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Ankle Sprains in Dancers Interview with Dr William G. Hamilton by Peter Lewton-Brain For this article I had the great pleasure to speak to Dr. William G. Hamilton, consulting orthopedic surgeon to New York City Ballet and American Ballet Theatre (among others), about his perspectives on evaluating and treating ankle sprains in dancers. Q: In the literature, ankle sprains are regarded as one of the most common injuries in dancers. Do you also find this to be true? WGH: Ankle sprains are extremely common even in the general population, with one sprain per 10,000 people every day. They are one of the most frequent injuries in dance. The word sprain refers to an injury to a ligament, while a strain is an injured muscle or tendon. Ligaments are particularly important for dancing because they control movement of the joint. When an ankle sprain happens, a ligament is stretched and results in a partial or complete tear. Symptoms associated with ankle sprains include swelling, bruising, and pain with weight bearing. Typically, ankle sprains occur when the foot is inverted. The dancer may fall inward from pointe, demi-pointe or when landing from a jump. This overstretches the outer, or lateral, ligaments. About 90% of ankle sprains are inversion injuries. The dancer usually feels pain on the outside of the ankle, except in rare cases when there is additional damage on the inside of the ankle. Q: I have never forgotten your description of grading ankle sprains at a lecture you gave at an IADMS meeting as "not so loose," a "little loose" and "loose as a goose," corresponding to Grade I, II, and III sprains. Can you expound on these concepts for grading ankle sprains? WGH: The severity of the symptoms tends to correlate with the extent of damage to the ligaments, but not always. Ankle sprains fall into the following three categories: The Grade I or “not so loose" ankle sprain comes from over-stretching the ligaments with only minor damage. There is pain and swelling but a minimal “drawer sign” when you test the ankle joint for looseness. Most dancers can walk without crutches, but they may not be able to relevé or jump. The Grade II ankle sprain is more severe with a partial tear of the ligaments. There is usually more significant swelling and bruising caused by bleeding under the skin. Dancers often can only take a few steps and cannot do pliés because of the pain. The drawer test gives you a slightly loose feeling compared to the normal ankle. The Grade III ankle sprain is a major injury with complete tears of the ligaments and gross instability. The ankle is usually quite painful and even walking can be difficult or impossible. The dancer may complain that the ankle joint feels like it gives way. Meanwhile, the drawer sign is “loose as a goose.” This injury is rare. As I have already mentioned, pain and swelling are the most common symptoms of an ankle sprain. The bruising initially occurs over the site of injury. Over the next few days, gravity pulls the blood downwards, causing the bruising to move towards the foot and toes. This process can be alleviated somewhat by elevation. It is important to be aware that significant swelling does not always correspond to the severity of the sprain. Even with a minor sprain, a blood vessel can be torn and give a grapefruit appearance to the ankle, especially if the dancer continued to work with it after the injury. Also, there can be a severe sprain (Grade III) or even a high ankle sprain without much swelling. The latter injury affects the syndesmosis ligaments above the ankle and will take much longer to heal. Q: Do dancers need to see a doctor if they have an ankle sprain? WGH: If they have significant symptoms following a sprained ankle, they should seek medical attention. Signs that should raise concern include: Inability to walk on the ankle or bear weight, significant swelling, gross distortion of the normal anatomy, and symptoms that do not improve quickly or persist beyond a few days of home treatment. If there is pain in the foot or above the ankle, differentiating between a sprained ankle and an undisplaced ankle fracture can be difficult. This may require an x-ray. While moderate pain and swelling are common symptoms following a simple sprained ankle, symptoms such as inability to bear weight, distortion in the appearance of the ankle, numbness in the toes, or pain that is unusual should raise concern. If dancers think they might have more than a sprained ankle, they should definitely seek medical attention. An accurate diagnosis is crucial for implementing a correct treatment plan. Q: At what point do you consider surgery and what are the general outcomes for dancers? WGH: Surgical treatment for acute ankle sprains is usually not needed. For the Grade I, II, and III injuries, we