Review Article

Acute Ankle Sprain in Dancers

Jeffrey A. Russell, Ph.D., A.T.C.

Abstract they experience significant trauma deltoid ligament, the anterior and 7-19 Ankle sprain is a common injury in danc- to the musculoskeletal system. posterior talotibial complex, located ers. Because of the relative frequency of Consequently, it is not surprising at the medial ankle.23,24 The ligamen- this injury and its wide acceptance as a that ankle injuries are also the most tous support on the lateral side is less likely part of an active lifestyle, in many common acute injury across all forms substantial, and includes the anterior individuals it may not receive the careful of dance, with injury rates as high as talofibular (ATF), calcaneofibular attention it deserves. An extreme ankle 31% (Table 1). Further, although the (CF), and posterior talofibular (PTF) range of motion and excellent ankle stabil- literature does not reveal a consistent, ligaments. Of the two commonly ity are fundamental to success in dance. clearly defined method of categoriz- injured lateral ligaments, the ATF Hence, following a proper treatment pro- 17,20 24-26 tocol is crucial for allowing a dancer who ing an injury episode, it seems and CF, the ATF is the weaker. obvious that dancers are frequently Overall the lateral side is the suffers an ankle sprain to return to dance 27-29 as soon as possible without impaired func- confronted with ankle injuries. An most often injured ankle region, tion. This article reviews the basic prin- ankle sprain can be quite debilitat- with the most common mechanism ciples of the etiology and management of ing for the dancer because dance of injury involving ankle inversion ankle sprain in dancers. Key concepts are requires extremes of mobility and and internal rotation either with on-site examination and treatment, early stability in the foot and ankle com- or without plantar flexion,3 such restoration, dance-specific rehabilitation, plex that are unlike those found in as occurs during jump landings. and a carefully administered safe return most other activities. One example Dancers with lower thigh muscle to dance. Additionally, injuries that may is the female ballet dancer, who is power outputs have been shown to occur in conjunction with ankle sprain required to move repeatedly into and experience an increased incidence of are highlighted, and practical, clinically out of maximum forced dorsiflexion lower extremity injuries, including relevant summary concepts for dance 30 healthcare professionals, dance scientists, during a demi-plié and maximum injuries to the ankle. Individuals dance teachers, and dancers are provided. forced plantar flexion during the with functional ankle instability tend demi-pointe and en pointe positions. to have compromised function of the nkle sprains are known to be Ligamentous ankle injuries oc- peroneal muscles prior to landing on a frequent occurrence across cur in one of three regions: lateral, the ground, thus increasing their risk 31 all sports, accounting for medial, or at the tibiofibular syn- of additional inversion injury. Fur- A15% of injuries.1-4 Furthermore, in desmosis. The anatomy of the ankle thermore, adverse functional sequelae many sports ankle sprains are the and its ligaments as they pertain to following ankle injury may not be most common injury that athletes dance have been discussed in detail confined to the ankle and leg. Other 22 sustain.2 Unquestionably dancers elsewhere. The strongest of these components of the lower extremity are athletes,5,6 and like other athletes structures is the deep portion of the kinetic chain have been linked to chronic ankle instability, including ipsilateral hip abduction weakness32 Jeffrey A. Russell, Ph.D., A.T.C., is an Assistant Professor of Dance Science, and ipsilateral knee flexor and exten- Department of Dance, University of California, Irvine. sor weakness.33 Correspondence: Jeffrey A. Russell, Ph.D., A.T.C., Department of Dance, University The maximal plantar flexion of of California, Irvine, 300 Mesa Arts Building, Irvine, California 92697-2775; the en pointe position is a special [email protected]. situation that separates dance from

89 90 Volume 14, Number 3, 2010 • Journal of Dance Medicine & Science

