NORTHERN OHIO FOOT& ANKLE · Inversion Ankle Sprains One of the most commonly reported dance...

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The Northern Ohio Foot & Ankle Foundation Journal, 2016

NORTHERN OHIO FOOT & ANKLEFOUNDATION

Review of Common Foot and Ankle Injuries Sustained by Dancers by Megan L. Oltmann, DPM1 The Northern Ohio Foot and Ankle Journal 3 (2): 4 Dance places extreme biomechanical demands on the dancer, if technique is improperly executed it could lead to either an acute or chronic injury. The likelihood of a dancer sustaining an acute injury such as a fracture or a sprain increases with fatigue. Both serious recreational and professional dancers have highly demanding rehearsal schedules often leading to fatigue. Chronic overuse injuries such as Achilles tendonitis, Flexor Hallucis Longus tendonitis, stress fractures, or epiphysitis in the adolesecent tend to occur due to the repetitive nature of dance. Studies have shown lifetime incidence of a dance related injury is upwards of 90%. Care must be taken when treating this subset of athletes due to their extreme biomechanical challenges, less than supportive shoe gear, compliance issues when competition, auditions, or performances are looming, and the possible female athlete triad. Key words: Dance, Dance Medicine, Ankle Sprain, Achilles Tendonitis, Flexor Hallucis Longus Tendonitis, Epiphysitis, Stress Fracture

Accepted: December, 2015 Published: February 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution License. It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Northern Ohio Foot and Ankle Foundation Journal. (www.nofafoundation.org) 2014. All rights reserved.

ance historians have not been able to clearly identify a time period in which the art form of dance became woven into human culture.

Through the centuries dance has undoubtedly been an important part of rituals, ceremonies, religious celebrations, and entertainment. In the modern era of dance it has become a catalyst for expression for not only the choreographer but for the dancer as well. Dance has evolved over time from an unsophisticated technique, to a field that has grown immensely over the last century into countless disciplines, with each discipline setting forth their own technicalities.

Address correspondence to: [email protected]. 1. Podiatric Medicine and Surgery Resident, Mercy Health

The high demands that multidisciplinary dance places on one’s body make it a highly demanding field requiring a heightened level of endurance, power that can be met with grace, and extraordinary flexibility that stretches beyond the human body’s anatomic alignment. It is no wonder the lifetime incidence of a dance related injury is upwards of 90%. [7]

Risk of injury is greatest in the adolescent population and at the professional level. Females ages 8-12 and males ages 10-14 are at the greatest risk of injury during periods of rapid growth. [1] Throughout this time span individuals will have a considerable increase in body mass, height, arm and leg lengths. [1] During active growth spurts bones grow at a greater speed than soft tissues, such as muscles, tendons, and ligaments, yet bone mineralization

D

Volume 3, No. 2, February 2016 The Northern Ohio Foot & Ankle Foundation Journal!

The Northern Ohio Foot & Ankle Foundation Journal, 2014!

experiences a lag causing low bone mineral density. This lack of density will cause a decrease in the bones resistance to increased stress, thereby putting the dancer at greater risk for stress fracture. The asynchrony between bone growth and soft tissues can give dancers a sense of loss of flexibility, strength, and power, in turn this can cause a dancer to push themselves harder, causing injury due to the new biomechanical challenges that arise. This phenomenon is known as “reprogramming” or the relearning of previous learned dance technique. [1]

The purpose of this article is to review the most common traumatic and overuse injuries experienced by dancers, both recreational and professional. Rapid increases in training volume with repetitive movement places increased stress on bones, tendons, and ligaments. Injuries sustained can cause a dancer to accommodate by altering technique thereby causing abnormal increased stresses to the foot and ankle complex. Hincapie et al. performed a meta-analysis determining a high prevalence and incidence of overuse injuries, with back and lower extremity injuries pre-dominating. [5] A lifetime prevalence of dance injuries ranging from 40-84% in the professional ballet group was determined. [5]

Inversion Ankle Sprains

One of the most commonly reported dance injuries in the literature is an inversion ankle sprain. [10] This particular injury can be attributed to falling out of pirouettes, landing jumps or leaps in an improper position, as well shoe gear worn by dancers such as high heels and pointe shoes. Ballet dancers who dance en pointe balance their weight on their hallux while the ankle is in extreme plantarflexion. Dancers on pointe also rapidly move from a point of maximal dorsiflexion in demi pointe to maximal plantarflexion in en pointe positions. Extreme plantarflexion of the ankle causes tautness and potential strain of the already weak anterior talofibular ligament (ATFL). Over time this can cause deformation of the ligament, weakening the lateral ankle complex placing the dancer at risk of an inversion ankle injury.

