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Acute ankle sprain in dancers.

Ankle sprains are known to be a frequent occurrence across all sports, accounting for 15% of injuries. (1-4) Furthermore, in many sports ankle sprains are the most common injury that athletes sustain. (2) Unquestionably dancers are athletes, (5,6) and like other athletes they experience significant trauma to the musculoskeletal system. (7-19) Consequently, it is not surprising that ankle injuries are also the most common acute injury across all forms of dance, with injury rates as high as 31% (Table 1). Further, although the literature does not reveal a consistent, clearly defined method of categorizing an injury episode, (17,20) it seems obvious that dancers are frequently confronted with ankle injuries. An ankle sprain can be quite debilitating for the dancer because dance requires extremes of mobility and stability in the foot and ankle complex that are unlike those found in most other activities. One example is the female ballet dancer, who is required to move repeatedly into and out of maximum forced dorsiflexion during a demi-plie and maximum forced plantar flexion during the demi-pointe and en pointe positions.

Ligamentous ankle injuries occur in one of three regions: lateral, medial, or at the tibiofibular syndesmosis. The anatomy of the ankle and its ligaments as they pertain to dance have been discussed in detail elsewhere. (22) The strongest of these structures is the deep portion of the deltoid ligament, the anterior and posterior talotibial complex, located at the medial ankle. (23,24) The ligamentous support on the lateral side is less substantial, and includes the anterior talofibular (ATF), calcaneofibular (CF), and posterior talofibular (PTF) ligaments. Of the two commonly injured lateral ligaments, the ATF and CF, the ATF is the weaker. (24-26)

Overall the lateral side is the most often injured ankle region, (27-29) with the most common mechanism of injury involving ankle inversion and internal rotation either with or without plantar flexion, (3) such as occurs during jump landings. Dancers with lower thigh muscle power outputs have been shown to experience an increased incidence of lower extremity injuries, including injuries to the ankle. (30) Individuals with functional ankle instability tend to have compromised function of the peroneal muscles prior to landing on the ground, thus increasing their risk of additional inversion injury. (31) Furthermore, adverse functional sequelae following ankle injury may not be confined to the ankle and leg. Other components of the lower extremity kinetic chain have been linked to chronic ankle instability, including ipsilateral hip abduction weakness (32) and ipsilateral knee flexor and extensor weakness. (33)

The maximal plantar flexion of the en pointe position is a special situation that separates dance from traditional sports. With increasing plantar flexion the anterior talofibular ligament undergoes increased strain (26,34-36) as it moves to a nearly vertical position, (27,37) thus enhancing its risk of injury. Strain (a measure of deformation caused by tensile force) increases as the ligament is stretched between its talar and fibular attachments. This, coupled with the relative weakness of the anterior talofibular ligament, (24-26) suggests a predisposition to lateral ankle sprain in dancers. However, once en pointe a mediating factor is the stability of the ankle gained through the compressive locking of the posterior tibial plafond against the posterior talus and superior calcaneus, (38-41) and further supported during dynamic movement by the musculotendinous component of stability offered by the leg, ankle, and foot musculature. (42)

Acute Assessment of Ankle Injuries

One role of certified athletic trainers--and other healthcare providers who have the opportunity to be first responders to a dance injury--is to achieve an initial evaluation of an injury prior to pain, swelling, and muscle spasm complicating the task. The primary result of this evaluation is to determine whether the dancer should return to activity, receive onsite treatment, or be transported to a clinical site. Assessment of ankle injuries should follow the standard history, inspection, palpation, and special testing paradigm. While a detailed description of this process is beyond the scope of this article, the steps can be summarized as follows.

History

This is the formative first step, entailing a series of questions designed to elicit the factors surrounding the ankle injury and any ancillary information that may be germane in arriving at a diagnosis. Previous history of injury is particularly important because the chance of re-injury following ankle sprain is substantial. (43)

Inspection (Observation)

This step is a careful visual analysis of the injured area and regions adjacent to it. Information is collected regarding swelling, deformity, discoloration, weightbearing ability, and other observable clues about the type and extent of injury. The contralateral limb is used for comparison.

Palpation

Important details are gained by a systematic probing of the injured area and surrounding tissues, including painful points, abnormal contours, crepitus, and other clinical signs. The contralateral limb is again used as a reference.

Special Testing

Once the previous three steps have been completed, the examiner performs a series of appropriate assessments to further determine the nature and severity of the injury. These may include range of motion, manual muscle testing, joint stability, neurologic examination, accessory motions, and functional performance. The results of these tests add information to the diagnostic process and decisions about returning to dance.

