Foot and Ankle Surgery 16 (2010) 4549

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Foot and Ankle Surgery

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Overuse ankle injuries in professional Irish dancers

R.J. Walls MB, MRCSI, MFSEMa,*, S.A. Brennan MB, MRCSIa, P. Hodnett MB, MRCPI, FFRb, J.M. OByrne MCh, FRCSI, FRCS (Tr. & Ortho.), FFSEMa, S.J. Eustace MB, MRCPI, FFR, FRCR, FFSEMb, M.M. Stephens MSc (Bioeng), FRCSIa
a b

Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland

A R T I C L E I N F O

A B S T R A C T

Article history: Received 15 December 2008 Received in revised form 29 April 2009 Accepted 3 May 2009 Keywords: Overuse injury Ankle Irish dancers Magnetic resonance imaging

Background: Overuse ankle injuries have been described in elite athletes and professional ballet dancers however the spectrum of injuries experienced by professional Irish dancers has not been dened. Methods: A troupe of actively performing dancers from an Irish-dance show were recruited (eight male, ten female; mean age, 26 years). The prevalence of overuse injuries in the right ankle was determined from magnetic resonance imaging. Foot and ankle self-report questionnaires were also completed (AOFAS and FAOS). Results: Only three ankles were considered radiologically normal. Achilles tendinopathy, usually insertional, was the most frequent observation (n = 14) followed by plantar fasciitis (n = 7), bone oedema (n = 2) and calcaneocuboid joint degeneration (n = 2). There were limited correlations between MRI patterns and clinical scores indicating that many conditions are sub-clinical. Dancers with ankle pain had poor low (p = 0.004) and high (p = 0.013) level function. Conclusions: Overuse ankle injuries are common in Irish dancers. Incorporating eccentric exercises and plantar fascia stretching into a regular training program may benet this population. 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction Overuse injuries of the foot and ankle have been frequently reported in athletes and professional dancers. Commonly described conditions include Achilles tendinopathy, plantar fasciitis, peroneal, tibialis posterior and exor hallucis longus tendon injury, metatarsalgia, calcaneal apophysitis, ankle impingement, bone oedema, and stress fractures [16]. Nilsson et al. found the foot and ankle to be the most common region of injury in a cohort of 98 ballet dancers with overuse accounting for 6065% [5]. Most injuries were minor and permitted them to continue performing, although at a somewhat restricted level. Modern dancers have similar rates of injuries affecting the foot and ankle with the majority also due to overuse [1]. Irish dancing has recently become prominent as an international dance-form. As well as rehearsing regularly, professional Irish dancers typically perform eight shows per week, participating in several high intensity routines during a 2 h performance. Given

that Irish dance incorporates components akin to tap dance and ballet, we would expect a similar spectrum of injury. Our principle objective was to assess the ankles of professional Irish dancers using magnetic resonance imaging (MRI) to determine the prevalence and patterns of bone and soft tissue injuries. Ankle specic scoring instruments provided information regarding symptomology. 2. Methods 2.1. Patients A complete troupe of actively performing professional Irish dancers were recruited from an international touring Irish-dance show. Participants received individual counselling before enrolment to ensure they understood the nature of the study after which written informed consent was obtained. The local ethics review committee gave full approval for this study. The cohort consisted of 18 subjects (eight male, ten female; mean age, 26 years; range, 2132) with only the right ankle specically evaluated. As part of a routine warm-up and in addition to individual cardio-respiratory preparation, the dancers participate in a 15 min group stretching program approximately 45 min before each show.

* Corresponding author at: Professorial Unit, Cappagh National Orthopaedic Hospital, Dublin 11, Ireland. Tel.: +353 87 2963651; fax: +353 1 4419405. E-mail address: raywalls1@hotmail.com (R.J. Walls).

1268-7731/$ see front matter 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.05.003

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R.J. Walls et al. / Foot and Ankle Surgery 16 (2010) 4549 Table 1 Baseline characteristics of subjects grouped according to the presence of ankle pain. Group No ankle pain Number of subjects Age (years) Gender (M:F) Age values are means SD. 8 26.6 2.9 4:4 Ankle pain 10 25.2 2.9 4:6

