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Pathoanatomy of Posterior Ankle Impingement in Ballet Dancers
Clinical Anatomy
Abstract
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.
... The foot, which serves as the support surface, is a complex structure comprising multiple joints that change shape flexibly or rigidly depending on functional demands [5]. In non-dancers, the range of motion of each foot joint is generally not large; in comparison, dancers' foot joints are characterized by hypermobility and are reportedly responsible for approximately 30% of the range of motion during maximum ankle plantarflexion (PF) [6,7]. These findings suggest that it is important for dancers to stabilize their foot joints to minimize postural sway during tiptoe standing. ...
... In contrast, most COP variables in dancers did not change with increasing ankle PF angle, and COP-Area was rather lower in the 60 • than 20 • task. This may be attributable to the fact that dancers often perform tiptoe standing at nearly maximum PF joint angle [6,7], i.e., balance training has a highly task-specific effect [24,25]. Theoretically, as the ankle PF angle increases, the tibia (i.e., the long axis of the lower leg) and the metatarsal (i.e., the long axis of the foot) become closer to vertical and the moment arm of the ground reaction force on the ankle joint (i.e., the talocrural joint and several foot joints) becomes smaller. ...
... Interestingly, correlation analysis in dancers revealed that EMG-CV time was strongly correlated with COP-Velocity only in the 60 • task. This may be attributable to the aforementioned task specificity [24,25], in which dancers' PIFM activity is most clearly reflected by their performance at the closest angle they often practice [6,7]. This strong correlation specific to the highest angle (60 • ) in dancers, together with the clearly lower EMG-CV time (i.e., more stable activity) in dancers than in non-dancers, provides novel evidence that PIFM activity is involved and is likely to play an important role in achieving less postural sway during tiptoe standing in dancers. ...
... The foot, which serves as the support surface, is a complex structure comprising multiple joints that change shape flexibly or rigidly depending on functional demands [5]. In non-dancers, the range of motion of each foot joint is generally not large; in comparison, dancers' foot joints are characterized by hypermobility and are reportedly responsible for approximately 30% of the range of motion during maximum ankle plantarflexion (PF) [6,7]. These findings suggest that it is important for dancers to stabilize their foot joints to minimize postural sway during tiptoe standing. ...
... In contrast, most COP variables in dancers did not change with increasing ankle PF angle, and COP-Area was rather lower in the 60 • than 20 • task. This may be attributable to the fact that dancers often perform tiptoe standing at nearly maximum PF joint angle [6,7], i.e., balance training has a highly task-specific effect [24,25]. Theoretically, as the ankle PF angle increases, the tibia (i.e., the long axis of the lower leg) and the metatarsal (i.e., the long axis of the foot) become closer to vertical and the moment arm of the ground reaction force on the ankle joint (i.e., the talocrural joint and several foot joints) becomes smaller. ...
... Interestingly, correlation analysis in dancers revealed that EMG-CV time was strongly correlated with COP-Velocity only in the 60 • task. This may be attributable to the aforementioned task specificity [24,25], in which dancers' PIFM activity is most clearly reflected by their performance at the closest angle they often practice [6,7]. This strong correlation specific to the highest angle (60 • ) in dancers, together with the clearly lower EMG-CV time (i.e., more stable activity) in dancers than in non-dancers, provides novel evidence that PIFM activity is involved and is likely to play an important role in achieving less postural sway during tiptoe standing in dancers. ...
... The acute or chronic fractures of SP are relatively unusual lesions, and they give rise to malunion and early degenerative changes in patients with SP (Nyska et al. 1998). SP fractures may Page 2 of 11 Ogut Bulletin of the National Research Centre (2022) 46:280 occur due to tension forces created by fibers of the PTFL, tibial compression, or avulsion fractures (Russell et al. 2010). There are contributing mechanisms for nonavulsion fractures in the literature. ...
... There are contributing mechanisms for nonavulsion fractures in the literature. These are a gradual detachment of the lateral tubercle caused by repetitive plantar flexion or traumatic sudden plantar flexion of the foot (Russell et al. 2010). The profile of SP fractures is similar to that of an ankle sprain (Moore and Harger 2018), and it can be misdiagnosed as a sprain or mistaken for a standard variant and affects the management of the patient. ...