The severity of ankle injuries is rated based on the results of the clinical examination, using a variety of special tests explicitly designed to assess the integrity of the individual ligaments. One common method of assigning a severity index to ankle sprains is by grading them 1, 2, or 3. A grade 1 sprain is a stretching of a ligament with little or no obvious tissue damage. No instability is noted when a stress exam is performed, but mild to moderate pain is usually present. A grade 2 sprain involves partial tearing of a ligament; a diagnosis that can involve a wide range of damage. Some instability is present during the ligament stress exam, but the examiner will feel a definite endpoint. This restriction is not present in a grade 3 sprain; instead, the exam yields an indistinct, soft endpoint, which suggests that the substance of the ligament is completely disrupted. A dancer's ability to continue dancing with an acute ankle sprain generally will be related to the severity of the injury.

The Ottawa Ankle Rules (44,45) have fundamentally changed ankle injury imaging practices in emergency departments and other healthcare settings. (46-48) These rules (Table 2 and Fig. 1) are designed to determine when acute injuries require radiography by applying very specific criteria to assess the probability of fracture. Implementing the rules has decreased the need for x-rays and increased healthcare cost savings. (49) It is important to note that the Ottawa Ankle Rules appear to be most useful when applied by healthcare workers, as patients may not be able to accurately apply the rules to their own ankle injuries. (50)

Acute Treatment

The common standard for acute care of an ankle injury is known by the acronym P.R.I.C.E.: protection, rest, ice, compression, and elevation. (51) The generally accepted period for the acute treatment described below is the first 48 to 72 hours following injury. Protection, in the form of bracing, splinting, or non-weightbearing transport is important to reduce the chance of further trauma to an injured area. Rest from the activity that caused the injury, or similar activities, is warranted when a significant potential exists for re-injury or further injury.

With the heavy emphasis on ensuring evidence-based quality in health care, ice has recently come under scrutiny to determine its actual, rather than presumed, effectiveness in procuring a therapeutic benefit. (52-54) Nonetheless, applying ice to the injured ankle is helpful for reducing pain. (54-56) Other traditional reasons for utilizing ice include minimizing edema (swelling) and decreasing the likelihood of secondary cellular hypoxic injury (57) in the affected region.

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Circumferential compression, such as that provided by an elastic bandage, enhances control of edema by increasing the tissue pressure in the region of the injury. The protrusion of the malleoli in the normal contours of the ankle may prevent the areas anterior and posterior to the malleoli from receiving adequate compression by an elastic bandage. Focal compression has been shown to hasten return to function following ankle sprain more readily than simple circumferential pressure. (58) Horseshoe shaped pads cut from 1/4 inch foam or orthopaedic felt and positioned underneath the bandage during wrapping (Fig. 2) alleviate collection of edema in this area. Elevation of the injured extremity so the ankle is positioned above the level of the heart promotes a reduction in swelling by assisting lymphatic drainage. (57) Although the degree of post-injury swelling is not necessarily correlated with measures of function, (59-61) ankle effusion does alter neuromuscular function in the leg. (62-64) Therefore, it is crucial that dancers who experience ankle sprains receive appropriate acute care and follow-up treatment.

Subacute Care

The treatment and rehabilitation of physically active people trying to return to high level activity requires a proactive and creative approach. In dancers, return of function must be maximized while duration of time away from dance is minimized without introducing unnecessary or unwise risk of re-injury or further injury, either to the ankle or another body region. The subacute phase of ankle injury care immediately follows the acute phase. If the ankle injury is not sufficiently severe to require x-rays, immobilization, crutches, or other types of advanced care, a program designed to return the individual to dancing should be initiated. This involves a progressive advancement of activity to encourage restoration of movement, flexibility, and strength, along with improving the dancer's confidence about functioning with the injury.

Early motion is essential for ensuring a successful return to activity. (65,66) Basic home care exercises include gentle pain-free motion by moving the foot in circles, drawing the letters of the alphabet with the toes, using a towel or belt held in the hands and passed under the forefoot to pull the toes upward, and sitting with the foot on the floor and raising just the forefoot off the floor, then from the same position raising just the heel. As progress is made, another important rehabilitative step is proprioceptive balancing. Research shows that proprioceptive ability in dancers decreases following ankle injury, (67) and that individuals who experience ankle instability from serious or multiple sprains may exhibit a reduced ability to balance on the injured limb. (68) Therefore, it is imperative that this component of rehabilitation be initiated as expeditiously as possible.