Table 1 Ankle Injury Incidence in Dance Ankle Injury Study Incidence Comments Byhring and Bø9 4.7% 3 of 64 injuries Kerr et al.11 7.6% 7 of 92 injuries Washington12 13.0% 55 of 414 injuries Garrick and Requa17 13.3% 41 of 309 injuries Nilsson et al.10 16.7% 65 of 390 injuries; authors only reported incidence for ankle and foot combined (54%). The 16.7% figure was calculated from tabular data about ankle injuries presented in their article. Bowling13 19.0% 11 of 58 dancers suffered ankle injury in six months prior to data collection Garrick20 19.9% 269 of 1,353 injuries Rovere et al.16 22.2% 78 of 352 injuries Laws14 24.0% raw data not reported; UK national inquiry into dancers’ health and injuries Luke et al.21 31.0% 22 of 71 injuries traditional sports. With increasing a clinical site. Assessment of ankle Special Testing plantar flexion the anterior talo- injuries should follow the standard Once the previous three steps have fibular ligament undergoes increased history, inspection, palpation, and been completed, the examiner per- 26,34-36 strain as it moves to a nearly special testing paradigm. While a forms a series of appropriate assess- 27,37 vertical position, thus enhancing detailed description of this process is ments to further determine the nature its risk of injury. Strain (a measure beyond the scope of this article, the and severity of the injury. These may of deformation caused by tensile steps can be summarized as follows. include range of motion, manual mus- force) increases as the ligament is History cle testing, joint stability, neurologic stretched between its talar and fibu- examination, accessory motions, and lar attachments. This, coupled with This is the formative first step, entail- functional performance. The results the relative weakness of the anterior ing a series of questions designed to of these tests add information to the 24-26 talofibular ligament, suggests a elicit the factors surrounding the ankle diagnostic process and decisions about predisposition to lateral ankle sprain injury and any ancillary information returning to dance. in dancers. However, once en pointe that may be germane in arriving at a The severity of ankle injuries is a mediating factor is the stability of diagnosis. Previous history of injury rated based on the results of the the ankle gained through the com- is particularly important because the clinical examination, using a variety pressive locking of the posterior chance of re-injury following ankle of special tests explicitly designed to 43 tibial plafond against the posterior sprain is substantial. assess the integrity of the individual talus and superior calcaneus,38-41 and Inspection (Observation) ligaments. One common method of further supported during dynamic assigning a severity index to ankle movement by the musculotendinous This step is a careful visual analysis of sprains is by grading them 1, 2, or component of stability offered by the the injured area and regions adjacent 3. A grade 1 sprain is a stretching of 42 leg, ankle, and foot musculature. to it. Information is collected regard- a ligament with little or no obvious ing swelling, deformity, discoloration, tissue damage. No instability is noted Acute Assessment of Ankle weightbearing ability, and other Injuries when a stress exam is performed, but observable clues about the type and mild to moderate pain is usually pres- One role of certified athletic train- extent of injury. The contralateral limb ent. A grade 2 sprain involves partial ers—and other healthcare providers is used for comparison. tearing of a ligament; a diagnosis that who have the opportunity to be first Palpation can involve a wide range of damage. responders to a dance injury—is to Some instability is present during the achieve an initial evaluation of an Important details are gained by a ligament stress exam, but the exam- injury prior to pain, swelling, and systematic probing of the injured area iner will feel a definite endpoint. This muscle spasm complicating the task. and surrounding tissues, including restriction is not present in a grade 3 The primary result of this evaluation painful points, abnormal contours, sprain; instead, the exam yields an in- is to determine whether the dancer crepitus, and other clinical signs. The distinct, soft endpoint, which suggests should return to activity, receive on- contralateral limb is again used as a that the substance of the ligament is site treatment, or be transported to reference. completely disrupted. A dancer’s abil- Journal of Dance Medicine & Science • Volume 14, Number 3, 2010 91