prescribe RICE [Rest, Ice, Compression, Elevation], an air splint or CAM walker with physical therapy, and weight bearing as tolerated (WBAT). We do not use cast immobilization even in Grade III sprains because the muscles atrophy. Most ankle sprains have an excellent outcome if they are treated and rehabilitated correctly the first time around. Surgical treatment (the Modified Bröstrom procedure) is used to correct chronic instability later, if it is needed. Q: What do you think is the underlying factor that causes so much long-term difficulty for dancers following an ankle sprain? WGH: We call those “the sprains that won’t heal,” and the common symptoms are pain, swelling, and chronic instability. These symptoms can come from a multitude of different causes and last a long time. They include: The sinus tarsi syndrome (soft tissue entrapment); FHL [flexor hallucis longus] tendonitis; OCD [osteochondritis dessicans], or damage to the ankle bone; and aggravation of a tarsal coalition where two bones are joined. Other important factors are peroneal weakness in the tendons that run down the outside of the ankle, rotary instability in the joints, posterior impingement that causes pain in the back of the ankle, and Shepherd’s fracture of the posterior ankle bone, to name a few. Be aware that peroneal weakness can come from trauma, tendon damage, and even neurological causes. It is also important to look for subtle Charcot- Marie-Tooth disease (CMT), a congenital disorder comprised of skinny legs, high arches, and rolled-in heels that make dancers prone to repeated sprains. Q: Have you found that female dancers are more at risk due to pointe work? WGH: I’m not sure. There are more sprains in female dancers, but there are more female dancers in the companies than male dancers. Dancers with hypermobile ankles have an increased risk for sprains. In any case, be aware of the hypermobile ankle in any gender. Q: Have you found the contemporary/modern dancers more or less prone to ankle sprains? WGH: There appears to be fewer hypermobile ankles in contemporary dancers, so less likelihood of ankle sprains, but anyone can have one. It is usually just bad luck or fatigue. Q: What advice would you give to a medical practitioner when treating a dancer following an ankle sprain? WGH: After taking all the factors into consideration to get a precise diagnosis, they should remind performers not to try to dance themselves back into shape, but to get in shape first and then dance! They must also continue to work with their rehab team to regain peroneal strength before returning to a full dance schedule. Q: In conclusion, do you have any other special considerations that you think are especially important to keep in mind with the dancer’s ankle sprain? WGH: Look at the whole dancer, including body and foot type, workload, lifestyle, personal stresses, etc. Ankle sprains must be taken seriously, as they can have lasting influences on the ability to dance if they are not treated both mechanically and functionally. Always remember, “The dancer who treats himself or herself has a fool for a doctor.” Submitted by Peter Lewton-Brain RICE method for the treatment of ankle sprains: Rest: The first 24–48 hours after the injury is a critical treatment period when activities need to be curtailed. Weight is gradually added to the injured ankle as tolerated. Crutches are discontinued when the dancer can walk with a normal gait (with minimal pain or limp). Ice: Post-injury, the dancer elevates his or her ankle and should use ice packs twenty minutes every 3–4 hours for the first 48 hours. The ice pack can be a bag of frozen vegetables (peas or corn) wrapped in a cloth to prevent frostbite. Another popular treatment method is to fill a paper cup with water, freeze it and massage the injury peeling away paper as the ice melts. Do NOT ice an ankle sprain for more than 20 minutes at a time! It will not make the ankle sprain heal any faster, and it can cause damage to the tissues! Compression: Wrap the ankle with an ACE bandage from the toes to mid-calf, overlapping the elastic wrap by one-half of the width of the wrap until the swelling has subsided. The wrap should be snug, but not cut off circulation to the foot and ankle. If the foot becomes cold, blue or falls asleep, re-wrap a bit less tight! Elevation: Keep the ankle sprain higher than the heart as often as possible for the first few days. At night sleep with the foot on top of one or two pillows. More severe ankle sprain injuries, including complete tears of the ligaments and fractures of the bone, may need different treatments than a simple ankle sprain, such as a cast immobilization. A doctor's visit is necessary before treatment for serious sprains or if symptoms do not steadily improve over time.
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