Ankle Injuries in Dancers

Immediate effect of the use of toe separators on dynamic balance and ankle range of motion: a pilot study

BACKGROUND AND OBJECTIVES

Injuries involving ankle stability and range of motion are among the most frequent in athletes and in the general population. In response, this study aimed to assess the immediate effects of toe separators on dynamic stability and ankle range of motion in healthy young individuals.

METHODS

Among the 68 eligible participants, 50 healthy and active subjects completed all trials. The impact of the intervention was evaluated using the Weight Bearing Lunge Test and Y-Test. The control condition performed the tests without toe separators, while the experimental condition performed the tests with toe separators. All participants performed both conditions with a wash-out period of at least 7 days between trials.

RESULTS

Statistical analysis revealed no significant differences in dynamic balance (p > 0.05) and range of motion (p > 0.05) between the two conditions. Additionally, no asymmetries were detected between the lower limbs in both tests (p > 0.05).

CONCLUSIONS

The results of this pilot study indicate that using toe separators does not have an immediate effect on ankle range of motion and dynamic balance in young, healthy individuals. Future research should consider evaluating intervention programs of longer duration and exploring different populations.

Foot pain in children and adolescents: a problem-based approach in musculoskeletal ultrasonography

Various etiologies and risk factors contribute to foot pain in children and adolescents, including conditions such as Kohler's disease, Sever's disease, Iselin's disease, rigid flat foot, accessory navicular, Freiberg's disease, sesamoiditis, os trigonum syndrome, and more. High-frequency musculoskeletal ultrasonography can show both the bone surface and the surrounding soft tissue clearly from various angles in real-time, thereby providing a higher level of detail that is helpful for identifying the etiology of foot pain and monitoring disease progression compared with other imaging modalities. This review provides an overview of the epidemiology, pathophysiology, clinical manifestations and characteristic ultrasonographic findings of select foot pain conditions in children and adolescents.

Collegiate Dancers With Chronic Ankle Instability Possess Altered Strength and saut de chat Leap Landing Mechanics

INTRODUCTION

Ankle sprains are among the most common injuries in dancers. Following one or more severe sprains, some individuals will experience residual mechanical and functional deficits, otherwise known as chronic ankle instability (CAI). Dancers who suffer from CAI may have weaker musculature surrounding the ankle and altered landing mechanics. The purpose of this study was to compare ankle strength and saut de chat landing mechanics between dancers with and without CAI.

METHODS

Dancers with and without CAI, defined by the Identification of Functional Ankle Instability (IdFAI), participated in the study (CAI n = 8; IdFAI = 18.75 ± 5.50 points; age = 20 ± 1.5 years; training = 15.5 ± 3.5 years) (Control n = 8; IdFAI = 7.13 ± 3.40 points; age = 19 ± 0.6 years; training = 15.9 ± 2.5 years). Strength and leap landing mechanics were measured on the affected ankle for the CAI group and on the preferred landing leg of a leap for the control group. Concentric and eccentric ankle plantar flexion, and subtalar inversion and eversion strength were determined with dynamometry set at an angular velocity of 60°•s-1. Force plates and motion capture cameras were used to calculate lower extremity kinematic and kinetic data as participants performed 3 saut de chat leaps. Independent t-tests were calculated to determine differences between groups.

RESULTS

Compared to dancers without CAI, dancers with CAI had lower eccentric plantar flexor strength, landed with higher vertical ground reaction forces, and absorbed greater power at the knee-joint during landing.

CONCLUSION

Whether dancers who are weaker are more prone to injury or ankle-joint injury leads to muscular weakness is unknown. Dancers with CAI appear to lack control during leap landing while concomitantly shifting loads proximally away from the ankle-joint. We encourage dancers with and without CAI to engage in additional training that enhances ankle strength.

Flexor hallucis longus tendon morphology in dancers clinically diagnosed with tendinopathy

PURPOSE

The unique demands of dance technique make dancers more prone to certain pathologies especially of the foot and ankle. Flexor hallucis longus (FHL) tendinopathy, colloquially known as "dancer's tendinopathy," is common in dancers and not well studied. The purpose of this study was to assess if morphological alterations in tendon structure occur as an adaptive response to dance activity by comparing the FHL tendon in dancers to non-dancers, and if pathology further alters tendon morphology in dancers clinically diagnosed with tendinopathy.

METHODS

Three groups of ten participants were recruited (healthy non-dancers, healthy dancers, and dancers with FHL tendinopathy). Ultrasound images of the FHL tendons were analyzed for macromorphology by measuring the tendon thickness. The micromorphology was analyzed by determining the peak spatial frequency radius of the tendon. Our study did find increased tendon proper and composite tendon thickness in dancers with tendinopathy but no difference between asymptomatic dancers and non-dancers.

