Lower Extremity Injury Patterns in Elite Ballet Dancers: Ultrasound/MRI Imaging Features and an Institutional Overview of Therapeutic Ultrasound Guided Percutaneous Interventions.
ABSTRACT: Altered biomechanics from repetitive microtrauma, such as long practice hours in en pointe (tip of the toes) or demi pointe (balls of the feet) predispose ballet dancers to a multitude of musculoskeletal pathologies particularly in the lower extremities. Both ultrasound and magnetic resonance imaging (MRI) are radiation-sparing modalities which can be used to confidently evaluate these injuries, with ultrasound (US) offering the added utility of therapeutic intervention at the same time in experienced hands.The purposes of this paper were: (1) to illustrate the US and MRI features of lower extremity injury patterns in ballet dancers, focusing on pathologies commonly encountered at a single orthopedic hospital; (2) to present complementary roles of both ultrasound and MRI in the evaluation of these injuries whenever possible; (3) to review and present our institutional approach towards therapeutic ultrasound-guided interventions by presenting explicit cases.Online searches were performed using the search criteria of "ballet biomechanics" and "ballet injuries." The results were then further narrowed down by limiting articles published in the past 15 years, modality (US and MRI), anatomical region (foot and ankle, hip and knee) and to major radiology, orthopedics, and sports medicine journals.Performing ballet poses major stress to lower extremities and predisposes dancer to several musculoskeletal injuries. These can be adequately evaluated by both US and MRI. US is useful for evaluating superficial structures such as soft tissues, tendons, and ligaments, particularly in the foot and ankle. MRI provides superior resolution of deeper structures such as joints, bone marrow, and cartilage. In addition, US can be used as a therapeutic tool for providing quick symptomatic improvement in these athletes for who "time is money".Performing ballet may cause major stress to the lower extremities, predominantly affecting the foot and ankle, followed by the knee and hip. US and MRI play complementary roles in evaluating various orthopedic conditions in ballet dancers, with US allowing for dynamic evaluation and guidance for interventions.
Project description:Introduction:Dance-related injuries have become a field of great interest to researchers, with the most commonly reported injuries being those sustained by ballet dancers. However, there is a lack of research into injuries sustained by those who perform modern and hip-hop dance. Methods:A systematic literature review using the MEDLINE research database was performed and a search carried out for full-text studies that investigate injuries in modern and hip-hop dance. Results:While a total of 74 hits were obtained from various searches, only nine studies were included in the systematic literature review. Six of them examined modern dancers, two examined break dancers and one examined hip-hop dancers. The results show that hip-hop dancers (and especially break dancers) sustain more injuries in comparison to modern dancers. The most common injuries are in the lower extremities, with studies revealing that overuse injuries occur in up to 71% of cases. Conclusions:The injury incidence rate in hip-hop dance seems to be higher compared to modern dance, chiefly because of the more demanding biomechanics involved and the dance techniques employed. Prevention management can have a positive effect on the number of injuries.
Project description:In spite of the high rate of overuse injuries in ballet dancers, no studies have investigated the prevalence of overuse injuries in professional dancers by providing specific diagnoses and details on the differences in the injuries sustained as a function of age and/or years of professional practice.Overuse injuries are the most prevalent injuries in ballet dancers. Professional ballet dancers suffer different types of injuries depending on their age and years of professional practice.Descriptive epidemiology study.This descriptive epidemiological study was carried out between January 1, 2005, and October 10, 2010, regarding injuries sustained by professional dancers belonging to the major Spanish ballet companies practicing classical, neoclassical, contemporary, and Spanish dance. The sample was distributed into 3 different groups according to age and years of professional practice. Data were obtained from the specialized medical care the dancers received from the Trauma and Orthopaedic Surgery Service at Fremap in Madrid. The dependent variable was the study of the injury.A total of 486 injuries were identified over the study period, with overuse injuries being the most common etiology (P < .0001); these injuries were especially prevalent in junior professional dancers practicing classical ballet and veteran dancers practicing contemporary ballet (P = .01). Specifically, among other findings, stress fractures of the base of the second metatarsal (P = .03), patellofemoral syndrome, and os trigonum syndrome were more prevalent among junior professionals (P = .04); chondral injury of the knee in senior professionals (P = .04); and cervical disc disease in dancers of intermediate age and level of experience.Overall, overuse injuries were more prevalent in younger professionals, especially in women. This finding was especially true for the more technical ballet disciplines. On the other hand, in the athletic ballet disciplines, overuse lesions occurred mainly in the more senior professionals.This study provides specific clinical diagnoses obtained through physical examination as well as details on the different injury types sustained as a function of age and/or years of professional practice, an important aspect for ballet and sports practice in general.
