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The Relationship Between Lateral Ankle Sprain and Ankle Tendinitis in Ballet Dancers

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The Relationship Between Lateral Ankle Sprain and Ankle Tendinitis in Ballet Dancers Original Article The Relationship Between Lateral Ankle Sprain and Ankle Tendinitis in Ballet Dancers Stephanie Ritter, M.P.T., and Marjorie Moore, P.T., M.S.(kines.), Ph.D. Abstract and ankle tendinitis in ballet dancers. attempt to compensate. Their overuse for The lateral ligament complex of the ankle Informal interviews were conducted with this static stabilizing function, as well as for is the most frequently injured structure physical therapists who specialize in treat- dynamic dance movements, then leads to in the body. Although most simple ankle ing ballet dancers, providing a clinical tendonitis. This knowledge may heighten sprains do not result in long-term disability, context for this report. An extensive review awareness of the potential for developing a significant number do not completely of the literature was conducted, includ- tendonitis following ankle sprains, and resolve, leading to residual symptoms that ing electronic databases, reference lists lead to better rehabilitation of the injured may persist for years. The most commonly from papers, and relevant reference texts. ballet dancer. reported symptoms, particularly among Numerous studies have investigated ankle athletes, include instability, re-injury, and sprains and residual complaints; nearly all allet dancers spend a pre- tendinitis. Ballet dancers are a combination report that lateral ankle sprains commonly ponderance of their time in of artist and high-performance athlete; lead to chronic ankle instability. Studies ex- extreme plantar flexion, par- consequently, they are subjected to the ploring ankle stability have demonstrated Bticularly females who are en pointe same types of injuries as other athletes, that the peroneal muscles play a crucial including lateral ankle sprains and their role in ankle stabilization; EMG studies (on toe). This position is potentially sequelae. Furthermore, ballet dancers confirm they are the first to contract during unstable, especially in ankles with perform in unusual positions such as en ankle inversion stress. The dancer’s need decreased ligamentous support follow- pointe, which places the ankle in extreme for exceptional ankle stabilization may ing a sprain. To compensate for this plantar flexion, requiring stabilization by lead to peroneal overuse and tendinitis. instability ballet dancers may overuse surrounding muscles. Dancers’ extraordi- Studies have linked peroneal pathology to their peroneal muscles. The result nary performance demands place them a history of ankle sprain, but there is no may be development of tendinitis in at risk for other ankle injuries as well, dance medicine literature linking peroneal these muscles. In fact, clinicians who including inflammation of several tendons, tendinitis to prior ankle sprains. A growing work with dancers report that this especially the peroneals. This report reviews body of literature confirms myriad connec- tendinitis is common in ballet danc- the relevant literature to characterize the tions between lateral ankle sprains, residual ers. Interestingly, studies exploring the scope of lateral ankle sprains and sequelae, instability, peroneal muscle increased ac- discuss the importance of the peroneal tivity, and tendinitis. It is our belief that relationship between this ubiquitous muscles in ankle stability, and explore a ankle sprains lead to instability, particular tendinitis and prior ankle sprains can- relationship between lateral ankle sprain en pointe, for which the peroneal muscles not be found in the dance medicine literature. The purpose of this paper is to Stephanie Ritter, M.P.T., was a student in the Master of Physical Therapy Program review the current literature to: 1. at the College of St. Catherine at the time this paper was written. Marjorie Moore, characterize the scope of lateral ankle P.T., M.S.(kines.), Ph.D., is an Associate Professor, College of St. Catherine, Minneapolis, Minnesota. sprains and their sequelae; 2. highlight the role that bony anatomy plays in Correspondence: Marjorie Moore, P.T., M.S.(kines.), Ph.D., College of St. Catherine, reduced ankle stability when ballet 601 25th Avenue South, Minneapolis, Minnesota 55454; [email protected]. dancers are plantar flexed en pointe; Versions of this article were presented as posters at the Minneapolis chapter of the 3. discuss the importance of the pe- American Physical Therapy Association, Brooklyn Park, Minnesota, April 2005; roneal muscles in ankle stability; and and the International Association for Dance Medicine and Science, Stockholm, 4. explore the evidence for a relation- Sweden, November 2005; and was published in the IADMS Annual Conference ship between lateral ankle sprain and Proceedings, 2005. peroneal tendinitis. 