RESULTS

There was no significant difference in micromorphology found between any of the groups. As expected, dancers with tendinopathy demonstrated increased composite tendon and tendon proper thickness however, there was no evidence of adaptive thickening of the FHL tendon as might be expected for the dance population. There was also no evidence of micromorphological changes in the presence of clinically diagnosed FHL tendinopathy.

CONCLUSION

Because of the limited normative data for this pathology, these results can help improve diagnosis and therefore treatment for dancers to decrease the impact of this injury on their careers.

Dance-related musculoskeletal injury leading to forced time-loss in elite pre professional dancers - a retrospective study

OBJECTIVES

Describe the epidemiology of dance-related musculoskeletal injury leading to forced time-loss in elite pre-professional dancers and provide descriptive data on the prevalence concerning diagnoses, location, and injury type, stratified by gender and skill level.

METHODS

Retrospective cohort, over a 3-year period on a full-time pre-professional Portuguese dance school featuring 70 both gender students with a mean age of 14.87 years. A total of 110 injuries were analyzed. Non-parametric statistics were used.

RESULTS

The most prevalent diagnosis leading to forced time-loss in female dancers were Medial Tibial Stress Syndrome (MTSS), 14.29%, and Posterior Ankle Impingement Syndrome (PAIS), 7.14%, whereas in male dancers these were Hallux Sprain, 17.50%, and Lumbar Spine Joint Injuries, 7.50%. Differences were found in injuries' anatomical location between genders and in Incidence Proportion and Clinical Incidence between skill levels. 72.20% of the chronic injuries and 50.00% of the acute injuries occurred in Level III students.

CONCLUSIONS

With respect to forced time-loss injuries, male dancers were found to sustain more acute traumatic injuries and female dancers overuse, respectively, sprains and MTSS and PAIS. Identifying which injuries are most likely to lead to forced time-loss may be useful for helping health-care professionals in clinical decision-making and in developing more effective injury prevention and management strategies.

Epidemiological Characteristics of Foot and Ankle Injuries in 2 Professional Ballet Companies: A 3-Season Cohort Study of 588 Medical Attention Injuries and 255 Time-Loss Injuries

Background

The foot and ankle are often reported as the most common sites of injury in professional ballet dancers; however, epidemiological research focusing on foot and ankle injuries in isolation and investigating specific diagnoses is limited.

Purpose

To investigate the incidence rate, severity, burden, and mechanisms of foot and ankle injuries that (1) required visiting a medical team (medical attention foot and ankle injuries; MA-FAIs) and (2) prevented a dancer from fully participating in all dance-related activities for at least 24 hours after the injury (time-loss foot and ankle injuries; TL-FAIs) in 2 professional ballet companies.

Study Design

Descriptive epidemiological study.

Methods

Foot and ankle injury data across 3 seasons (2016-2017 to 2018-2019) were extracted from the medical databases of 2 professional ballet companies. Injury-incidence rate (per dancer-season), severity, and burden were calculated and reported with reference to the mechanism of injury.

Results

A total of 588 MA-FAIs and 255 TL-FAIs were observed across 455 dancer-seasons. The incidence rates of MA-FAIs and TL-FAIs were significantly higher in women (1.20 MA-FAIs and 0.55 TL-FAIs per dancer-season) than in men (0.83 MA-FAIs and 0.35 TL-FAIs per dancer-season) (MA-FAIs, P = .002; TL-FAIs, P = .008). The highest incidence rates for any specific injury pathology were ankle impingement syndrome and synovitis for MA-FAIs (women 0.27 and men 0.25 MA-FAIs per dancer-season) and ankle sprain for TL-FAIs (women 0.15 and men 0.08 TL-FAIs per dancer-season). Pointe work and jumping actions in women and jumping actions in men were the most common mechanisms of injury. The primary mechanism of injury of ankle sprains was jumping activities, but the primary mechanisms of ankle synovitis and impingement in women were related to dancing en pointe.

Conclusion

The results of this study highlight the importance of further investigation of injury prevention strategies targeting pointe work and jumping actions in ballet dancers. Further research for injury prevention and rehabilitation strategies targeting posterior ankle impingement syndromes and ankle sprains are warranted.

Dance-Related Foot and Ankle Injuries and Pathologies

Dancers are highly vulnerable to injuries due to high dynamic overload, extreme positions and motions, and excessive use. Increased load at the forefoot with jumping and high-impact lands can cause sesamoiditis and stress fractures of the metatarsals. Significant plantarflexion can lead to posterior joint impingement and flexor hallucis longus tendonitis, whereas forced dorsiflexion can cause anterior joint impingement. Most pathologies can be diagnosed on physical examination and various imaging modalities. Treatment should be tailored to the dancers' needs and should begin with a course of conservative therapy with immobilization, physical therapy, and activity cessation.

