatment lies in a 4 to 6 week weightbearing stoppage, by using orthesis or a Barouk shoe. Radiological consolidation does not exist and so recovery is indicated by the disappearance of pain. Only after several months of adverse evolution, would surgical excision be suggested.

Bibliography:

De Labareyre H., Rodineau J., Les fractures de fatigue du pied, 2e Partie, Médecins du sport N° 24 Dec 1998 p15-16.

De Labareyre H., Rodineau J., Les fractures de fatigue du pied, Rhumatologie pratique N°187 Oct 1999.

Poux D., Les fractures de fatigue, Sport et appareil locomoteur sous la direction de Boyer Th. Ed Masson 1989 p85-87.

Thiescé A., Le geste dansé et ses conséquences en rhumatologie. Ed Laboratoires Ciba-Geigy 1996.

Thiescé A., Les fractures de fatigue en danse, Médecine des Arts N° 20 juin 1997.