Table 2 Ottawa Ankle Rules44,45,47,49 Ankle should be x-rayed if… …the posterior half of the distal 6 cm AND …the patient cannot bear weight for 4 of the fibula or tibia or tip of the lateral steps on the injured limb at the time of malleolus is painful to palpation… injury and at the time of the evaluation (limping is irrelevant) Midfoot should be x-rayed if… …the base of the fifth metatarsal or the AND …the patient cannot bear weight for 4 navicular is painful to palpation… steps on the injured limb at the time of injury and at the time of the evaluation (limping is irrelevant) ity to continue dancing with an acute ankle sprain generally will be related to the severity of the injury. The Ottawa Ankle Rules44, 45 have fundamentally changed ankle injury imaging practices in emergency de- partments and other healthcare set- tings.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. Imple- menting the rules has decreased the need for x-rays and increased health- care 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 Figure 1 According to the Ottawa Ankle Rules, the shaded areas on the medial and not be able to accurately apply the lateral aspects of the ankle and foot are locations that, when painful on palpation and rules to their own ankle injuries.50 accompanied by the inability to walk four steps, suggest the need for x-rays. 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 brac- ing, 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 war- ranted when a significant potential exists for re-injury or further injury. Figure 2 With the heavy emphasis on Horseshoe pads made from 1/4 inch thick foam padding or orthopaedic felt are useful for controlling edema in an acute ankle injury. An elastic bandage or other ensuring evidence-based quality in compressive dressing is used to affix the pads cut to the shapes and applied in the posi- health care, ice has recently come tions shown by the shaded areas. under scrutiny to determine its actual, rather than presumed, effectiveness in for utilizing ice include minimizing as that provided by an elastic bandage, procuring a therapeutic benefit.52-54 edema (swelling) and decreasing the enhances control of edema by increas- Nonetheless, applying ice to the likelihood of secondary cellular hy- ing the tissue pressure in the region injured ankle is helpful for reducing poxic injury57 in the affected region. of the injury. The protrusion of the pain.54-56 Other traditional reasons Circumferential compression, such malleoli in the normal contours of the 92 Volume 14, Number 3, 2010 • Journal of Dance Medicine & Science ankle may prevent the areas anterior towel or belt held in the hands and basic premise of sports medicine is and posterior to the malleoli from passed under the forefoot to pull the that early return to activity following receiving adequate compression by toes upward, and sitting with the ankle sprain is acceptable as long as an elastic bandage. Focal compression foot on the floor and raising just the the risks of re-injury and extended has been shown to hasten return to forefoot off the floor, then from the recovery time are known, accepted, function following ankle sprain more same position raising just the heel. As and ameliorated to the greatest extent readily than simple circumferential progress is made, another important possible. This means that healthcare pressure.58 Horseshoe shaped pads rehabilitative step is proprioceptive professionals must focus on evidence- cut from 1/4 inch foam or orthopae- balancing. Research shows that pro- based care that ensures both effective dic felt and positioned underneath prioceptive ability in dancers decreases restoration of function and safe return the bandage during wrapping (Fig. following ankle injury,67 and that to activity for the injured dancer. 2) alleviate collection of edema in individuals who experience ankle Dance medicine requires modification this area. Elevation of the injured instability from serious or multiple of certain sports medicine principles extremity so the ankle is positioned sprains may exhibit a reduced abil- that facilitate a dancer’s return follow- above the level of the heart promotes ity to balance on the injured limb.68 ing ankle sprain, including consider- a reduction in swelling by assisting Therefore, it is imperative that this ation of the extreme motion required lymphatic drainage.57 Although the component of rehabilitation be initi- of the ankle and costume appearance degree of post-injury swelling is not ated as expeditiously as possible. requirements that often prohibit cus- necessarily correlated with measures of Initially balance training is done tomary methods