Musculo-skeletal   [back to the Category]

Stress fractures   [read the french version]

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Ballet is not just an art, it is also a profession. A profession that originates from a technique that has been expanded to such an extent that it puts accomplished dancers on a par with top competition sportsmen.

Ballet dancers are in fact athletes. They practise between 4 and 8 hours a day for almost 365 days a year. Ballet does not have an off or rest season. Stress disorders are especially common because every movement is practised virtually until the dancer drops.
30% of ballet dancers will have or have had a stress fracture whilst stress fractures represent only 10% of sporting disorders.
Numerous factors are responsible for this high percentage:

1) Osseous hyper-solicitation, coupled with movement repetition, accelerates osseous resorption, exhausts osteoblastic capacity and leads to vascularization problems aggravating the dissociation of the osteolysis / osteosynthesis couple.

2) Delayed puberty and menstruation irregularity in young female dancers show relative hypo-oestrogenia, a factor of osseous hypodensity.

3) Training which consists of stretching, strengthening, flexibility, endurance and technical exercises in balanced proportions, but the risk of fractures is increased by a change whether quantitative or qualitative (training courses, rehearsals).

4) Floors in dance studios must absorb a certain amount of the shocks, whilst possessing a bounce, thus making elevations easier. Hence, they reduce the constraints put on lower limbs and the spine. These conditions can be obtained with a suspended parquet flooring which has been a French legal requirement since 1989. Even so, dancers still rehearse and dance on hard surfaces made of concrete, or even tarmac, in theatres and in premises not designed for ballet dancing.

This diagnosis of stress fracture must always be considered especially when faced with localised pains. These pains can be chronic and moderate or acute, beginning suddenly after a minor trauma. Palpation and osseous percussion usually reveal an exquisite pain over a limited area which is sometimes tumified. Pain increases with exertion and weight-bearing. X-rays are negative in the early stages, the diagnosis is made by scintigraphy. It shows a focal hyperfixation which will be multi-focal in the case of multiple fractures. Rest is imperative, activities can be resumed when the pain has gone completely and / or when faced with a normalisation of the fixation shown in the early scintigraphy photographs.
These stress fractures are most common in the lower limb and spine.

Bibliography:

De Labareyre H., Rodineau J., Les fractures de fatigue du pied, Rhumatologie pratique No.187 Oct 1999.

Hamilton L. H, MA, Hamilton W.G., MD, Meltzer J. D., PhD, Marshall P., PT, and
Molnar M., MA, PT, Personality, stress and injuries in professional ballet dancers, The Am. J Sports Med, Vol. 17, No. 2 1989 pp 263-267.

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.

Seale EM., A study of dance surfaces, Clinics in sports medicine 2: 557-562 1983.

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 No.20 juin 1997.

Thiescé A., Pied et danse classique. Encycl Méd Chir (Elsevier, Paris), Podologie, 27-140-A-65, 1999, p6.


Stress fractures of the foot

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.
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.
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.
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 using a lateral support on their fore-foot. 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, show a change in the sesamoid concerned. Usually, it is a fragmentation of the medial 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, weight-bearing 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.

Stress fractures of the leg

Stress fractures of the leg affect the fibula and / or the tibia and are often multiple. They are, together with tibial periostitis, one of the main aetiologies of leg pains. According to studies, they represent 6 to 15% of pathologies found in dancers. Stress fractures of the tibia amount to 22% of stress fractures found in female ballet dancers. Palpation reveals one, or several, points of exquisite pain in a limited and sometimes tumified area of the leg. X-rays are only positive in the case of a late diagnosis; early diagnosis is confirmed by scintigraphy. Hyperfixation is focal or multi-focal which indicates the existence of multiple fractures. It is imperative that dancing be stopped. Activities can be resumed when there is absolutely no more pain and when a control scintigraphy shows a normalisation of the fixation shown in the early photographs. These stress fractures usually heal well, but sometimes, even with an early diagnosis, recourse to surgical treatment is obligatory

Bibliography:

Garrick J. G., MD, and Requa R. K., MSPH, Ballet injuries, The Am. J Sports Med, Vol 21, No. 4 1993 pp 586-590.

Washington E. L. MD, Musculoskeletal injuries in theatrical dancers, site, frequency, and severity, The Am. J Sports Med., Vol. 6, No. 2 1978 pp 75-98.