23 24 Volume 12, Number 1, 2008 • Journal of Dance Medicine & Science We hypothesized that there may Lateral ankle sprains are also the are often complex, involving multiple be a direct link between a history of most common injury in sports, con- structures; therefore, “ankle sprain lateral ankle sprain and subsequent stituting 38% to 45% of all injuries syndrome” may be a more appropri- development of peroneal tendinitis in athletic populations.2,7,8 Most stud- ate descriptor.7 Furthermore, previous so commonly seen in ballet dancers. ies agree that the lateral ligamentous literature has inadequately described This clinical relationship may also be complex of the ankle is the most fre- this multi-component involvement. present in other types of dance, but quently injured structure in the body.2,5 The result may be suboptimal care, we believe it will be stronger in ballet Furthermore, it has been reported that incomplete healing, and, ultimately, dancers due to their more precarious ankle injuries account for 25% of all persistent residual symptoms. ankle positions over a smaller base of time-loss injuries in sports involving support in pointe shoes. In addition running and jumping.4,11,12 Residual Symptoms Following to this increased need for lateral ankle Lateral Ankle Sprains stabilization, ballet dancers may also Sprained Ankle Syndrome Although most acute ankle sprains overuse the peroneals to achieve an A sprain is a tear of one or more do not lead to long-term disability, a aesthetically everted foot. ligaments at a joint (Fig. 1). An significant number do not completely To provide a clinical context for this ankle sprain or “twisted ankle” is often resolve, leading to residual symptoms report, informal interviews were con- thought of as a relatively simple injury that may persist for years.14 Symptoms ducted with two local physical therapists involving trauma to only the ankle liga- widely reported in the literature in- who specialize in treating ballet dancers.1 ments.7 However, Fallat and colleagues clude recurrent pain and swelling, While treating dancers with ankle ten- proposed that these injuries are actually functional and mechanical instability, donitis these therapists had noted a fre- more complicated, frequently involv- recurrent re-injury, and tendinitis.5 quent history of ankle sprain. Given this ing injury to additional surrounding Among the general medical clinic anecdotal information, we conducted an structures, such as the joint capsule.7 population up to 40% of patients extensive review of the literature to sup- Indeed, in recent studies of the char- experience these residual symptoms port the hypothesis that there is a direct acteristics of acute ankle sprains the after sprains,5,9,10,15,16 some even ten link between the two clinical conditions. investigators confirmed the presence years later.14 Chronic instability is First, several electronic databases were of concomitant soft tissue injuries to the most common complaint, and searched, including CINAHL, Medline, multiple structures surrounding the symptoms can be severe enough to Infotrac, PubMed, and Rehabilitation ankle.7,13 This finding was true in a limit the patient’s lifestyle.9 Despite and Physical Medicine. Then, further ci- majority of 639 cases7 and in all 61 efforts to rehabilitate these injuries, tations were identified from the reference cases13 examined surgically. Moreover, the recurrent re-injury rate for ath- sections of the papers retrieved. Finally, the investigators encountered tendini- letes has been reported to be as high relevant anatomy and kinesiology refer- tis of the peroneal tendons in 15.2%7 as 80%.12,16-19 ence texts were consulted. to 77%13 of these patients with ankle sprains. They noted that incidence of Lateral Ankle Sprains and Epidemiology of Lateral Ankle involvement of the peroneals had not Sequelae in Ballet Dancers Sprains previously been documented.7 It was Dance has long been understood to More than 20 years ago studies concluded that acute ankle injuries be an art form requiring tremendous identified ankle sprains as the most common injury treated in physi- cians’ offices and emergency rooms.2-4 Since then, research literature has consistently reported that the ankle continues to be the most frequently injured joint in the body. Fully 85% of those ankle injuries are sprains, and 85% of sprains occur to the lateral ligamentous complex,5 result- ing from the combined motions of plantar flexion and inversion.5-8 In fact, it is estimated that each day one ankle inversion sprain occurs for every 10,000 people, totaling 23,000 to 27,000 injuries per day in the Figure 1 Ankle sprain. Inversion sprain with tearing of lateral ankle ligaments. (Re- U.S. and accounting for up to 10% printed from: Peterson L, Renstrom P. Sports Injuries: Their
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