Assessment of the inversion ankle injury

History of injury and physical exam are of the utmost importance to properly diagnosis an inversion ankle sprain. A dancer being able to recall the mechanism of the injury and any popping or clicking felt at time of injury is key to diagnosis. For an inversion injury to occur the ankle would need to be in an inverted position on the leg with some degree of plantarflexion, dancers may call this “sickling” of the foot. Primary assessment is important to determine whether or not a dancer can return to activity or be taken to a tertiary facility to be evaluated and treated.

On examination palpation along the lateral collateral ligaments for pain and instability is important to determine which ligaments are involved. An anterior drawer test should be performed to evaluate the integrity of the lateral collateral ligaments. This is done by stabilizing the tibia and attempting to bring the talus forward in the mortise. It is important to note any increase in anterior displacement from contralateral side. According to the Ottawa ankle rules radiographs should be performed if there is an inability to bear weight for 4 steps, bone tenderness along the distal 6 cm of the posterior edge of the fibula or tibia, and pain at the lateral or medial malleolus. [12]

February 2016 The Northern Ohio Foot & Ankle Foundation Journal!


Treatment of the Inversion Ankle Sprain

After ankle fracture, involvement of peroneal tendons, and sinus tarsi is ruled out immediate treatment should begin to minimize edema and pain. The standard of care following an ankle sprain is P.R.I. C.E. therapy: protection, rest, ice, compression, and elevation. Stabilization and protection of the lateral ankle complex can be achieved with a lace up ankle brace, this will control motion in the frontal plane, but still allow sufficient sagittal plane motion. Resting from activity that caused injury due to potential for further injury. Icing the affected area 20 minutes at a time, several times per day until injury is resolved. Lastly a compression garment with 15-20 mmHg should be utilized for edema control. Acute treatment period generally lasts for the first 48-72 hours following injury.

Following acute treatment of an inversion ankle injury, subacute care should be started immediately to ensure a successful return to activity. This may be achieved by home therapy or through formal physical therapy. Early active range of motion is encouraged to restore strength, flexibility, and proprioception. Research shows that proprioceptive ability of a dancer diminishes following ankle injury, causing decreased ability to balance on affected limb [10]. Therefore this component of therapy maybe the most important on a dancer’s return to full rehearsal schedule.

There is no specific parameters that a dancer must meet before returning to full participation but should be guided by pain, swelling, proprioception, and range of motion. It is important that dancers be assessed for pre-injury level function utilizing their shoe gear rather than athletic shoes that provide much more support.

Dancer’s Fracture

A Dancer’s Fracture is caused by the same mechanism as a lateral ankle sprain, inversion and plantarflexion, and may even be coupled with an ankle sprain. It occurs after a

jump or leap has been completed, demi pointe position achieved, and a slight shift in weight to the outside of the foot. This can cause a fracture at the distal 1/3 shaft of the 5th metatarsal, known as the Dancer’s Fracture. Often the fracture pattern is spiral oblique, running distal lateral to proximal medial, and are typically extra-articular. [3] Prior lateral ankle injury with residual instability puts a dancer at risk for this fracture pattern. [3]

Assessment of a Dancer’s Fracture

On clinical evaluation, pain, edema, ecchymosis, and tenderness over the 5th metatarsal with history of inversion-plantarflexion injury should lead to health care provider to rule out a dancer’s fracture. Radiographic evaluation of the foot is necessary to confirm fracture. An AP, lateral, and oblique views are best to evaluate the level of displacement and comminution. One view may show significantly more displacement than another.

Treatment of Dancer’s Fracture

Depending on results of radiographs this will determine whether conservative vs. surgical treatment will be deemed necessary. If a dancer’s fracture is mildly displaced it may be treated conservatively, in a short leg fiber glass cast or fracture boot for 6-8 weeks depending on radiographic signs of healing. Due to the high mobility of the 5th metatarsal compared to the central metatarsals, and increased risk of non-union and malunion it is best to have an initial period of non-weight bearing. If fracture is severely displaced than open reduction internal fixation maybe necessary to properly align the fracture fragments.



Dancer’s fractures tend to have long oblique fracture fragments, making them amendable to 2.0 mm or 2.7 mm lag screws or plate fixation. With both conservative and surgical treatment, patients generally return to pain free walking by 8 weeks, with a return to full activity in 3-5 months. [9]

2nd Metatarsal Stress Fracture

Dancing places a high repetitive mechanical load on the forefoot which can in turn cause a stress fracture. Although Wolff’s law dictates the cortical hypertrophy often seen in the metatarsals of dancers, repeated micro trauma combined with physiologic stress exceeds the reparative capacity of the bone, therefore causing a stress or fatigue fracture. [9] It is no secret in the dance community that a female athlete triad is not uncommon consisting of an eating disorder, amenorrhea, and osteoporosis, further placing dancers at risk for stress fracture. [9]

The 2nd metatarsal base is the most common place for a stress fracture in a dancer due to the length of the metatarsal. The 2nd metatarsal is the longest, therefore it bears the most weight, especially in the demi-pointe position.