Initially balance training is done standing on the floor; five one-minute sessions of balancing in the morning and evening is appropriate. During the early post-injury period, the dancer can use the barre for support, if needed, and keep the eyes open while balancing. Progression of this exercise's difficulty is accomplished by closing the eyes to eliminate visual cues while free-standing. More advanced proprioceptive work can be achieved by performing the balancing on a pillow or cushion, floor trampoline, wobble board, or other device that offers a relatively unstable surface. (69,70) Although proprioceptive function in dancers improves with training following an ankle sprain, (67) participation in dance is not, by itself, necessarily related to increased proprioceptive function in the ankle. (71) Furthermore, individuals with chronic lateral ankle instability exhibit compromised balance function, (68) as do dancers. (72) This underscores the importance of dancers engaging in balance rehabilitation.

Care to Expedite Return to Activity

Ankle ligaments typically require six weeks to three months to heal, (73,74) though the return of ligament tissue to its full strength may be substantially longer. (75) It is important to note that a sizeable number of ankle sprains result in persistent symptoms that include instability and pain. (73,74,76) A basic premise of sports medicine is that early return to activity following ankle sprain is acceptable as long as the risks of re-injury and extended recovery time are known, accepted, and ameliorated to the greatest extent possible. This means that healthcare professionals must focus on evidence-based care that ensures both effective restoration of function and safe return to activity for the injured dancer. Dance medicine requires modification of certain sports medicine principles that facilitate a dancer's return following ankle sprain, including consideration of the extreme motion required of the ankle and costume appearance requirements that often prohibit customary methods of care, such as ankle taping and bracing.

The main factors requiring assessment as the dancer with an ankle injury gradually and safely returns to activity are pain, swelling, range of motion, strength, muscle endurance, agility, proprioception, and psychological status. Individual differences in these factors and the demands of an individual's dance program preclude this article from providing a single paradigm for determining readiness to return to dance. However, increasingly complex dynamic movement patterns for the lower extremities are integral to success. The possible exercises and available accessories for developing physical capacity are virtually unlimited in today's activity conscious society, but they should be prescribed with careful attention to their specific contributions to the dancer's rehabilitation.

Generally, a dancer's physical parameters upon return to full class, rehearsal, and performance activity should be at the same level as they were prior to the injury. Before returning to unrestricted participation, the dancer must be able to demonstrate proficiency in clinical rehabilitation, functional exercises, and the specific dance movements to be resumed. A gradual return and appropriate protective measures such as taping or bracing usually are indicated to reduce the chance of re-injury. It is helpful if the rehabilitation professional can work closely with the injured dancer's teachers or directors to help ensure smooth re-entry.

Complicating Injuries

Lateral ankle sprains can give rise to a chronic impingement syndrome secondary to hypertrophic scar tissue that forms from the anterior talofibular ligament; the incidence of this anterolateral ankle impingement has been reported to be between 1.2% and 3.0%. (77-79) Wolin and colleagues (80) were the first to describe this, labeling the condition a "meniscoid" lesion because the fibrotic nature of the entity resembles the characteristics of a knee meniscus. Several other investigators have corroborated that such an outgrowth may manifest following a sprain. (81-85) Bassett and associates (86) reported on seven cases of chronic anterior ankle pain and impingement caused by the distal fascicle of the anteroinferior tibiofibular ligament in patients who had suffered an inversion ankle sprain, an etiology of enduring anterolateral ankle pain also described by others. (87)

"Dancer's fracture" (88-90) is a spiral fracture of the distal shaft of the fifth metatarsal. This is usually associated with the plantar flexion-inversion mechanism of lateral ankle sprain (91) when the foot rolls onto its outside border (especially from the demipointe position) when landing after a jump. (89) Also associated with the lateral ankle is a fracture of the proximal portion of the fifth metatarsal at the junction of the metaphysis and diaphysis. First described by Jones in 1902, (92) this is commonly known as a Jones fracture and, interestingly, Jones reported it after he sustained this fracture himself while dancing. It typically occurs when the foot is weightbearing in slight plantar flexion and inversion and is most often seen in modern dancers. (91) Dancers with Jones fractures present challenges, including delayed union, nonunion, and surgery following failed conservative care. (91,93)

A number of additional fracture complications that may accompany ankle sprains include avulsion fracture of the base of the fifth metatarsal by the peroneus brevis tendon, fractures of the medial or lateral malleolus, Maisonneuve fracture of the proximal fibula, and osteochondral fracture of the talar dome. Other injuries associated with lateral ankle sprains include sprain of the dorsal calcaneocuboid ligament, cuboid subluxation, and tibiofibular syndesmosis injury. Injuries to the Lisfranc joint also must be ruled out. A thorough examination of all ankle injuries is very important because if any of these conditions are overlooked or misdiagnosed the sequelae will impair the dancer's ability to return to participation.