of care, such as ankle function,59-61 ankle effusion does alter standing on the floor; five one-minute taping and bracing. neuromuscular function in the leg.62‑64 sessions of balancing in the morning The main factors requiring assess- Therefore, it is crucial that dancers and evening is appropriate. Dur- ment as the dancer with an ankle who experience ankle sprains receive ing the early post-injury period, the injury gradually and safely returns to appropriate acute care and follow-up dancer can use the barre for support, activity are pain, swelling, range of treatment. if needed, and keep the eyes open motion, strength, muscle endurance, while balancing. Progression of this agility, proprioception, and psycho- Subacute Care exercise’s difficulty is accomplished logical status. Individual differences The treatment and rehabilitation of by closing the eyes to eliminate vi- in these factors and the demands of an physically active people trying to sual cues while free-standing. More individual’s dance program preclude return to high level activity requires advanced proprioceptive work can this article from providing a single a proactive and creative approach. be achieved by performing the bal- paradigm for determining readiness In dancers, return of function must ancing on a pillow or cushion, floor to return to dance. However, increas- be maximized while duration of trampoline, wobble board, or other ingly complex dynamic movement time away from dance is minimized device that offers a relatively unstable patterns for the lower extremities without introducing unnecessary or surface.69,70 Although proprioceptive are integral to success. The possible unwise risk of re-injury or further function in dancers improves with exercises and available accessories injury, either to the ankle or another training following an ankle sprain,67 for developing physical capacity are body region. The subacute phase of participation in dance is not, by it- virtually unlimited in today’s activity ankle injury care immediately follows self, necessarily related to increased conscious society, but they should the acute phase. If the ankle injury proprioceptive function in the ankle.71 be prescribed with careful attention is not sufficiently severe to require Furthermore, individuals with chronic to their specific contributions to the x-rays, immobilization, crutches, or lateral ankle instability exhibit com- dancer’s rehabilitation. other types of advanced care, a pro- promised balance function,68 as do Generally, a dancer’s physical gram designed to return the individual dancers.72 This underscores the impor- parameters upon return to full class, to dancing should be initiated. This tance of dancers engaging in balance rehearsal, and performance activity involves a progressive advancement rehabilitation. should be at the same level as they of activity to encourage restoration of were prior to the injury. Before return- movement, flexibility, and strength, Care to Expedite Return to ing to unrestricted participation, the along with improving the dancer’s Activity dancer must be able to demonstrate confidence about functioning with Ankle ligaments typically require six proficiency in clinical rehabilitation, the injury. weeks to three months to heal,73,74 functional exercises, and the specific Early motion is essential for ensur- though the return of ligament tissue dance movements to be resumed. A ing a successful return to activity.65,66 to its full strength may be substantially gradual return and appropriate protec- Basic home care exercises include longer.75 It is important to note that tive measures such as taping or bracing gentle pain-free motion by moving a sizeable number of ankle sprains usually are indicated to reduce the the foot in circles, drawing the letters result in persistent symptoms that chance of re-injury. It is helpful if the of the alphabet with the toes, using a include instability and pain.73,74,76 A rehabilitation professional can work Journal of Dance Medicine & Science • Volume 14, Number 3, 2010 93 closely with the injured dancer’s teach- Key Points ers or directors to help ensure smooth re-entry. Dancer Complicating Injuries Ankle injuries, while common, may not be simple and straightforward. Due Lateral ankle sprains can give rise to to the unique demands of dance and the potential for chronic and compli- a chronic impingement syndrome cating injuries, dancers who sustain any ankle injury should seek healthcare secondary to hypertrophic