2.2. Radiological evaluation A Gyroscan Intera 1.5T MRI scanner (Philips Medical Systems, Holland) was used to image the right hindfoot and ankle. Subjects were positioned supine with an extremity coil placed around the foot and ankle. The protocol involved coronal and sagittal STIR (TR/ TE/T1 = 1500/12/160) sequences. Slice thickness was 3 mm with a 0.3 mm slice gap. Images were produced with a eld of view of 200 mm (256 256 pixel matrix). Two musculoskeletal radiologists, blinded to subject symptomology, examined the images for the presence of ligamentous, osseus, tendinous and cartilage abnormalities. 2.3. Clinical evaluation Individual perception of disability was assessed with two ankle specic questionnaires. These were completed by all dancers prior to imaging. The American Orthopaedic Foot and Ankle Society (AOFAS) score is a clinical rating system developed for conditions of the ankle and hindfoot [7]. It consists of subjective and objective components to describe function, alignment and pain producing overall scores from 0 to 100 (worst to best, respectively). We used the AOFAS pain scale to dene ankle pain over the preceding 4 weeks: none, mild, moderate, and severe. The Foot and Ankle Outcome Score (FAOS) is a 42 item subjective questionnaire subcategorised into pain, symptoms, function in activities of daily living (ADL), function in sports (Sports), and quality of life (QoL) [8]. Each subscale is normalised so that scores of 0 and 100 represent extreme symptoms and no symptoms, respectively. 2.4. Statistical analysis Statistical tests were performed using the Statistical Package for Social Sciences version 15.0 (SPSS, Inc., Chicago, IL). Subjects were divided into those with or without ankle pain and between group comparisons performed using the MannWhitney test. The relation between selected parameters was determined using Spearmans rho correlations. A two by two Pearsons Chi Square test evaluated the relation between MRI patterns and ankle pain. Statistical signicance was set at p = 0.05.

3. Results 3.1. Ankle pain Eight subjects reported no ankle pain during the preceding 4 weeks. Mild pain was reported by nine subjects and moderate pain by one. Both groups (ankle pain versus no ankle pain) were similar with respect to age (p = 0.179) and gender (p = 0.680) (see Table 1). 3.2. Radiographic patterns of injury Despite having normal imaging, two of three cases reported ankle pain (see Table 2). Four ankles had one radiological abnormality while the remainder (11 ankles) were found to have 2 abnormalities. Achilles tendinopathy was the most common radiographic nding. It was seen in 14 ankles of which 12 were insertional (see Fig. 1) and two non-insertional (see Fig. 2). Subjects with noninsertional Achilles tendinopathy did not report ankle pain. Seven of the 12 cases with insertional tendinopathy reported ankle pain. With the numbers available, there was no gender difference found in the prevalence of Achilles tendinopathy (p = 0.192). Inammation of the plantar fascial attachment (plantar fasciitis) (see Fig. 3) was seen in seven ankles; three of these cases did not report ankle pain. Achilles tendinopathy was also noted in all cases of plantar fasciitis (r2 = 0.181, p = 0.039). Degeneration of the calcaneocuboid joint was found in two dancers. This was associated with impaction bone oedema in subject six (see Fig. 4) who reported moderate ankle pain. One further dancer (subject 18) had evidence of mild bone oedema along the margin of the posterior subtalar joint. This subject did

Table 2 Magnetic resonance imaging patterns found in the ankles of professional Irish dancers. Subject number Age Gender Ankle pain Magnetic resonance imaging patterns Normal imaging No No No No No No No Yes Yes Yes No No No No No No No No Achilles tendinopathy NonInsert NonInsert Insert Insert Insert No Insert No No No Insert Insert Insert Insert Insert Insert Insert Insert Plantar fasciitis No Yes No Yes Yes No Yes No No No Yes Yes Yes No No No No No Bone oedema Additional abnormalities

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

30 29 25 23 28 23 23 27 28 32 24 21 25 26 23 28 26 24

Male Male Male Male Male Male Male Male Female Female Female Female Female Female Female Female Female Female

None None Mild Mild None Moderate Mild None Mild Mild Mild None Mild Mild Mild None None None

No No No No No Yes calcaneocuboid No No No No No No No No No No No Yes talus

Degeneration at the calcaneocuboid joint Nil Nil Nil Nil Degeneration at the calcaneocuboid joint Nil Nil Nil Nil Nil Nil Nil Traction inammation of the interosseus ligament Nil Nil Tibiotalar joint effusion/retrocalcaneal bursitis Tibiotalar joint effusion

NonInsert: non-insertional Achilles tendinopathy; Insert: insertional Achilles tendinopathy.

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Fig. 1. Insertional Achilles tendinopathy (Subject 4). Thickening of the Achilles tendon at its insertion.