... SP fractures are frequently caused by excessive inversion or plantar flexion(Judd and Kim 2002;Moore and Harger 2018;Paulos et al. 1983), which can occur in athletes when running or during plantar flexion of the foot(Berkowitz and Kim 2005;Bureau et al. 2000). It can form a posterior block to plantar flexion when the distal end of the tibia rests against it in forced plantar flexion(Russell et al. 2010). ...
Background
The Stieda process (SP) is an extended lateral tubercle of the posterior process of the talus. Although there are different classifications for SP in the literature, it is essential to know the differential diagnosis of SP from fractures and accessory ossicles. This review aims to classify the SP and to guide the formation, prevalence, etiopathology, symptoms, differential diagnosis, and treatment.
Main body of the abstract
The authors conducted a literature review that lasted up to September 2022 and used the databases PubMed, Web of Science, and Google Scholar to explore the SP of the talus in all of its aspects. Out of 3802 publications, only 34 could be included, and most of them were studies on posterior ankle impingement syndrome (PAIS). The occurrence, prevalence, etiopathology, clinical significance, symptoms, differential diagnosis, and treatment methods of SP were investigated based on the literature. SP is formed by the fusion of a secondary ossification center at the posterolateral side of the talus with an incidence of 12–36.5%. It is frequently observed in males. It causes reduced plantar flexion, impairment in the inversion of the foot, pain, and swelling in the posterior ankle joint, PAIS, and SP fractures after trauma.
Short conclusion
SP can be diagnosed by lateral ankle radiography or MRI in patients complaining of PAIS. The initial treatment of the SP should include reducing inflammation, swelling, pain, and limiting activities. If neither modality affects the patient, surgical treatment will be performed, and SP will be resected until the impingement disappears.
... It is predominantly seen in ballet dancers and soccer and basketball players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing en pointe or demi-pointe or while doing push-off maneuvers. 27,36 Open and arthroscopic techniques have been used as effective methods in the treatment of PAIS and hindfoot. Advantages of arthroscopic intervention when compared to open procedures have been described in multiple joints and include decreased morbidity, reduced scarring and trauma to the surrounding tissues, and early rehabilitation, recovery, and return to daily and sporting activities. ...
... 26,33,45 Apart from ballet dancers, other sports with an inherent risk of OT syndrome include soccer, cricket, downhill running or walking, running or sprinting, swimming, and sports involving kicking. 15,36,40 Ankle overuse or acute trauma can lead to a fracture of the Stieda process (posterior process fracture of the talus), 5 cartilaginous synchondrosis disruption, os trigonum fracture, or an avulsion injury of the posterior talofibular ligament. ...
... Physical examination reveals posterolateral tenderness on palpation, typically between the Achilles and peroneal tendons. 5,36 Passive maximal plantarflexion may reproduce the patient's symptoms. Os trigonum syndrome often coexists with FHL tenosynovitis in the same patient population. ...
Background
The os trigonum (OT)—the most common accessory bone of the foot—although usually asymptomatic, may cause posterior ankle impingement syndrome (PAIS), which may be a severely debilitating problem for recreational or competitive athletes. The aim of the present study was to evaluate effectiveness of posterior ankle arthroscopy and to assess the outcome in the treatment of PAIS secondary to OT impingement or OT fractures within a group of young athletes and their return to previous sports level.
Methods
From 2011 to 2018, a retrospective review of 81 recreational athletes of mean age 27.8 years was performed. All patients were diagnosed with PAIS due to OT pathology and were operated on endoscopically with resection of the OT. Pre- and postoperative clinical evaluation were performed at 3 months, 1 year, and 2 years based on visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the Foot & Ankle Disability Index (FADI) scores, in a follow-up of at least 2 years.
Results
VAS score was significantly improved from an average of 7.5 (5-9) preoperatively to 1.9 (1-3) at 3 months postoperatively and to 0.6 (0-2) and 0.3 (0 -1) at 1 and 2 years postoperatively. Ankle ROM was significantly improved from an average of 24.8 (10-35) preoperatively to 58.0 (50-65) at 3 months postoperatively and to 64.0 (50-65) at 1 year and 64.7 (60-65) at 2 years postoperatively. AOFAS and FADI scores were significantly improved from 39.4 (18-55) and 49.7 (42.3-62.5) preoperatively to 85.2 (74-89) and 87.3 (81.7-88.5) postoperatively at 3 months to 97.7 (85-100) and 97.9 (93.3-100) postoperatively at 1 year, respectively ( P < .001). Only 5 patients dropped to a lower activity level. There were 5 complications (4 transient).
