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.