Project description:Professional ballet is a highly challenging art, but studies have rarely examined factors associated with injury status in ballet professionals. This study aimed to prospectively examine gender-specific correlates of injury occurrence and time-off from injury in professional ballet dancers over a one-year period. The participants were 99 professional ballet dancers (41 males and 58 females). Variables included: (i) predictors: sociodemographic data (age, educational status), ballet-related factors (i.e., experience in ballet, ballet status), cigarette smoking, alcohol drinking, and consumption of illicit drugs; and (ii) outcomes: injury occurrence and time-off from injury. Participants were questioned on predictors at the beginning of the season, while data on outcomes were collected continuously once per month over the study period. Dancers reported total of 196 injuries (1.9 injuries (95% CI: 1.6⁻2.3) per dancer in average), corresponding to 1.4 injuries per 1000 dance-hours (95% CI: 1.1⁻1.7). In females, cigarette smoking was a predictor of injury occurrence in females (OR: 4.33, 95% CI: 1.05⁻17.85). Alcohol drinking was a risk factor for absence from dance in females (OR: 1.29, 95% CI: 1.01⁻4.21) and males (OR: 1.21, 95% CI: 1.05⁻3.41). Less experienced dancers were more absent from dance as a result of injury than their more experienced peers (Mann-Whitney Z: 2.02, p < 0.04). Ballet dancers and their managers should be aware of the findings of this study to make informed decisions on their behavior (dancers) or to initiate specific programs aimed at the prevention of substance use and misuse in this profession (managers).
Project description:The turnout of the lower extremities is the major component of the classical ballet positions (CPs) and correctly is initiated in the hips. The aim of this research was to determine the differences in the electromyographic and kinematic variables in the five CPs in ballet students with greater and lesser amount of passive hip external rotation (HER). A group of 14 female pre-professional ballet dancers 11-16 years of age participated in the study. Based on the amount of passive HER, participants with higher values made up greater rotation group (n = 7) whereas those with lesser values formed lesser rotation group (n = 7). Electromyographic activity of 14 muscles from right side of the trunk and right lower extremity was recorded with the surface electrodes while subjects were standing in all five CPs (CP1-CP5). The external rotation of the hips, knees and feet were recorded with the motion capture system. The kinematic differences between the groups were revealed in asymmetric positions CP4 and CP5 where foot progression angle was significantly lesser in forward than backward setting only in lesser rotation group. In lesser rotation group the ankle and back muscles were more engaged in CPs while abdominal and hip muscles less when compared with greater rotation group. This finding suggests that in the group with lesser passive HER the mechanism of forced turnout was employed. The most remarkable finding in our work was that various electromyographic patterns can be observed between groups in all CPs, while kinematic differences may be marked only in asymmetric positions.
Project description:Background:During ballet, injuries to the Achilles tendon are associated with the take-off phase of various jumps. Research question:The purpose of the study was to assess differences in mechanical demand on the body, specifically at the ankle, in two single-leg jumps commonly trained in ballet: a saut de chat (SDC) and a temps levé (TL). Methods:Fifteen classically trained female dancers had 16 reflective markers placed on the lower body and each dancer performed each jump three times on a force plate. The marker position data and ground reaction forces (GRF) were captured synchronously at 250 Hz and 1000 Hz, respectively. Peak vertical GRF, mean rate of force development (RFD), peak ankle moment, and peak ankle power were determined and averaged across trials. Paired t-tests were used to determine differences between the SDC and the TL. Results:When compared to the TL, the SDC displayed significantly higher peak vertical GRF (p = 0.003), RFD (p = 0.002), and peak ankle moment and power (p < 0.001). The effect sizes for these differences were large for all variables (Cohen's d > 0.80). Conclusion:The mechanical demand at the ankle joint is significantly greater for the SDC than the TL.
Project description:Overall performance, particularly in a very popular sports activity such as running, is typically influenced by the status of the musculoskeletal system and the level of training and conditioning of the biological structures. Any change in the musculoskeletal system's biomechanics, especially in the feet and ankles, will strongly influence the biomechanics of runners, possibly predisposing them to injuries. A thorough understanding of the effects of a therapeutic approach focused on feet biomechanics, on strength and functionality of lower limb muscles will contribute to the adoption of more effective therapeutic and preventive strategies for runners.A randomized, prospective controlled and parallel trial with blind assessment is designed to study the effects of a "ground-up" therapeutic approach focused on the foot-ankle complex as it relates to the incidence of running-related injuries in the lower limbs. One hundred and eleven (111) healthy long-distance runners will be randomly assigned to either a control (CG) or intervention (IG) group. IG runners will participate in a therapeutic exercise protocol for the foot-ankle for 8 weeks, with 1 directly supervised session and 3 remotely supervised sessions per week. After the 8-week period, IG runners will keep exercising for the remaining 10 months of the study, supervised only by web-enabled software three times a week. At baseline, 2 months, 4 months and 12 months, all runners will be assessed for running-related injuries (primary outcome), time for the occurrence of the first injury, foot health and functionality, muscle trophism, intrinsic foot muscle strength, dynamic foot arch strain and lower-limb biomechanics during walking and running (secondary outcomes).This is the first randomized clinical trial protocol to assess the effect of an exercise protocol that was designed specifically for the foot-and-ankle complex on running-related injuries to the lower limbs of long-distance runners. We intend to show that the proposed protocol is an innovative and effective approach to decreasing the incidence of injuries. We also expect a lengthening in the time of occurrence of the first injury, an improvement in foot function, an increase in foot muscle mass and strength and beneficial biomechanical changes while running and walking after a year of exercising.Clinicaltrials.gov Identifier NCT02306148 (November 28, 2014) under the name "Effects of Foot Strengthening on the Prevalence of Injuries in Long Distance Runners". Committee of Ethics in Research of the School of Medicine of the University of Sao Paulo (18/03/2015, Protocol # 031/15).