Conclusion
Endoscopic treatment of PAIS due to OT pathology demonstrated excellent results. Posterior ankle arthroscopy was an effective treatment and allowed for a prompt return to a high activity level of their athletic performance.
Level of Evidence
Level IV, therapeutic study / retrospective case series.
... Posterior ankle impingement syndrome (PAIS) is a common cause of posterior ankle pain that has been classically described in ballet dancers and soccer players [1][2][3][4] . It is caused by mechanical pinching of bony or soft tissue structures during terminal plantar-flexion in the posterior part of the ankle [1][2][3][4][5] . ...
... Posterior ankle impingement syndrome (PAIS) is a common cause of posterior ankle pain that has been classically described in ballet dancers and soccer players [1][2][3][4] . It is caused by mechanical pinching of bony or soft tissue structures during terminal plantar-flexion in the posterior part of the ankle [1][2][3][4][5] . Even though it can present acutely, PAIS more commonly presents with chronic pain secondary to repetitive stresses in the posterior ankle with forced plantar-flexion activities. ...
... Posterior ankle impingement syndrome has been well-described in the literature, particularly in dancers and soccer players [1,2,4] . PAIS is due to the mechanical pinching of structures in the posterior ankle, which may be secondary to bony or soft tissue causes, or a combination of both [1,2] . ...
Background:
Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.
Aim:
To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.
Methods:
This descriptive prospective study at a tertiary children's hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.
Results:
35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).
Conclusion:
This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.
... 2,3 While the presence of an os trigonum increases the risk of symptom development, a considerable disease list, which has been previously described elsewhere in great detail, contributes to PAIS. [3][4][5][6] Some examples include osteophyte formation, thickened joint capsule and surrounding ligaments, additional accessory ossicles, fracture or syndesmotic injury, and accessory soft tissue components. As such, the syndrome is synonymous with several terms, including posterior talar compression syndrome, os trigonum syndrome, posterior ankle block, nutcracker-type impingement, and posterior tibiotalar impingement syndrome. ...
... As such, the syndrome is synonymous with several terms, including posterior talar compression syndrome, os trigonum syndrome, posterior ankle block, nutcracker-type impingement, and posterior tibiotalar impingement syndrome. 5 More generally, the pathologic contributors can be categorized as either osseous or soft tissue, and, when affected, may all contribute to pain in hyper-plantarflexion. 6 The presence of an os trigonum is a relatively common occurrence in the general population, with an estimated prevalence of nine to 25% in normal feet and ankles, often observed bilaterally. [7][8][9] Typically, it is asymptomatic in the non-sporting population. ...
... The en-pointe and demi-pointe positions seen in ballet dancers have been proposed as a potential contributor to the high incidence of PAIS in this population, particularly as this highly repetitive forced plantar flexion is practiced during skeletal maturation. 6,14 In a biomechanical study of soccer players, the degree of plantar flexion during ball strike exceeded that which was reproducible with passive clinical assessment, suggesting a consistent, repeatable compression of the posterior tibiotalar structures. 30 Rogers describes the mechanism of horizontal jumping athletes, who transition their running momentum into take-off foot in a rapid (40-70ms) compressive-based plantar flexion movement, during which time upwards of 10-15 times body weight is applied through the lead leg in maximal plantarflexion. ...
Introduction:
Os trigonum syndrome is a relatively uncommon condition, resulting from compression of a congenital bony anomaly (os trigonum) and adjacent soft tissues during repetitive hyper-plantarflexion. This condition is currently well-described in ballet, soccer, and running athletes, but few cases exist describing os trigonum syndrome in overhead athletes.
Case presentation:
A 22-year-old national level male javelin athlete presented with a recalcitrant history of posterior ankle pain following a hyper-plantarflexion mechanism. Imaging demonstrated a symptomatic os trigonum and inflammation of surrounding soft tissues. Re-aggravation following a conservative trial of care led to orthopaedic referral. Surgical excision of the os trigonum was performed with an open posterolateral approach. The athlete returned to competition three months later with no recurrence of symptoms.
Summary:
This case discusses the clinical presentation, imaging, and management of a symptomatic os trigonum and related pathologies in a javelin thrower.