Conclusion

This article reviewed acute injuries to the ankle and highlighted methods that are useful for evaluation, treatment, and rehabilitation of dancers who suffer such an injury. Ankle sprains are a common dance injury, and certain features of these injuries may become problematic. Early intervention offers the best opportunity for optimum management and successful, safe return to dance.

Key Points

Dancer

Ankle injuries, while common, may not be simple and straightforward. Due to the unique demands of dance and the potential for chronic and complicating injuries, dancers who sustain any ankle injury should seek healthcare assistance when necessary in order to ensure full recovery, rather than trying to "dance through" the injury.

Teacher

When a dancer suffers an ankle injury, the teacher--as a trusted authority--should ensure that proper care is administered and realize the potential for persistent symptoms and complicating injuries that may require follow-up care. Items for proper injury care should be kept in a studio or theater first aid kit, including elastic bandages, felt horseshoe pads, ice, and ice bags.

Scientist

The high incidence of ankle sprains in dance coupled with a dancer's need for absolutely maximum ankle range of motion suggests that additional scientific research is needed to study ankle injury prevention, treatment, and rehabilitation specifically in the dance setting. Fatigue and injury seem to be related, as do proprioceptive ability, injury incidence, and injury recurrence. Researchers can make extraordinary contributions to understanding these and other factors.

Healthcare Professional

An on-site acute evaluation of an ankle injury is the ideal opportunity to establish a diagnosis, and proactive early management is crucial to a satisfactory return to dance participation. A number of lateral ankle sprains will exhibit chronic symptoms that may be related to hypertrophic tissue in the anterolateral aspect. This should be suspected in dancers for whom symptoms persist following an ankle sprain.

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(92.) Jones R. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg. 1902;35(6):697 700.

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Jeffrey A. Russell, Ph.D., A.T.C., is an Assistant Professor of Dance Science, Department of Dance, University of California, Irvine.

Correspondence: Jeffrey A. Russell, Ph.D., A.T.C., Department of Dance, University of California, Irvine, 300 Mesa Arts Building, Irvine, California 92697-2775; jeff.russell@uci.edu.
Table 1 Ankle Injury Incidence in Dance

                         Ankle Injury
Study                    Incidence      Comments

Byhring and B0 (9)       4.7%           3 of 64 injuries

Kerr et al. (11)         7.6%           7 of 92 injuries

Washington (12)          13.0%          55 of 414 injuries

Garrick and Requa1 (7)   13.3%          41 of 309 injuries

Nilsson et al. (10)      16.7%          65 of 390 injuries; authors
                                        only reported incidence for
Bowling (13)             19.0%          ankle and foot combined (54%).
                                        The 16.7% figure was
                                        calculated from tabular data
                                        about ankle injuries presented
                                        in their article. 11 of 58
                                        dancers suffered ankle injury
                                        in six months prior to data
                                        collection

Garrick (20)             19.9%          269 of 1,353 injuries

Rovere et al. (16)       22.2%          78 of 352 injuries

Laws (14)                24.0%          raw data not reported; UK
                                        national inquiry into dancers'
                                        health and injuries

Luke et al. (21)         31.0%          22 of 71 injuries

Table 2 Ottawa Ankle Rules (44,45,47,49)

Ankle should be         ... the posterior       ... the patient
x-rayed if ...          half of the distal 6    cannot bear weight
                        cm AND of the fibula    for 4 steps on the
                        or tibia or tip of      injured limb at the
                        the lateral malleolus   time of injury and at
                        is painful to           the time of the
                        palpation.              evaluation (limping
                                                is irrelevant)

Midfoot should be       ... the base of the     ... the patient
x-rayed if ...          fifth metatarsal or     cannot bear weight
                        the AND navicular is    for 4 steps on the
                        painful to palpation.   injured limb at the
                                                time of injury and at
                                                the time of the
                                                evaluation (limping
                                                is irrelevant)
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Author:Russell, Jeffrey A.
Publication:Journal of Dance Medicine & Science
Article Type:Disease/Disorder overview
Geographic Code:1CANA
Date:Jul 1, 2010
Words:5546
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