Fig. 3. Inammatory change at the plantar fascial insertion (Subject 4).

not report ankle pain. Small effusions of the tibiotalar joint were seen in two ankles although neither was associated with pain. There were no signicant associations between ankle pain and individual MRI radiographic abnormalities. 3.3. Clinical outcome measures When the dancers were grouped according to the presence or absence of ankle pain, those with no pain reported signicantly

better function in activities of daily living (p = 0.004), function in sports (p = 0.013) and superior quality of life scores (p = 0.011) compared to those with ankle pain (see Table 3). When individual MRI patterns were correlated with the outcome scores, only a moderate inverse association between bone oedema and the FAOS symptoms subscale was determined (r2 = 0.215, p = 0.026). In particular, there were no signicant associations found with Achilles tendinopathy or plantar fasciitis.

Fig. 2. Non-insertional Achilles tendinopathy (Subject 2). Thickening at the midportion of the Achilles tendon.

Fig. 4. Mild arthritic changes at the calcaneocuboid articulation with associated subarticular impaction bone oedema of the cuboid (Subject 6).

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Table 3 Clinical scoresdifferences between groups with and without ankle pain. Scale Group No ankle pain AOFAS FAOS pain FAOS symptoms FAOS ADL FAOS sports FAOS QoL 98.9 3.1 98.3 3.3 87.5 11.0 99.4 1.6 95.6 6.8 92.2 11.0 Ankle pain 87.7 5.6 82.2 12.0 72.1 10.6 89.6 13.8 82.5 12.5 74.4 13.0 0.000 0.001 0.020 0.004 0.013 0.011 p value

Values are means SD; AOFAS, American Orthopaedic Foot and Ankle Society score; FAOS, Foot and Ankle Outcome Score; ADL, function in activities of daily living; Sports: function in sports; QoL, quality of life.

4. Discussion This is the rst study to determine the prevalence of overuse ankle injuries in professional Irish dancers. Approximately 80% demonstrated at least one radiological abnormality with Achilles tendinopathy the most common injury. Plantar fasciitis, bone oedema, degeneration of the calcaneocuboid joint and tibiotalar joint effusions were also seen. Since almost half the cohort had no ankle pain, many conditions were considered sub-clinical. Three quarters of the dance troupe had Achilles tendinopathy which was insertional in the majority of cases. In contrast, Fernandez-Palazzi et al. reported 19 cases of Achilles tendinopathy in 13 ballet dancers of which only four were insertional [9]. Rates for elite runners are somewhat comparable at 57% although again non-insertional tendinopathy is generally more common [3]. Chronic Achilles tendinopathy is considered a degenerative rather than inammatory process in response to repetitive microtrauma [9,10]. Irish dancers land from jumps on the forefoot with the knee extended and ankle plantar-exed during which up to six times their body weight is transmitted [11]. They also perform on their toe-tips and metatarsal heads, analogous to enpointe and demi-pointe in ballet, during which the Achilles tendon is kept tightened. In addition, some dancers may have to force pronation in order to keep their feet turned out. Ankle pronation contributes to the onset of Achilles injury, as can muscle imbalance, tight heel cords, a small or thin tendon mass, hindfoot valgus, and pes cavus with associated haglunds disease [4,9,12]. Maganaris et al. proposed a theory of stress-shielding for insertional tendinopathy since lower rather than higher strains are often found at sites were pathological changes occurs [13]. Certain joint positions result in a lack of tensile loading producing focal atrophy and degeneration. Other positions may subsequently stress an already weakened tendon causing injury. The requirement for greater ranges of ankle motion with alternating positions of relative stress may explain the higher rates of insertional tendinopathy seen in Irish dancers. Additional extrinsic factors such as footwear and types of performance surface must be considered. The dancers in this study performed in a touring show with the stage elevated on a cushioned platform. This should reduce the incidence of injury by providing shock absorption. The soft shoes (pumps) worn by female dancers are laced tightly around the ankle. This method of shoe-fastening has been implicated in the pathogenesis of Achilles tendinopathy [4]. Progressive eccentric loading can improve tendon vascularity and collagen synthesis, and effectively alleviated symptoms in elite athletes and normal individuals with insertional and noninsertional Achilles tendinopathy [1417]. The psyche of elite dancers, driving them to succeed, is associated with overuse injuries [18]. As such they often perform despite the presence of a chronic injury, since prolonged rest periods have consequences for tness, exibility, technical skill and nancial loss. Silbernagel