... [1][2][3][4][5] The increased load placed on the dancer's ankle and foot when dancing en pointe has been identified as a potential contributor to increased injury risk, which may be exacerbated by premature pointe initiation. [5][6][7][8][9] Various assessment criteria exist to determine a dancer's readiness to begin pointe training and to mitigate injury risk. Chronological age is the most common criteria used, with twelve years of age most frequently cited as a requirement to determine a dancer's readiness to begin training en pointe. ...
... 22 This increased load placed on the ankle and foot during pointe work may further increase the risk of injury for young dancers who do not have adequate strength and motor control to dance safely en pointe. 2,6,7 Dance instructors also indicated that they require an average of 4.2 years of ballet experience, with a range of 2 to 8 years, prior to allowing a dancer to progress en pointe. This finding is consistent with the current literature which reports that the majority of instructors agree that a minimum of 3 to 4 years of ballet training is needed prior to beginning pointe work. ...
Introduction: Transiting to dancing en pointe is an important milestone for young dancers who wish to progress in ballet training. Various criteria exist regarding pointe readiness, including age, range-of-motion, endurance, strength, balance, and technique. However, awareness and use of these criteria by dance instructors is currently unknown. The purpose of this pilot study was to assess the awareness and use of pointe readiness criteria by youth ballet instructors. Methods: A cross-sectional web-based survey study design was used, which included questions regarding dance instruction experience, dance studio characteristics, and criteria used to assess pointe readiness. Ballet instructors were recruited for participation. Data are presented as percentages and frequencies. Results: Thirty-one ballet instructors completed the survey from 15 states (1 international). Years of pointe ballet instruction ranged from 2 to 30+ years, with 35% indicating more than 30 years of experience. Instructors reported students begin pointe at age 11.8 years (range 9-15 years). A majority of instructors require 5 years of ballet experience prior to dancing en pointe (range 2-8 years). Reported pointe readiness criteria included strength (100%), dance technique (94%), age (87%), and years of ballet experience (71%). While all instructors reported evaluating a dancer’s strength, assessments of flexibility and movement quality were not evaluated by 42% and 45% of instructors, respectively. Strength, dance technique, and age were rated as the greatest indicators of a dancer’s readiness to begin pointe. Finally, instructors reported low knowledge of existing pointe readiness criteria. Conclusion: Ballet instructors initiated pointe work at age 12 and required 5 years of ballet experience before beginning to dance en pointe. While strength, dance technique, and age were the top considerations for evaluating readiness, approximately 40% of instructors did not evaluate flexibility or movement quality prior to progressing to pointe, and overall, knowledge of existing criteria was low.
... However, in situations of high postural demands or heavy foot loading, stabilization of the foot arch structure is achieved by additional muscle-generated forces 6,7 . Given that the foot joints of dancers are characterized by hypermobility 8, 9 , the activity of the muscles involved in the stability of these joints may be important in reducing postural sway during STS. ...
... The tiptoe standing that dancers perform in daily practice and on stage requires a large ankle plantar exion (PF) angle, which is not achievable in non-dancers, and this is even more so during STS 8, 9,16 . When comparing muscle activity between individuals/conditions and examining its relationship to other parameters such as postural sway, a well-controlled task setting with the speci ed/same joint angle is appropriate 17,18 . ...
During tiptoe standing, especially with the single-legged support, the foot joints in ballet dancers are heavily loaded. Thus, the activity of the plantar intrinsic foot muscles (PIFMs), which stabilize the foot joints, may be important in reducing postural sway during tiptoe standing. We compared PIFM activity during single-legged and bipedal tiptoe standing and examined its relationship to postural sway in dancers. In 11 female ballet dancers, the electromyography (EMG) amplitudes of PIFMs and the center of pressure (COP) data were recorded during single-legged and bipedal tiptoe standing tasks. The EMG amplitudes were normalized to those during the maximal voluntary contraction, and PIFM activity level and its coefficient of variation over time (EMG-CVtime) during the task were assessed. From the COP data, standard deviations in the anteroposterior (COP-SDAP) and mediolateral (COP-SDML) direction, velocity, and area were calculated. PIFM activity level and COP velocity were 2–2.5-fold higher in the single-legged than bipedal task (p≤0.003). Significant correlations were found between PIFM activity level and COP velocity (r=0.666, p=0.025) and between EMG-CVtime and COP-SDAP or COP-SDML (r≥0.738, p≤0.010) only in the single-legged task. These results suggest that PIFM activity is associated with postural sway, especially during single-legged tiptoe standing in dancers.