scar tissue assistance when necessary in order to ensure full recovery, rather than trying that forms from the anterior talo- to “dance through” the injury. fibular ligament; the incidence of this Teacher anterolateral ankle impingement has been reported to be between 1.2% When a dancer suffers an ankle injury, the teacher—as a trusted authority— and 3.0%.77-79 Wolin and colleagues80 should ensure that proper care is administered and realize the potential for were the first to describe this, labeling persistent symptoms and complicating injuries that may require follow-up the condition a “meniscoid” lesion care. Items for proper injury care should be kept in a studio or theater first because the fibrotic nature of the aid kit, including elastic bandages, felt horseshoe pads, ice, and ice bags. entity resembles the characteristics of Scientist a knee meniscus. Several other inves- tigators have corroborated that such The high incidence of ankle sprains in dance coupled with a dancer’s need an outgrowth may manifest following for absolutely maximum ankle range of motion suggests that additional sci- a sprain.81-85 Bassett and associates86 entific research is needed to study ankle injury prevention, treatment, and reported on seven cases of chronic rehabilitation specifically in the dance setting. Fatigue and injury seem to be anterior ankle pain and impingement related, as do proprioceptive ability, injury incidence, and injury recurrence. caused by the distal fascicle of the Researchers can make extraordinary contributions to understanding these anteroinferior tibiofibular ligament in and other factors. patients who had suffered an inversion Healthcare Professional ankle sprain, an etiology of enduring anterolateral ankle pain also described An on-site acute evaluation of an ankle injury is the ideal opportunity to by others.87 establish a diagnosis, and proactive early management is crucial to a satisfac- “Dancer’s fracture”88-90 is a spiral tory return to dance participation. A number of lateral ankle sprains will fracture of the distal shaft of the fifth exhibit chronic symptoms that may be related to hypertrophic tissue in the metatarsal. This is usually associated anterolateral aspect. This should be suspected in dancers for whom symptoms with the plantar flexion-inversion persist following an ankle sprain. mechanism of lateral ankle sprain91 when the foot rolls onto its outside border (especially from the demi- the peroneus brevis tendon, fractures who suffer such an injury. Ankle pointe position) when landing after of the medial or lateral malleolus, sprains are a common dance injury, a jump.89 Also associated with the Maisonneuve fracture of the proximal and certain features of these injuries lateral ankle is a fracture of the proxi- fibula, and osteochondral fracture of may become problematic. Early inter- mal portion of the fifth metatarsal at the talar dome. Other injuries associ- vention offers the best opportunity for the junction of the metaphysis and ated with lateral ankle sprains include optimum management and successful, diaphysis. First described by Jones sprain of the dorsal calcaneocuboid safe return to dance. in 1902,92 this is commonly known ligament, cuboid subluxation, and as a Jones fracture and, interestingly, tibiofibular syndesmosis injury. Inju- References Jones reported it after he sustained ries to the Lisfranc joint also must be 1. Fong DT-P, Hong Y, Chan L-K, et al. this fracture himself while dancing. ruled out. A thorough examination A systematic review on ankle injury It typically occurs when the foot is of all ankle injuries is very important and ankle sprain in sports. Sports weightbearing in slight plantar flexion because if any of these conditions are Med. 2007;37(1):73-94. and inversion and is most often seen in overlooked or misdiagnosed the se- 2. Hootman JM, Dick R, Agel J. Epide- 91 miology of collegiate injuries for 15 modern dancers. Dancers with Jones quelae will impair the dancer’s ability sports: summary and recommenda- fractures present challenges, including to return to participation. tions for injury prevention initiatives. delayed union, nonunion, and surgery J Athl Train. 2007;42(2):311-9. 91,93 following failed conservative care. Conclusion 3. Garrick JG. The frequency of injury, A number of additional fracture This article reviewed acute injuries to mechanism of injury, and epidemi- complications that may accompany the ankle and highlighted methods ology of ankle sprains. Am J Sports ankle sprains include avulsion fracture that are useful for evaluation, treat- Med. 1977;5(6):241-2. of the base of the fifth metatarsal by ment, and rehabilitation of dancers 4. Yeung MS, Chan KM, So CH, Yuan 94 Volume 14, Number 3, 2010 • Journal of Dance Medicine & Science

