Revista de Medicina Desportiva (English) January 2019 | Page 31

and extrinsic. 10 The intrinsic include:
biomechanics of the movement,
physical condition, body biotype and
age of the athlete. The extrinsic are
defined as: local climate, conditions
of training sites, own security rules
for each institution and available
equipment.
For a total of 159 professional
dancers, 110 report between one
and four injuries each year. 11  On
the other hand, for each 1000 hours
of training, 0.62 to 5.6 injuries are
reported. 11,12  However, some authors
call attention for the prevalence of
no-reported injuries by the ballet
dancers in order not to adversely
affect the trials and the harmony of
the dance, which leads to the under-
sizing of the numbers. 1 Among the
injured, the majority, independently
of the gender, presented injuries due
to repeated movements, correspon-
ding to the double of the traumatic
acute injuries. 12 The majority of the
injuries occurs on the distal area of
the lower limbs during the periods
of training for great events, which
demands more hours of dedication
by the athletes, or during the pre-
sentation itself. A minor part of the
injuries occurs at the usual training
rooms, which is in accordance with
the greater demand as the competi-
tion approaches. 1,11,12 
Dividing the injuries according the
localization, there is the following
distribution: 53% on the feet and
ankles, 21.6% on the hips, 16.1%
on the knees and 9.3% on spine. 12
As far as gender is related and to
type practiced, the great majority
occurs on the female (75.9%) and
on the classic ballet (83.6%). Sta-
tistically, the patelofemoral pain
syndrome, the tears of the adductors
muscles of the thigh, the snapping
hip syndrome, the Achilles tendi-
nopathy and the mechanic back
pain are the five most frequented
reported injuries. 13 The prevalence
of specific injuries according the
gender of the dancer varies. On the
women the most prevalent are the
stress fracture of the 1 st metatarsal,
the fracture or dislocation of the
tarsometatarsal Lisfranc joint, the
pathologies of the hip and cervical
muscle injuries. In the male sex, the
rotator cuff tears, the subacromial
bursitis and the sprains of the 1 st
metatarsophalophalangeal joint
are more prevalent. These specific
differences by gender are justified
by the following factors: men on the
classical ballet have more physical,
while to the women more technical
abilities are required. Besides, there
are movements more specific for
women more directed to the use
of sneakers of the tips and to the
en dehors (pronounced plantar inver-
sion) and for the men like larger
jumps and portées to hold the dancer
partner on his arms in order she can
make some movement on the air). 14
Regarding the feet, due to the
exhaustive hallux dorsiflexion
during this sport, a characteristic
of the relevé, the overload of the 1 st
metatarsophalangeal is frequent,
causing sprains, instability, stress
fractures and arthrosis of this joint,
as well as pathologies on the sesa-
moids of the hallux, in particular
of the medial sesamoid, including
sesamoiditis, dislocations and stress
fractures. 23 This movement asso-
ciated to the plantar hyperflexion
of the ankle increases the risk for
stress fractures on the diaphysis of
the metatarsals, in particular on
first two, where the stress fracture
at the base of the 2 nd metatarsal is
typical of the ballet dancer. Other
also quite frequent reported injury is
the tenosynovitis of the long flexor
of the hallux, on its path between
the two sesamoids. Both are more
frequent on the classical dancers
due to the rigor of movements and
to the almost uninterrupted wear
of sneakers. 15–17 The tendinopathy
of the Achilles is the most common
injury of the professional dancers’
ankle on the classical ballet, cor-
responding to 9% of all injuries. It
occurs because the repeated and
constant effort over the tendon,
mainly during the intense and fre-
quent jumps and runs. 18,19 The per-
manent position of plantar hyper-
flexion of the ankle on this sport
could be responsible to trigger off
the posterior conflict syndrome of
the ankle, in which there is a conflict
between the posterior face of the
distal tibia and the posterior-lateral
tubercle of the astragalus or os trigo-
num if it is present. 20 This tubercle,
where the posterior fibulotalar liga-
ment of the lateral ligament com-
plex of the ankle is inserted, can be
abnormally elongated, called Stieda
process, or there is an associated
accessory ossicle, the os trigonum,
the 2 nd most frequent sesamoid in
the body, that could be or nor be
united to the tubercle by a fibrous,
cartilaginous or fibrocartilaginous
joint. Therefore, the presence of
an elongated process, the os trigo-
num or even the disruption of its
joint with the tubercle after repea-
ted movements of plantar flexion
typical of the ballet, might initiate
symptoms of posterior conflict of
the ankle. 20
Regarding the hips, 91% corres-
pond to the snapping hip syndrome,
being more frequent the lateral
bounce than the anterior. It occurs
due to a thickening of the posterior
border of the iliotibial band caused
by the large and repeated lateral
rotation of the hips, and as conse-
quence of the lower limb – en dehors
– during the practice of this sport. 21-24
Several studies mention that in
relation to knees of the dancers,
the most frequent pathology is
the patelofemoral pain. 14,25 On the
majority of the cases, the diagnosis
is made by excluding other entities
that could cause pain on the ante-
rior surface of the knee, including
patellar tendinopathy, described by
a small number of authors as the
most prevalent pathology on the
knee. The important prevalence of
the pathology patelofemoral is pro-
bably due also to the repeated move-
ments, sometimes intense, on load,
with important range of motion of
flexion of the knees. 26
Back pain occurs most frequently
on of contemporary ballet dancers.
A possible justification for that is
the greater frequency and range
of motion of the back on this type
of ballet, including hyperflexion,
extension and lateralization of the
lower back. On the other hand, on
the classic ballet, because of the fre-
quent position cambreé (Figure 1) on
lower back hyperextension, there is
an increase of the low back lordosis
and predisposition for hyperexten-
sion injuries, namely on the inter-
-apophyseal or facet joints. 26
On the upper limbs, the most
frequent musculoskeletal injuries
are muscle contractures or tears.
The rotator cuff tendinopathies, that
includes acute tendinitis and tendi-
nosis and other chronic ruptures, are
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