... 15 Therefore, increased forces and load located at the ankle and foot could increase the risk and incidence of pointe-related injury, especially in those dancers who train en pointe prematurely or lack the physical attributes needed to dance safely en pointe. 4,10,28,30,32,33 The most prevalent injuries occurring in young adolescent dancers are found at the ankle, knee, and foot and are often caused by poor technique (generally because of overuse and fatigue), 34 weak hip musculature associated with inversion of the subtalar joint and increased postural sway, [35][36][37] and an increase in training load when en pointe. 38 Posterior ankle impingement and ankle sprains are frequent in dancers en pointe and are conceivably caused by premature initiation of pointe training. ...
... 38 Posterior ankle impingement and ankle sprains are frequent in dancers en pointe and are conceivably caused by premature initiation of pointe training. 4,10,28 Additionally, reduced ankle ROM can cause stress fractures in dancers who "over pointe" the feet while en pointe. 39 Consequently, dancing with poor technique while wearing ill-fitting pointe shoes can lead to retrocalcaneal bursitis (inflammation of the bursa at the attachment of the Achilles tendon), hallux rigidus (arthritis in the joint at the base of the big toe), and sesamoiditis (inflammation of the sesamoid bones at the ball of the foot beneath the joint of the big toe). ...
Dancing en pointe is an integral aspect of ballet for female dancers and they start pointe training in young adolescence. The primary objective of this review was to investigate the screening tests used to determine pointe readiness in young adolescent female dancers, and the secondary objective was to determine the injuries associated with pointe training. The search engines Google Scholar, PubMed, Scopus, and Web of Science were mined using medical subject heading terms “pointe,” “pointe readiness,” “injury,” “young,” “adolescent,” “female,” and “dancer,” and a manual search of relevant articles was conducted. The inclusion criteria were: females aged 8 to 20 years, pre-pointe, training en pointe, and pointe-related injury. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following data were extracted; first author, year of publication, study design, participant size, mean age, testing, outcome, and general notes of each study. Risk of bias was evaluated using the Research Triangle Institute Item Bank (RTI-IB). Eight cross-sectional studies met the inclusion criteria. Results suggested that the topple, airplane, sauté, and relevé tests are statistically better determinants of pointe readiness than chronological age alone. Utilizing these methods alongside age, strength, body maturation, range of motion (ROM), and teacher evaluation could provide an all-round insight into a dancer’s readiness for pointe. However, the included studies had contradictory outcomes with regard to pointe-related injury and the review’s conclusions are limited by methodological design.
... The PAIS is usually found in athletes and ballet dancers. 1 The posterior part of the talus is an irregular bone surface composed of posterolateral and posteromedial tubercles, and the groove for the flexor halluces longus tendon lies between these 2 tubercles. 1,2 The pathology of PAIS is varied from bony variation to a fracture of the posterolateral tubercle of the talus. The bone variation of posterolateral tubercle of the talus is the failure of fusion of the secondary ossification center as os trigonum. ...
... Soft tissue impingement is caused by an accessory ligament, such as the posterior intermalleolar ligament, the posterior inferior tibiofibular ligament, or the PTFL. 2 The ligament may protrude further into the joint during ankle plantarflexion, becoming entrapped and torn. The bony structures responsible for PAIS include the posterior subtalar joint, the posterolateral process of the talus, and the os trigonum. ...
Purpose
The purpose of this study was to evaluate the attachment areas of the posterior talofibular ligament (PTFL) on the posterolateral tubercle of the talus and the remaining PTFL attachment areas after consequential bony excision.
Methods
Thirty fresh cadaveric ankles were dissected to study the proximal and distal attachment of the PTFL and separated the PTFL into anterior and posterior bundles. The description of the PTFL footprint and the anatomic landmarks from the surrounding structures were analyzed during consequential posterolateral bony excision.
Results
The average PTFL dimension was 26.11 mm (length), 7.65 mm (width), and 1.82 mm (thickness). The footprint area of the PTFL on the talar site consists of the posterior bundle (76.82%) and the anterior bundle (23.18%). If posterolateral tubercle excision was stayed up to a line of a bottom of the flexor hallucis longus (FHL) groove, at least 89% of the PTFL can be preserved.