et al. incorporated eccentric exercises into the training regime of professional soccer players with Achilles tendinopathy [19]. This improved clinical symptoms and permitted them to continue playing. Logically, such a program should be applicable to Irish dancers. Refractory cases may benet from low-energy shock-wave therapy, immobilisation in an ankle brace and taping [9,20,21]. Periods of rest with activity modication may have to be enforced if these measures fail. Repeated local injection with corticosteroids or sclerosants should be avoided as the consequences on tendon weakening or rupture have not been fully dened [9,12,22]. While various operative procedures are described their application must be considered carefully to ensure preservation of a dancers career [12,23,24]. Plantar fasciitis was seen in 37% of ankles. This is much greater than levels reported in athletes (813%) [3,6]. Messier et al. found ankle plantarexion of more than 60 degrees to predispose to injury in runners [25]. While not measured clinically, Irish dancers would be expected to obtain high degrees of plantar-exion in order to keep the toes pointed-down. Other precipitants include excessive hindfoot motion and greater ankle pronation, as well as hamstring and Achilles tendon inexibility [2528]. The aims of rehabilitation are to restore normal muscle strength and exibility, thereby facilitating the windlass mechanism [28]. Treatment generally involves rest, anti-inammatories, heel cord and plantar fascia stretching, intrinsic muscle and tibialis posterior strengthening, Achilles tendon and hamstring stretching and prefabricated arch supports [2,28]. Local corticosteroid injection may be considered for recalcitrant cases. Regular stretching of the plantar fascia can be preventative, aided by rolling the plantar aspect of the foot over a small ball placed on the ground while weightbearing [29]. There are other notable differences between this cohort of Irish dancers and previous studies on ballet dancers. We found no injuries of exor hallucis longus. This contrasts with ballet where such an injury is common [5]. Even though both dance forms require performance on the toe-tips and metatarsal heads as well as repetitive forefoot push off, the en-pointe position is not sustained in Irish dancing to the same extent, and may explain this difference. Bone injury was an uncommon overuse injury, seen in only two ankles of Irish dancers. Conversely, a recent study found 75% of ballet dancers to have bone oedema in the talus [30]. This difference is surprising. Irish dancing involves jig-shoe routines, comparable with tap dance, with high impact forces recurrently transmitted across the ankle joint. We would therefore have expected a similar if not greater occurrence of bone injury in Irish dancers. Despite their low prevalence, a jig-shoe that incorporates a shock-absorbing sole may further prevent bone injury. The AOFAS and FAOS scoring instruments were used to assess subjective symptoms. However neither correlated strongly with any radiographic abnormality. This can be explained by the high proportion of dancers who reported no ankle pain indicating subclinical pathology. For example, approximately 50% of cases of Achilles tendinopathy in this study were pain free. Similar preclinical changes have been previously reported in ballet dancers as well as professional and recreational athletes [12,31]. Maffulli et al. have cited caution when interpreting radiographic abnormalities of the Achilles tendon, stressing the need to relate ndings to specic patient symptoms [32]. A limitation of this study was that a detailed clinical examination was not performed. Therefore it is not possible to determine if ankle pain was attributable to a single pathology, especially when more than one was present on imaging. This is most evident in cases with plantar fasciitis where Achilles tendinopathy was always a concomitant nding. Accordingly, the rates of symptomatic conditions may be lower. Further study should specically evaluate Achilles tendinopathy in Irish dancers

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where management outcomes can be evaluated by focused clinical examination, graded radiological assessments and disease-specic scoring instruments. Despite the relatively small study cohort, all members of a dance troupe from an international Irish-dance show were recruited and none withdrew from the study. We therefore consider these results to be reective of the spectrum of ankle injuries typical in professional Irish dancers performing at an elite level. In conclusion, overuse injuries are common in professional Irish dancers with Achilles tendinopathy and plantar fasciitis the most frequent abnormalities. Given that Irish dancers land from jumps with an extended knee and plantarexed ankle, as well as frequently performing on their top tips and metatarsal heads, they are predisposed to recurrent stresses causing injury. We recommend that eccentric loading exercises and intrinsic muscle strengthening combined with stretching of the hamstrings, plantar fascia and gastrosoleus complex should be mandatory as an integral part of a training program for Irish dancers. Female dancers must avoid over-tightening their shoe-laces around the ankle to reduce the prevalence of Achilles tendinopathy. Consideration should be given to modifying the jig-shoe with a shockabsorbing tap heel to reduce bone injury and including a heel counter to provide a cushion for the Achilles tendon. Conict of interest statement There were no conicts of interest (nancial or otherwise) of any researcher involved in this study. No funds were received in support of this study. References
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