THE ROLE OF FUNCTIONAL DYNAMIC STRETCHING TRAINING IN DANCE SPORTS

ABSTRACT Introduction Dynamic stretching is a particular form of training. Currently, there is little research in academia about dynamic stretching in sports dancing. Objective Explore the role of functional dynamic stretching training in dance sports. Methods 60 sports dancers with a history of ankle injuries were randomly divided into a control and experimental group. All performed a training protocol twice a week, lasting 45 minutes, for eight weeks. A functional dynamic stretching training session was added to the control group. The effects were evaluated by the Cumberland scale, bilateral stability comparison, and balance control by the Perkin system. Data were statistically treated for analysis. Results There was no significant difference between the scores of healthy ankle joints and injured ankle joints in the two groups (P>0.05). After eight weeks of functional dynamic stretching training, there was a significant difference between the experimental and control groups on injured ankle joints (P<0.05). Conclusion Dynamic stretching training can effectively improve ankle joint stability in sports dancers. Concomitantly, this method effectively prevents injuries to the athlete’s ankle joint. Evidence level II; Therapeutic Studies - Investigating the results.

Prevalence of ankle instability in performers of Chinese classical dance: a cross-sectional study of 105 Chinese dancers

Objectives

Foot and ankle injuries are commonly seen in dancers, yet limited studies exist on the injury prevalence of performers of Chinese classical dance. This study aims to determine and assess the prevalence of chronic ankle instability (CAI) in Chinese dancers and correlate the impact of CAI with foot function.

Methods

This is a cross-sectional study of 105 Chinese dancers. CAI was assessed using the Cumberland Ankle Instability Tool and foot function via the Foot and Ankle Outcome Score (FAOS). Both self-reported assessment tools were distributed online between January and February 2021. Subjects were divided into CAI and healthy groups to observe any correlations in demographics, training hours and foot function.

Results

CAI was seen in 28% of Chinese dancers, with most being unilateral instability. The number of training hours, level of expertise, occupation, gender and age showed no statistical significance with CAI. The FAOS showed that subjects with CAI had significantly greater pain and poorer quality of life.

Discussion and conclusion

CAI is a problem affecting 28% of performers of Chinese dance. Future research should investigate the ankle biomechanics in Chinese dance and specific risk factors for CAI to formulate strategies to prevent ankle injuries in Chinese dancers.

Ballet Rehabilitation: A Novel Return to Sport Protocol

Dance injuries and re-injuries are common but can be difficult to rehabilitate because of the unique demands and motor skills required. During tissue healing, pain resolves prior to tissue maturation and re-injury often occurs if the original injury is not properly rehabilitated.

The purpose of this narrative review is to analyze the existing literature addressing ballet injury, re-injury, and recovery, and to provide clinicians with timing guidelines for entering and implementing a Return to Sport (RTS) ballet rehabilitation protocol designed to prevent re-injury by progressive, sport-specific tissue loading. Thus far, a literature-based ballet-specific and body region-specific late-stage rehabilitation RTS protocol has not been established. The authors sought to address this literature gap by combining this comprehensive narrative review with our extensive clinical expertise to develop a late-stage rehabilitation RTS protocol to help guide medical clinicians treating injured ballet dancers.

Relationship of Extrinsic Risk Factors to Lower Extremity Injury in Collegiate Ballet Dancers

Ballet dancers are thought to be at higher risk of lower extremity injury. This objective of this study was to describe the self-reported incidence, location, and factors associated with lower extremity injury in collegiate ballet dancers. Two hundred and forty-nine female ballet dancers responded to a questionnaire that addressed their injury event/location, dance behavior over the past 2 years, and overall dance history. Behaviors assessed included the following: types and number of shoes worn (pointé shoes/ballet slippers), wear time, training time (session frequency and duration), use of warm-up/cool-down, and use of a strengthening program and lower extremity accessory. Overall dance history included age of the onset of training, total years of experience, and number of dance styles. Backward multivariable logistic regression analysis was used to determine the extent to which variables measured were associated with injury. Ankle injury was the most prevalent injury. Years of wearing pointé shoes (adjusted odds ratio = 1.21, p = 0.01) and days/weeks in pointé shoes (adjusted odds ratio = 1.26, p = 0.04) were associated with an increased risk of injury; while additional strengthening (adjusted odds ratio = 0.39, p = 0.02) and use of lower extremity accessories during classes/rehearsals (adjusted odds ratio = 0.64, p = 0.01) were protective associations. These findings suggested that the use of pointé shoes, lower extremity accessories, and additional exercise should specifically be recorded during evaluation of injured ballet dancers; and must be considered potential factors to modify during rehabilitation.