Assessment of 2nd Metatarsal Stress Fracture

Dancers will often complain of pain and tenderness over the area of the 2nd metatarsal at its proximal aspect. Another common overuse injury to the area is synovitis of the Lis Franc joint complex, consequently making it hard for the practitioner to differentiate clinically between the 2 injuries. [3] Radiographic evaluation tends to be unremarkable as there is a lag time seen on plain film radiographs of approximately 2 weeks for a stress fracture and Lis Franc synovitis would have no radiographic findings. MRI is useful in early diagnosis and treatment of stress fracture.

Treatment of 2nd Metatarsal Stress Fracture

Early diagnosis and treatment of stress fractures is important, if left untreated with continued activity, stress fracture could become a through and through fracture with a poorer prognosis. Treatment often consists of avoidance of offending activity and protected weight bearing in a fracture boot. Serial radiographs are also an important part of management to evaluate for bone callus formation, a sign of healing. Typically stress fractures take 6-8 weeks to heal. [3] Return to activity is guided by radiographic evidence of healing, and residual pain and swelling. May also to be prudent to send dancer for a nutrition consult if female athlete triad is suspected.

Achilles Tendonitis

The Achilles tendon can translate up to 6 times a person’s body weight while running and jumping making it a common site for injury in the dancer. [6] Many times Achilles tendon overuse injuries can be attributed to a tight heel cord, known as equinus. A dancer may experience pain along the Achilles tendon approximately 3 cm to 6 cm from the insertion of the Achilles tendon, this area is called the Watershed Zone. Symptoms tend to occur after periods of rest and while performing high impact activities such as leaps and jumps.

Assessment of Achilles Tendonitis

Achilles Tendonitis, which is acute inflammation of the tendon or surrounding paratenon, must be differentiated from Achilles Tendinosis, where chronic intrasubstance tendon degeneration is seen. To confirm Achilles Tendonitis on physical exam one will find pain and tenderness to the tendon and surrounding area with possible crepitus. Achilles Tendinosis presents with focal pain and swelling that will move as the ankle is plantarflexed or dorsiflexed, focal nodule may be present. If dancer has a history of previous Achilles tendonapathy practitioner is more likely to be dealing with Achilles Tendinosis.



Treatment of Achilles Tendonitis

Treatment protocol of strict rest from activity with immobilization in a fracture boot and heel lift, coupled with a course of oral anti-inflammatories, and daily icing will help to minimize symptoms. After quiescence of pain and swelling a course of formal physical therapy may be started. Steroid injections should not be given due to risk of increase rupture of the Achilles tendon but iontophoresis administered by physical therapist may be started with Dexamethasone for local anti-inflammatory affect. Dancer should also be evaluated for other muscles imbalances and treated. Before returning to full activity dancer should be evaluated in dance shoe gear with painless resisted plantarflexion and dorsiflexion, no pain with palpation of Achilles tendon, as well as painless jumps and leaps. If symptoms do not improve with treatment protocol MRI is warranted to evaluate structure of Achilles tendon, as well as surrounding structures that could be problematic such as Flexor Hallucis Longus (FHL) Tendonitis or Posterior Impingement Syndrome. [6]

Flexor Hallucis Longus Tendonitis

Tendonitis of the FHL occurs so commonly among dancers that it has become known as “Dancer’s Tendonitis”. [4] The commonality of this injury is attributed to the anatomy of the FHL. Its origin is on the middle posterior aspect of the fibula with its insertion on the plantar aspect of the distal phalanx of the hallux. As the muscle belly ends and gives rise to the FHL tendon, it courses through a fibrosseous tunnel behind the talus, between the medial and lateral tubercles. It is in this tunnel that damage typically occurs in the dancer. As the tendon becomes frayed in its pulley system, it causes micro tears and swelling, the longer the injury is left untreated the worse the prognosis. Triggering can ensue if there is an

obstruction, such as a nodule in the tunnel causing “hallux saltans” where the tendon freezes causing pseudo hallux rigidus. [4] The tendon can also become pathologic at the Master Knot of Henry where the FHL and FDL cross, or during its course through the sesamoid apparatus just proximal to its insertion. [6]

Assessment of Flexor Hallucis Longus Tendonitis

Dancers will likely present with complaints of pain and clicking to the posterior aspect of the ankle during en pointe, demi pointe, and grande plie, where repetitive push-off from the forefoot takes place. Isolated muscle strength testing is essential to differentiate from the Achilles tendon and other tendons that course on the posterior medial aspect of the ankle. Palpation of the FHL along the sustentaculum tali, the plantar medial foot, and at the sesamoid apparatus is also necessary. FHL stretch test is crucial if pseudo hallux rigidus is suspected. [8] The test is performed with the 1st metatarsal head stabilized and motion of the 1st metatarsal phalangeal joint is tested with the ankle in maximal plantarflexion and moderate dorsiflexion, a positive test will have pain with range of motion or have a decrease in motion by 20 degrees with ankle joint in dorsiflexion. [8]



