Publications

BACKGROUND: Ballet dancers require extreme range of motion of the ankle, especially weight-bearing maximum plantar flexion (en pointe). In spite of a high prevalence of foot and ankle injuries in ballet dancers, the anatomy and pathoanatomy of this position have not been sufficiently studied in weight-bearing. Magnetic resonance imaging (MRI) is a beneficial method for such study.

PURPOSE: To develop an MRI method of evaluating the ankles of female ballet dancers standing en pointe and to assess whether pathological findings from the MR images were associated with ankle pain reported by the subjects.

MATERIAL AND METHODS: Nine female ballet dancers (age, 21+/-2.9 years; dance experience, 16+/-4.1 years; en pointe dance experience, 7+/-4.9 years) completed an ankle pain visual analog scale questionnaire and underwent T1- and T2-weighted scans using a 0.25 T open MRI device. The ankle was scanned in three positions: supine with full plantar flexion, standing with the ankle in anatomical position, and standing en pointe.

RESULTS: Obtaining MR images of the ballet dancers en pointe was successful in spite of limitations imposed by the difficulty of remaining motionless in the en pointe position during scanning. MRI signs of ankle pathology and anatomical variants were observed. Convergence of the posterior edge of the tibial plafond, posterior talus, and superior calcaneus was noted in 100% of cases. Widened anterior joint congruity and synovitis/joint effusion were present in 71% and 67%, respectively. Anterior tibial and/or talar spurs and Stieda's process were each seen in 44%. However, clinical signs did not always correlate with pain reported by the subjects.

CONCLUSION: This study successfully established an ankle imaging technique for ballet dancers en pointe that can be used in the future to assess the relationship between en pointe positioning and ankle pathoanatomy in ballet dancers.

Dance is a high performance athletic activity that leads to great numbers of injuries, particularly in the ankle region. One reason for this is the extreme range of ankle motion required of dancers, especially females in classical ballet where the en pointe and demi-pointe positions are common. These positions of maximal plantar flexion produce excessive force on the posterior ankle and may result in impingement, pain, and disability. Os trigonum and protruding lateral talar process are two common and well-documented morphological variations associated with posterior ankle impingement in ballet dancers. Other less well-known conditions, of both bony and soft tissue origins, can also elicit symptoms. This article reviews the anatomical causes of posterior ankle impingement that commonly affect ballet dancers with a view to equipping healthcare professionals for improved effectiveness in diagnosing and treating this pathology in a unique type of athlete.

Female ballet dancers require extreme ankle motion, especially plantar flexion, but research about measuring such motion is lacking. The purposes of this study were to determine in a sample of ballet dancers whether non-weight-bearing ankle range of motion is significantly different from the weight-bearing equivalent and whether inclinometric plantar flexion measurement is a suitable substitute for standard plantar flexion goniometry. Fifteen female ballet dancers (5 university, 5 vocational, and 5 professional dancers; age 21 ± 3.0 years) volunteered. Subjects received 5 assessments on 1 ankle: non-weight-bearing goniometry dorsiflexion (NDF) and plantar flexion (NPF), weight-bearing goniometry in the ballet positions demi-plié (WDF) and en pointe (WPF), and non-weight-bearing plantar flexion inclinometry (IPF). Mean NDF was significantly lower than WDF (17° ± 1.3° vs 30° ± 1.8°, P < .001). NPF (77° ± 2.5°) was significantly lower than both WPF (83° ± 2.2°, P = .01) and IPF (89° ± 1.6°, P < .001), and WPF was significantly lower than IPF (P = .013). Dorsiflexion tended to decrease and plantar flexion tended to increase with increasing ballet proficiency. The authors conclude that assessment of extreme ankle motion in female ballet dancers is challenging, and goniometry and inclinometry appear to measure plantar flexion differently.

The ankle is an important joint to understand in the context of dance because it is the connection between the leg and the foot that establishes lower extremity stability. Its function coordinates with the leg and foot and, thus, it is crucial to the dancer's ability to perform. Furthermore, the ankle is one of the most commonly injured body regions in dance. An understanding of ankle anatomy and biomechanics is not only important for healthcare providers working with dancers, but for dance scientists, dance instructors, and dancers themselves. The bony architecture, the soft tissue restraints, and the locomotive structures all integrate to allow the athletic artistry of dance. Yet, there is still much research to be carried out in order to more completely understand the ankle of the dancer.

To evaluate the effectiveness of closed wound drainage in shoulder surgery, 300 patients were enrolled in a prospective randomized study. Three operations were studied: rotator cuff repair, anterior reconstruction for instability, and arthroplasty. One hundred patients were included in each group. All patients were evaluated for wound hematoma, infection, variation in postoperative rehabilitation caused by wound problems, and length of hospital stay. No statistical difference was found between the patients whose wounds were drained and those whose wounds were not drained. This finding existed within each category. Our data do not support the routine use of closed wound drainage in elective shoulder surgery.