WY. An epidemiological survey 20. Garrick JG. Early identification of Strain in the lateral ligaments of the on ankle sprain. Br J Sports Med. musculoskeletal complaints and in- ankle. Foot Ankle. 1988;9(2):59-63. 1994;28(2):112-6. juries among female ballet students. 35. Bahr R, Pena F, Shine J, et al. Liga- 5. Fitt SS. Dance Kinesiology (2nd ed). J Dance Med Sci. 1999;3(2):80-3. ment force and joint motion in the New York: Schirmer Books, 1996. 21. Luke AC, Kinney SA, D’Hemecourt intact ankle: a cadaveric study. Knee 6. Koutedakis Y, Jamurtas A. The PA, et al. Determinants of injuries in Surg Sports Traumatol Arthrosc. dancer as a performing athlete. young dancers. Med Probl Perform 1998;6:115-21. Sports Med. 2004;34(10):651-61. Art. 2002;17(3):105-12. 36. Colville MR, Marder RA, Boyle JJ, 7. Bronner S, Ojofeitimi S, Rose D. 22. Russell JA, McEwan IM, Koutedakis Zarins B. Strain measurement in Injuries in a modern dance company: Y, Wyon MA. Clinical anatomy and lateral ankle ligaments. Am J Sports effect of comprehensive management biomechanics of the ankle in dance. Med. 1990;18(2):196-200. on injury incidence and time loss. J Dance Med Sci. 2008;12(3):75-82. 37. Makhani JS. Lacerations of the lateral Am J Sports Med. 2003;31(3):365- 23. Attarian DE, McCrackin HJ, DeVito ligaments of the ankle. J Int Coll 73. DP, et al. Biomechanical characteris- Surg. 1962;38(5):454-66. 8. Bronner S, Ojofeitimi S, Spriggs tics of human ankle ligaments. Foot 38. Hamilton WG. Sprained ankles J. Occupational musculoskeletal Ankle. 1985;6(2):54-8. in ballet dancers. Foot Ankle. disorders in dancers. Phys Ther Rev. 24. Siegler S, Block J, Schneck CD. The 1982;3(2):99-102. 2003;8:57-68. mechanical characteristics of the col- 39. Macintyre J, Joy EA. Foot and ankle 9. Byhring S, Bø K. Musculoskel- lateral ligaments of the human ankle injuries in dance. Clin Sports Med. etal injuries in the Norwegian Na- joint. Foot Ankle. 1988;8(5):234-42. 2000;19(2):351-68. tional Ballet: a prospective cohort 25. Bonnin JG. Injuries to the Ankle (fac- 40. Shah S, Luftman J, Vigil DV. Stress study. Scand J Med Sci Sports. simile of the 1950 edition). Darien, injury of the talar dome and body 2002;12(6):365-70. CT: Hafner Publishing Co., 1970. in a ballerina: a case report. J Dance 10. Nilsson C, Leanderson J, Wykman 26. Nigg BM, Skarvan G, Frank CB, Med Sci. 2005;9(3):91-5. A, Strender L. The injury panorama Yeadon MR. Elongation and forces 41. O’Loughlin PF, Hodgkins CW, in a Swedish professional ballet com- of ankle ligaments in a physiologi- Kennedy JG. Ankle sprains and pany. Knee Surg Sports Traumatol cal range of motion. Foot Ankle. instability in dancers. Clin Sports Arthrosc. 2001;9(4):242-6. 1990;11(1):30-40. Med. 2008;27(2):247-62. 11. Kerr G, Krasnow D, Mainswaring 27. Anderson KJ, LeCocq JF. Operative 42. Clippinger K. Dance Anatomy and L. The nature of dance injuries. Med treatment of injury to the fibular col- Kinesiology. Champaign, IL: Human Probl Perform Art. 1992;7:25-9. lateral ligament of the ankle. J Bone Kinetics, 2007. 12. Washington EL. Musculoskeletal Joint Surg Am. 1954;36(4):825-32. 43. Holme E, Magnusson SP, Becher K, injuries in theatrical dancers: site, 28. Ferran NA, Maffulli N. Epidemiol- et al. The effect of supervised reha- frequency, and severity. Am J Sports ogy of sprains of the lateral ankle bilitation on strength, postural sway, Med. 1978;6(2):75-98. ligament complex. Foot Ankle Clin position sense and re-injury risk after 13. Bowling A. Injuries to dancers: preva- N Am. 2006;11(3):659-62. acute ankle ligament sprain. Scand J lence, treatment and perception of 29. Foetisch CA, Ferkel RD. Deltoid Med Sci Sports. 1999;9(2):104-9. causes. BMJ. 1989;298:731-4. ligament injuries: anatomy, diag- 44. Stiell IG, Greenberg GH, McKnight 14. Laws H. Fit to Dance 2. London: nosis, and treatment. Sports Med RD, et al. A study to develop clinical Dance UK, 2005. Arthrosc. 