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
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.