What Is the Efficacy of a Nonoperative Program Including a Specific Stretching Protocol for Flexor Hallucis Longus Tendonitis?

BACKGROUND

Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement.

QUESTIONS/PURPOSES

The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management?

METHODS

The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05.

RESULTS

Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001).

CONCLUSION

FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Snapping Plantaris Tendon: A Rare Case in a Competitive Dancer

Pathology associated with the plantaris includes rupture of the tendon and an association with mid-substance Achilles tendinopathy in some patients. There have only been two previous case reports in the literature in English language describing snapping of the plantaris tendon. We present a case report of a 15-year-old female competitive dancer who described pain and an audible popping at the medial margin of the Achilles tendon while squatting. Physical examination revealed visible and audible popping of the plantaris, and ultrasonography confirmed the diagnosis. After symptoms persisted despite nonsurgical treatment with physical therapy, the patient underwent an open plantaris tenotomy. By 8 weeks after surgery, she had resumed dancing. Twenty-three months after her operation, she reported an excellent outcome and full recovery with no limitations to her physical activity. She reported having no pain, a Foot and Ankle Ability Measure Activities of Daily Living Subscale score of 100, and a Foot and Ankle Ability Measure Sports Subscale score of 100. This case demonstrates a successful course of treatment for this uncommon pathology within the context of a competitive dancer.

Recalcitrant Flexor Hallucis Longus Dysfunction: A Case Study Demonstrating the Successful Application of an Adaptable Rehabilitation Program With a Two-Year Follow-Up

Flexor hallucis longus (FHL) dysfunction is a condition experienced primarily by athletes, including ballet dancers and runners. Accurate diagnosis and definitive treatment at the initial evaluation can often be difficult given the number of foot and ankle pathologies that share similar signs and symptoms. The evaluation process tends to be a diagnosis of inclusion rather than a specific pathology with an accepted rehabilitation plan. For example, patients with medial arch pain may undergo an extended rehabilitation period with an evolving differential diagnosis requiring several treatment modifications. A more appropriate rehabilitation paradigm should adapt to the potential changes in patient symptoms and presentation, addressing functional impairments as they arise. This case study describes the successful management of a patient with chronic FHL dysfunction, leveraging a flexible, multimodal treatment approach to address the evolving functional impairments rather than focusing on a single, discrete diagnosis. At a two-year follow-up, the patient remains pain-free.

Performing Arts Medicine

Performing artists are a unique subset of athletes. With the highly repetitive nature of performance training, emphasis on proper technique, ergonomics, and preventive cross-training is vital, as many injuries are due to overuse or poor technique. There are novel medical concerns in performers, including ENT problems, mental health concerns and substance use risks. While music is central to performances, it is also a treatment modality to address cognitive, sensory, and motor dysfunctions in certain neurological conditions. Due to this wide array of issues, it is imperative to understand the specific needs and risks of performers to provide optimal medical care.

Women's Foot Health-Related Quality of Life in Ballet Dancers and Nondancers

BACKGROUND

Prevalence and severity of symptoms related to muscle and joint pain seem to be high in most dancers.

HYPOTHESIS

There will be a worse quality of life related to foot health for ballet dancers compared with nondancers.

STUDY DESIGN

Case-control study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A sample of 156 women was recruited from a clinic of podiatric medicine and surgery. Self-reported data were measured by the Foot Health Status Questionnaire (FHSQ), which has 33 questions that assess 8 health domains of the feet and general health, namely, foot pain, foot function, general foot health, footwear, general health, physical activity, social capacity, and vigor.

RESULTS

Statistically significant differences (P < 0.05) were shown for foot pain, foot function, foot health, and general health, which together revealed a worse foot health-related quality of life (lower FHSQ scores) but a better general health (higher FHSQ scores) for ballet dancers compared with nondancers. The remaining domains did not show statistically significant differences (P > 0.05). According to multivariate linear regression models (P < 0.05), the practice of ballet dance (group) was the only independent variable that predicted the dependent variables, such as foot pain (R² = 0.052;β = +8.349), foot function (R² = 0.108; β = +11.699), foot health (R² = 0.039; β = +10.769), and general health (R² = 0.019; β = -6.795).

CONCLUSION

Ballet dancers showed a negative impact on quality of life related to foot health but better overall quality of life (general health) compared with nondancers.

CLINICAL RELEVANCE

Paying attention to a dancer's foot health could provide important benefits for the dancer's foot health and physical practice of dance.