One hundred consecutive Biomet modular shoulder arthroplasties were studied prospectively and were evaluated with a minimum 2-year follow-up (average 41 months). Fifty-seven women and 43 men with an average age of 64 years were evaluated for pain, activities of daily living, range of motion, cost, and complications. Fourteen patients had undergone previous surgery to the shoulder. Seventy patients underwent total shoulder arthroplasty, and thirty underwent hemiarthroplasty. Pain and range of motion demonstrated statistically significant improvement. Eight activities of daily living were rated on a 0 to 3 scale, and all were significantly improved. Complications were noted in 18 patients and included urinary retention, pulmonary embolus, rotator cuff tear, titanium synovitis, subluxation, and dislocation. Twelve shoulders underwent secondary procedures for rotator cuff repair, open reduction, and component revision for instability. Lucent lines were present in 62.5% of glenoids, 92.3% of cemented stems, and 0% of cementless stems on postoperative radiographs. No patients underwent revision surgery for component loosening, and no cases of humeral head-stem dissociation were seen. Ninety-five shoulders were rated by the patients as improved, and five were made worse.

This article describes a study that assesses whether patients who received ketorolac tromethamine (Toradol; Syntex Research, Palo Alto, California) during knee surgery had an increased tendency to develop ecchymosis in the lower limb versus patients who did not receive ketorolac tromethamine. Sixty-four patients who underwent anterior cruciate ligament (ACL) surgery were divided randomly into three groups: patients who received Toradol at tourniquet inflation (TorTourn) at the end of surgery (TorEnd), or not at all (TorNone). None of the patients exhibited abnormal preoperative bleeding times. One week postsurgery, patients were evaluated photographically for ecchymosis between the hip and malleoli of the surgical limb. Ecchymotic areas between the hip and malleoli were traced around their borders with a black marker. Three photographs of each surgical knee were taken: posterior, anterolateral, and anteromedial views. Each patient's photos then were scanned into a computer and the amount of encircled (ecchymotic) surface area and the total surface area of the limb were calculated. For each view, the ecchymotic surface area was divided by the total surface area to obtain a percentage of ecchymosis on that view. The percentages for the three views were added to obtain a single score for each patient. The mean ecchymotic surface area score was 21.9 +/- 31% for the TorTourn group, 27.5 +/- 25.5% for the TorEnd group, and 30.3 +/- 36.4% for the TorNone group. There was no significant difference in the ecchymotic surface area among the groups. This study suggests that ketorolac tromethamine does not affect the amount of ecchymosis that occurs following knee surgery.

Evaluation of the reliability of musculoskeletal testing equipment is an important step in establishing the usefulness of an assessment device's data. The purposes of this study were to determine the reliability of a specific upper body OmniTron testing protocol and to estimate reliabilities for several other protocols in order to determine the optimal one. After upper body warm-up, 32 subjects (22 men, 10 women; mean age = 20.7 +/- 2.6 years) were tested on the Hydra-Fitness OmniTron chest press (CP) and upper back pull (BP) exercise at a slow speed and high resistance. Peak force, work, and power values were obtained for each subject during a protocol consisting of two test sessions of four repetitions each, with an intervening 5-minute rest period. The first repetition of each test session was considered a warm-up, and data from these were discarded. A repeated measures ANOVA was conducted on the main effects (tests and repetitions), and a generalizability analysis was performed. Mean peak force output values were significantly higher (p < .0001) during the second test session (Test 1 CP = 654.9 +/- 167.5 N, Test 2 CP = 690.0 +/- 179.1 N; Test 1 BP = 547.5 +/- 139.0 N, Test 2 BP = 568.2 +/- 153.9 N), possibly indicating the presence of a learning effect. Work and power data showed similar trends, as peak force, work, and power were highly correlated with one another (r >/= .90). Reliability of the protocol was estimated for the peak force data of CP and BP. The coefficients were .993 and .985, respectively. Generalizability forecasting for alternate protocols demonstrated that for both CP and BP, a minimum of two tests of at least three repetitions each were necessary for optimum reliability, although all evaluated combinations exhibited high reliability (r >/= .949). This study suggests that the two test session/three repetition protocol (four repetitions, including the initial discarded one) with a 5-minute rest is highly reliable and may be desirable for use with subjects being tested for the first time in order to counteract a possible learning effect. The clinician may also choose another protocol shown to be reliable by this investigation. J Orthop Sports Phys Ther 1992;16(2):87-91.