2000;8:326-35. decision rules for the use of radiog- 15. Sohl P, Bowling A. Injuries to danc- 30. Koutedakis Y, Khaloula M, Pacy PJ, raphy in acute ankle injuries. Ann ers: prevalence, treatment and pre- et al. Thigh peak torques and lower- Emerg Med. 1992;21(4):384-90. vention. Sports Med. 1990;9(5):17- body injuries in dancers. J Dance 45. Stiell IG, McKnight RD, Green- 22. Med Sci. 1997;1(1):12-5. berg GH, et al. Implementation 16. Rovere GD, Webb LX, Gristina AG, 31. Delahunt E, Monaghan K, Caul- of the Ottawa ankle rules. JAMA. Vogel JM. Musculoskeletal injuries field B. Changes in lower limb 1994;271(11):827-32. in theatrical dance students. Am J kinematics, kinetics, and muscle 46. Bachmann LM, Kolb E, Koller MT, Sports Med. 1983;11(4):195-8. activity in subjects with functional et al. Accuracy of Ottawa ankle rules 17. Garrick JG, Requa R. Ballet injuries: instability of the ankle joint during to exclude fractures of the ankle and an analysis of epidemiology and fi- a single leg drop jump. J Orthop Res. mid-foot: systematic review. BMJ. nancial outcome. Am J Sports Med. 2006;24(10):1991-2000. 2003;326(7386):417-23. 1993;21(4):586-90. 32. Friel K, McLean N, Myers C, Caceres 47. Nugent PL. Ottawa ankle rules ac- 18. Arendt YD, Kerschbaumer F. Injury M. Ipsilateral hip abductor weakness curately assess injuries and reduce and overuse pattern in professional after inversion ankle sprain. J Athl reliance on radiographs. J Fam Pract. ballet dancers [German]. Z Orthop Train. 2006;41(1):74-8. 2004;53(10):785-8. Ihre Grenzgeb. 2003;141(3):349-56. 33. Gribble PA, Robinson RH. An 48. Leddy JJ, Smolinski RJ, Lawrence J, 19. Liederbach M, Dilgen FE, Rose examination of ankle, knee, and et al. Prospective evaluation of the DJ. Incidence of anterior cruciate hip torque production in individu- Ottawa Ankle Rules in a university ligament injuries among elite bal- als with chronic ankle instability. J sports medicine center: with a modi- let and modern dancers: a 5-year Strength Cond Res. 2009;23(2):395- fication to increase specificity for prospective study. Am J Sports Med. 400. identifying malleolar fractures. Am 2008;36(9):1779-88. 34. Renstrom P, Wertz M, Incavo S, et al. J Sports Med. 1998;26(2):158-65. Journal of Dance Medicine & Science • Volume 14, Number 3, 2010 95

49. Leddy JJ, Kesari A, Smolinski RJ. Ther. 2001;31(7):384-8. 73. Hubbard TJ, Kaminski TW, Vander Implementation of the Ottawa ankle 62. Hall RC, Nyland J, Nitz AJ, et al. Re- Griend RA, Kovaleski JE. Quan- rules in a university sports medi- lationship between ankle invertor H- titative assessment of mechanical cine center. Med Sci Sports Exerc. reflexes and acute swelling induced laxity in the functionally unsta- 2002;34(1):57-62. by inversion ankle sprain. J Orthop ble ankle. Med Sci Sports Exerc. 50. Blackham JEJ, Claridge T, Benger JR. Sports Phys Ther. 1999;29(6):339- 2004;36(5):760-6. Can patients apply the Ottawa ankle 44. 74. Aiken AB, Pelland L, Brison R, et al. rules to themselves? Emerg Med J. 63. Hopkins JT, Palmieri R. Effects Short-term natural recovery of ankle 2008;25(11):750-1. of ankle joint effusion on lower sprains following discharge from 51. Flegel MJ. Sport First Aid (4th ed). leg function. Clin J Sport Med. emergency departments. J Orthop Champaign, IL: Human Kinetics, 2004;14(1):1-7. Sports Phys Ther. 2008;38(9):566- 2008. 64. Palmieri RM, Ingersoll CD, Hoff- 71. 52. Bleakley C, McDonough S, Ma- man MA, et al. Arthrogenic mus- 75. Houglum PA. Soft tissue healing and cAuley D. The use of ice in the cle response to a simulated ankle its impact on rehabilitation. J Sport treatment of acute soft-tissue injury: joint effusion. Br J Sports Med. Rehabil. 1992;1(1):19-39. a systematic review of randomized 2004;38(1):26-30. 76. van Rijn RM, van Os AG, Bernsen controlled trials. Am J Sports Med. 65. Eiff MP, Smith AT, Smith GE. RMD, et al. What is the clinical 2004;32(1):251-61. Early mobilization versus immobi- course of acute ankle sprains? A sys- 53. Collins NC. Is ice right? Does cryo- lization in the treatment of lateral tematic literature review. Am J Med. therapy improve outcome for acute ankle sprains. Am J Sports Med. 2008;121(4):324-31. soft tissue injury? Emerg Med J. 1994;22(1):83-8. 77. DeBerardino TM, Arciero RA, 2008;25(2):65-8. 66. Glasoe WM, Allen MK, Awtry BF, Taylor D. Arthroscopic treatment 54. Hubbard TJ, Denegar CR. Does Yack HJ. Weight-bearing immobili- of soft-tissue impingement of the cryotherapy improve outcomes zation and early exercise treatment ankle in athletes. Arthroscopy. with soft tissue injury? J Athl Train. following a grade II lateral ankle 1997;13(4):492-8. 