Treatment of Flexor Hallucis Longus Tendonitis

Treatment is similar to the treatment described above for Achilles Tendonitis. Rest from inciting activity, immobilization in a fracture boot, icing, and a course of oral anti-inflammatories. At home stretching program or a formal course of physical therapy also recommended. Success of non-operative treatment ranges from 40%-100%. [15] If conservative treatment options have been exhausted debridement of tendon and/or release of fibrosseous tunnel is necessary for dancer to return to pre-activity level.

Epiphysitis of the 1st Metatarsal Phalangeal Joint

Dancers need an extreme amount of joint mobility at the 1st Metatarsal Phalangeal Joint, roughly 90-100 degrees. Rarely is anyone born with this much motion, yet for a dancer it is acquired through the molding of the growing physis at the base of the proximal phalanx of the hallux. Typically this is asymptomatic but when symptomatic young dancers will have pain and swelling to the area. Pain is typically relieved with rest.

Assessment of Epiphysitis of the 1st Metatarsal Phalangeal Joint

On assessment of dancer there will be pain with extreme dorsiflexion of the 1st metatarsal phalangeal joint with associated edema. Radiographic evaluation is important to rule out fracture of the growth plate, and eliminate any possibility of hallux limitus, or sesamoid pathology.

Treatment of Epiphysitis

Treatment of epiphysitis includes resting from activities that cause pain, icing affected area daily, and a short course of oral anti-inflammatories if tolerated. If pain relief is not seen fracture boot is necessary to immobilize 1st metatarsal phalangeal joint. Dancer typically can return to training pain free in 4-6 weeks, although there is a possibility of recurrence until maturation of growth plate. [2]

Summary

The dancer, choreographer, trainer, and physician must be attentive to the dancer’s total health to prevent and cope with injury. Overall heath, physical, and physiological attributes and prior injuries need to be addressed to minimize injury. Proper technique with progression of skill set should be preached by choreographers to prevent injury due to improper biomechanics and alignment. A dancer must understand a reduction of fatigue and proper nutrition are essential to a healing body and prevention of injury.

References

1. Bowerman, Erin Anne. “A Review of the Risk Factors for the Lower Extremity Overuse Injuries in Young Elite Female Ballet Dancers.” Journal of Dance Medicine and Science. Volume 19, Number 2, 2015.

2. Caselli, Mark. "How to Identify and Treat

Common Ballet Injuries." Podiatry Today 16.4 (2003). Web. 21 June 2015.

3. Goulart, Megan. “Foot and Ankle Fractures in

Dancers.” Clin Sports Med 27 (2008) 295-304.

4. Hamilton, WG et al. “Pain in the posterior aspect of the ankle in dancers. Differential diagnosis and operative treatment.” J. Bone Joint Surg. 78A:1491-1500, 1996.

5. Hincapie, CA et al. “Musculoskeletal Injuries and Pain in Dancers: A Systematic Review.” Arch Phys Med Rehab. 2008.

6. Hodgkins, Christopher. “Tendon Injuries in

Dance.” Clin Sports Med 27 (2008) 279-288.



7. Leanderson, Charolotte. “Musculoskeletal Injuries in Young Ballet Dancers.” Knee Surg Sports Traumatol Arthrosc (2011) 19:1531-1535.

8. Michelson, J et al. “Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment.” Foot Ankle Int. Apr;26(4):291-303, 2005.

9. Prisk, Victor et al. “Forefoot Injuries in

Dancers.” Clin Sports Med 27 (2008) 305-320.

10. Russell, Jeffery. “Acute Ankle Sprain in Dancers.” Journal of Dance Medicine and Science. Volume 14, Number 3, 2010.

11. Russell, Jeffery. “Preventing Dance Injuries:

Current Perspectives.” Open Access Journal of Sports Medicine (2013) 199-210.

12. Stiell, I.G. et al. “Implementation of the Ottawa Ankle Rules.” JAMA, 271 (1994) 827-832.

13. Steinberg, Nili. “Paratenonitis of the Foot and

Ankle in Young Female Dancers.” Foot and

Ankle International Volume 32, no. 12, December 2011

14. Weber, Bruce . “Dance Medicine of the Foot and

Ankle: A Review.” Clin Podiatry Med Surg 28 (2011) 137-154.

15. Keeling JJ, Guyton GP: Endoscopic flexor hallucis longus decompression: a cadaver study. Foot Ankle Int. Jul;28(7):810-4, 2007

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