Project description:Objectives:The user experience, content and conditions for use of an online dance-health surveillance system (Performing artist and Athlete Health Monitor, PAHM) was examined through a focus group interview with professional ballet dancers. Methods:Nine professional dancers (56% female (n=5), average age=27.56± 5.17) completed biweekly questionnaires using the PAHM, including questions on health problems, injuries, mental complaints and illnesses. After 6?weeks, nine dancers participated in a focus group interview to investigate the user experience, content and conditions for use of the PAHM. Data were analysed using thematic analysis. Results:25 of the 27 questionnaires were completed (response rate of 93%). Dancers were positive about using the PAHM. They recommend to clarifying the questions about pain and injury, expanding items on mental health, including items on workload, sleep, rest and nutrition, and receiving feedback regarding their own results. Dancers were reluctant regarding sharing their personal data with others. Data on an aggregated level can be shared because this might gain insight into the association between scheduling, workload and injury risk. Conclusion:The user experience of the monitor contributes to the willingness of dancers to keep using the PAHM. Dancers recommended adjusting the content in the PAHM to match their dance activities and health problems. The conditions for using the PAHM effectively within a company are a safe and trusting culture. Even though the PAHM alone cannot change the culture in a ballet company, it can play a role in the communication between staff and dancers.
Project description:Tenosynovitis of the flexor hallucis longus tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. It mostly involves the portion of the tendon behind the ankle joint. However, the portion of the tendon under the sustentaculum tali can also be involved. Open synovectomy requires extensive dissection. We report the technique of arthroscopic synovectomy of the deep portion of the flexor hallucis longus.
Project description:Ballet training has been reported to positively influence balance ability. It is not entirely clear how improved balance ability manifests under standing conditions with different demands on postural control. The aim of the study was to compare balance of ballet dancers and non-dancers in a unipedal stance under different conditions. Twenty-five professional ballet dancers and twenty-five controls completed four unipedal standing balance tests: firm surface with eyes open and closed; foam mat surface with eyes open; and firm surface with eyes open immediately after performing ten 360° whole-body turns. The centre of pressure (COP) data were obtained with a force platform and the direction-specific standard deviations, velocities, and sample entropy of the COP displacement were computed. A three-way analysis of variance was used to compare groups, genders, and conditions. For standing immediately after performing ten turns, the postural sway parameters were significantly larger in the control group compared to the ballet dancers in both men and women. In this stance condition the values of postural sway and COP velocities in the control group were larger in the men compared to the women. For both genders in the control group all postural sway and COP velocity parameters were larger in standing with eyes closed and standing after performing 10 turns compared to standing with eyes open on both firm and foam surface. In the ballet dancers all COP velocity parameters were larger in standing with eyes closed compared to all other conditions. The results from the present study indicate that professional ballet dancers do not have a better general balance ability than untrained subjects.
Project description:Background and Objectives: Flexor hallucis longus pathology is one of the most common conditions of the ankle and foot in dancers, due to the high demand of dance movements performed in an extreme plantar flexion and dorsiflexion range of motion. The objectives of this study were to determine the bilateral differences between the thickness and cross-sectional area of the flexor hallucis longus muscle in dancers, to establish possible differences between dance modalities, and to analyze whether there is a correlation between ultrasonographic parameters or performance variables and the dance modality. Material and Methods: A sample of 50 (29 classical and 21 contemporary) full-time pre-professional female dancers were included in the study. The thickness and cross-sectional area of the flexor hallucis longus muscle were evaluated for both limbs using ultrasound imaging. The range of movement of the first metatarsophalangeal joint was measured using functional extension with maximal ankle plantarflexion, balance was measured in a unilateral stance with the heel raised, endurance was evaluated through a modified heel rise fatigue test, and a counter movement jump to assess the vertical jump performance was measured bilaterally. Results: There were no significant differences recorded between the dominant and non-dominant limbs for each variable, within both groups. Contemporary dancers showed a greater thickness and cross-sectional area of the flexor hallucis longus muscle than classical dancers. However, classical dancers showed an increase of balance, endurance, range of movement of the first metatarsophalangeal joint, and counter movement jump with respect to contemporary dancers. Conclusion: Bilateral symmetry was identified in all variables for both groups. The size and performance of the flexor hallucis longus muscle may be influenced by the specific nature of dance modality.