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

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


Stress fractures of the femoral neck

Stress fractures of the femoral neck remain rare, but must not be ignored. Dancers very often have groin pains and they are usually caused by tendinitis. However, the clinical examination must remain very strict and, in case of doubt, additional examinations must be carried out quickly. The fracture line is on the internal edge of the femoral neck and is difficult to see on standard X-rays. Diagnosis is confirmed by tomography or scintigraphy. It is imperative that the patient avoids weight-bearing for at least 8 weeks. During this time, walking must be simulated with the help of two crutches in order to save the fracture line from continuing and causing a secondary migration.

Bibliography:

Baillon J.M., Lésions articulaires et musculaires chez les danseurs. Acta orthop. Belg. ("Les lésions chronique du sport") T 49 (1-2) 112-116 jan-avril 1983.

Schneider MD, Harold J., Athena Y King, Jeffrey L. Bronson and Miller E:
Stress injuries and developmental change of lower extremities in ballet dancers. Radiology 113(3) 627-32 Dec 1974.

Miller E, Harold J, Schneider MD, Jeffrey L. Bronson MD and David Mac Laine
A new consideration in athletic injuries: the classical ballet centre. Clin orthp no. III 181-193 Sept 1975.

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


Spinal stress fractures

Spinal stress fractures are common and affect the spinal isthmi, posterior articulations and pedicles.
Dancers begin practising their art at an early age and many devote themselves to intensive training throughout their growth years. Furthermore, dancers have not usually finished growing, when, from the moment they enter a company, they have to perform numerous "portés". This is a time when there is a risk of spondylolysis and spondylolisthesis appearing, possibly due to a lack of flexibility which results in a difference between the osseous and the musculo-tendinous growths: an imbalance which is often overlooked in ballet.
Common aetiological factors of stress fractures of the L5 isthmus, in addition to the morphological anomalies of the lombosacral hinges, are: stress during compression and shearing movements, muscular imbalance of the trunk flexors - extensors, the hyperlordosis required to compensate the lack of turn out by a lower limb or to carry out certain choreographic gestures, the retraction mainly of the psoas, the hardness of certain floors, the repeating of badly performed "portés" and during the growth of disharmonious musculature.
Isthmoid fractures affect 20% of dancers and usually occur between the ages of 9 and 15. They are usually localised on L5, but can be multiple and occur at superior lumbar levels. The discovery of an isthmoid lysis or a spondylolisthesis does not mean that ballet must be stopped as long as L5 does not slide over S1 by more than 40% (spondylolisthesis in stages 1 or 2).
When diagnosis is early, treatment lies in the dancer wearing a corset for at least a month. Ballet can then be resumed progressively with a lumbar belt, coupled with a suitable re-education. This lumbar belt can be worn later on for practising new "portés" or new choreography. When diagnosis is delayed and the stage of chronic stubborn pains is reached, a symptomatic treatment is necessary. Dancers must wear a lumbar belt when they feel pain and, after an appropriate re-education, follow a personalised daily exercise programme which will usually allow them to continue dancing.

Bibliography:

Pelletier A., Spondylolisthésis, Médecine et Sciences de la danse. IVe congrès international. 18/6/94.

Sabourin F., Pathologie rachidienne microtraumatique et danse. Médecine des Arts 1996 N°15 p37-40.

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


Stress fractures of the ribs

The possible aetiological factors of stress fractures of the rib comprise: intensive training, the practising of acrobatic "portés" in neoclassical choreography, exercises for making the trunk more supple and repetitive falls in certain contemporary choreography. These fractures are often bilateral.
The first rib is rarely affected. Its clinical translation, initially brings a cervical problem or a shoulder disorder under consideration. It can be caused by two actions, the sudden repetitive contraction of the scalenus anterior with the exertion of lifting weight with an arm, particularly when the cervical spine is in a position of hyper-extension, and the repeated contractions of the serratus during repetitive movements of horizontal arm adduction.

Bibliography:

Mikawa Y. and Kobori M., Stress fracture of the first rib in a weightlifter. Arch. Orthop Trauma Surg: 1991: 110: 121-122.

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

Thiescé A., Fracture de fatigue de la première côte, une localisation exceptionnelle en danse classique. J. Traumatol. Sport 1996,165-167.