2004;39(3):278-9. sprain. J Orthop Sports Phys Ther. 78. Ferkel RD, Karzel RP, Del Pizzo W, 55. Algafly AA, George KP. The effect 1999;29(7):394-9. et al. Arthroscopic treatment of an- of cryotherapy on nerve conduc- 67. Leanderson J, Eriksson E, Nilsson C, terolateral impingement of the ankle. tion velocity, pain threshold and Wykman A. Proprioception in classi- Am J Sports Med. 1991;19(5):440-6. pain tolerance. Br J Sports Med. cal ballet dancers: a prospective study 79. Umans HR. Ankle impingement syn- 2007;41(6):365-9. of the influence of an ankle sprain dromes. Semin Musculoskel Radiol. 56. Bleakley CM, McDonough SM, Ma- on proprioception in the ankle joint. 2002;6(2):133-9. cAuley DC, Bjordal J. Cryotherapy Am J Sports Med. 1996;24(3):370-4. 80. Wolin I, Glassman F, Sideman S, for acute ankle sprains: a randomised 68. Hiller CE, Refshauge KM, Herbert Levinthal D. Internal derangement controlled study of two different RD, Kilbreath SL. Balance and of the talofibular component of icing protocols. Br J Sports Med. recovery from a perturbation are the ankle. Surg Gynecol Obstet. 2006;40(8):700-5. impaired in people with functional 1950;91(2):193-200. 57. Dale RB, Harrelson GL, Leaver- ankle instability. Clin J Sport Med. 81. Kim S-H, Ha K-I. Arthroscopic Dunn D. Principles of rehabilitation. 2007;17(4):269-75. treatment for impingement of the In: Andrews JR, Harrelson GL, Wilk 69. Mulligan EP. Leg, ankle, and foot the anterolateral soft tissues of KE (eds): Physical Rehabilitation of rehabilitation. In: Andrews JR, Har- the ankle. J Bone Joint Surg Br. the Injured Athlete (3rd ed). Philadel- relson GL, Wilk KE, (eds): Physical 2000;82(7):1019-21. phia: Saunders 2004, pp. 157-188. Rehabilitation of the Injured Athlete 82. Liu SH, Raskin A, Osti L, et al. Ar- 58. Wilkerson GB, Horn-Kingery (3rd ed). Philadelphia: Saunders throscopic treatment of anterolateral HM. Treatment of the inversion 2004, pp. 157-188. ankle impingement. Arthroscopy. ankle sprain: comparison of dif- 70. Kidgell DJ, Horvath DM, Jackson 1994;10(2):215-8. ferent modes of compression and BM, Seymour PJ. Effect of six weeks 83. Meislin RJ, Rose DJ, Parisien S, cryotherapy. J Orthop Sports Phys of Dura disc and mini-trampoline Springer S. Arthroscopic treatment of Ther. 1993;17(5):240-6. balance training on postural sway synovial impingement of the ankle. 59. Makwana NK, Evans PA, Finlay DB, in athletes with functional ankle Am J Sports Med. 1993;21(2):186-9. Harper WM. Ankle effusions follow- instability. J Strength Cond Res. 84. Liu SH, Nuccion SL, Finerman ing acute ankle injury. Eur J Emerg 2007;21(2):466-9. G. Diagnosis of anterolateral ankle Med. 1999;6(3):223-6. 71. Schmitt H, Kuni B, Sabo D. Influ- impingement: comparison between 60. Man IO, Morrissey MC. Relation- ence of professional dance training magnetic resonance imaging and ship between ankle-foot swelling on peak torque and proprioception clinical examination. Am J Sports and self-assessed function after at the ankle. Clin J Sport Med. Med. 1997;25(3):389-93. ankle sprain. Med Sci Sports Exerc. 2005;15(5):331-9. 85. Ürgüden M, Söyüncü Y, Özdemir 2005;37(3):360-3. 72. Hiller CE, Refshauge KM, Beard H, et al. Arthroscopic treatment of 61. Pugia ML, Middel CJ, Seward SW, DJ. Sensorimotor control is im- anterolateral soft tissue impingement et al. Comparison of acute swelling paired in dancers with functional of the ankle: evaluation of factors and function in subjects with lateral ankle instability. Am J Sports Med. affecting outcome. Arthroscopy. ankle injury. J Orthop Sports Phys 2004;32(1):216-22. 2005;21(3):317-22. 96 Volume 14, Number 3, 2010 • Journal of Dance Medicine & Science

86. Bassett FH III, Gates HS III, Billys juries in dancers. Clin Sports Med. fractures in dancers. Clin Sports JB, et al. Talar impingement by the 1988;7(1):143-73. Med. 2008;27(2):295-304. anteroinferior tibiofibular ligament. J 89. O’Malley MJ, Hamilton WG, Mun- 92. Jones R. Fracture of the base of the Bone Joint Surg Am. 1990;72(1):55- yak J. Fractures of the distal shaft of fifth metatarsal bone by indirect 9. the fifth metatarsal: dancer’s fracture. violence. Ann Surg. 1902;35(6):697- 87. Akseki D, Pinar H, Yaldiz K, et al. Am J Sports Med. 1996;24(2):240-3. 700. The anterior inferior tibiofibular 90. Kadel NJ. Foot and ankle injuries 93. Nunley JA. Fractures of the base ligament and talar impingement: a in dance. Phys Med Rehabil Clin N of the fifth metatarsal: the Jones cadaveric study. Knee Surg Sports Am. 2006;17(4):813-26. fracture. Orthop Clin N Am. Traumatol Arthrosc. 2002;10:321-6. 91. Goulart M, O’Malley MJ, Hodgkins 2001;32(1):171-80. 88. Hamilton WG. Foot and ankle in- CW, Charlton TP. Foot and ankle