Conclusion
The posterior bundle of the PTFL is the main bundle on the talar footprint area. To maintain the majority of the attachment of the PTFL, the resection of the posterolateral process could be performed to the bottom of the FHL tendon groove. If resection reaches to the posterior articular cartilage, less than 50% of the PTFL will be preserved. Understanding the footprint of the PTFL plays a key role in posterior ankle impingement surgery.
Clinical Relevance
This study provides guidance for resection of the posterolateral tubercle of the talus and a portion of the PTFL attachment for posterior ankle impingement syndrome. Too much resection of the tubercle may cause instability symptoms.
... 9 In excess, these compressive forces in maximum plantarflexion can result in posterolateral ankle pain and restriction, known as posterior ankle impingement syndrome (PAIS). 11,21,25,26 PAIS can be caused by both osseous and soft tissue structures. One such osseous cause is the os trigonum, an accessory ossicle to the talus that is normally present in 13% of the population 31 and is usually asymptomatic. ...
... 32 Acquired os trigonum syndrome is caused by an injury that prevents fusion and can subsequently become symptomatic when it impinges on the surrounding soft tissue structures wedged between the tibia, talus, and calcaneus in plantarflexion. 11,21,26 It has been reported that repetitive plantarflexion trauma in a young dancer's training prevents proper closure of this trigonal ossification center 19,23 and is accompanied by pathology of the flexor hallucis longus (FHL) tendon. 13 Therefore, it is easy to understand that transitioning to relevé training during preadolescence can cause PAIS in a young dancer. ...
Background
Management of ankle pain in dancers can be challenging because of the repetitive stress and complex demands placed on this region. Despite the prevalence of ankle injuries in this population, literature on surgical outcomes and return to dance is limited.
Purpose
To retrospectively evaluate the efficacy and functional outcomes after surgical excision of a symptomatic os trigonum in dancers.
Study Design
Case series; Level of evidence, 4.
Methods
Between June 2006 and June 2016, a total of 44 dancers underwent surgical excision of a symptomatic os trigonum at a single institution and by a single surgeon. All patients presented with symptoms of posterior ankle impingement syndrome and subsequently failed nonsurgical treatment. Clinical analysis was conducted using various pre- and postoperative patient-reported outcome questionnaires, including the Veterans RAND 12-Item Health Survey (VR-12), Foot Function Index–Revised (FFI-R), and visual analog scale (VAS) for pain, as well as subjective patient satisfaction.
Results
A total of 44 patients (54 ankles; mean age, 18.2 years) were retrospectively evaluated at a mean follow-up of 33.4 months. The VR-12 Physical Health score improved from a mean score of 37.8 ± 11.9 to 51.2 ± 10.5 ( P < .001). The cumulative FFI-R score improved from 46.45 ± 13.8 to 31.2 ± 9.7 ( P = .044), with the subcategory of “activity limitation” representing the highest-scoring FFI-R subcategory at 65.28 ± 13.4 preoperatively and improving to 34.47 ± 12.4 at follow-up ( P < .001). The mean VAS score for subjective pain improved significantly from 5.39 ± 2.84 to 1.73 ± 2.10 ( P < .00044).
Conclusion
Overall, the findings of the present study demonstrate that dancers of varying style and level improved significantly according to various clinical measures. Patients included in this study reported that they returned to their previous level of dance upon completion of physical therapy and maintained thriving postoperative careers, which for several meant dancing at the professional level.
... For example, bone changes include the os trigonum and Stieda process, both originating from the accessory ossicle posterior to the talus (2,3) , as well as the fragmentation of the lateral tubule of the talus and local pseudarthrosis, which can irritate the posterior ankle when present. In particular, it can lead to the compression of the soft tissues adjacent to the distal tibia and the calcaneus during ankle flexion (3,6) . It can also rub against the flexor hallucis longus muscle and other local ligaments (7) . ...
... However, the effectiveness of conservative treatment cannot be accurately determined, and no long-term follow-up study has investigated this treatment with scientific validity (2) . Cases in which the anatomical changes associated with persistent complaints (failure of the conservative treatment) and reduced athletic performance are indications for surgery (2)(3)(4)6,15) . ...
Objective: This study sought to evaluate the results of 10 athletes diagnosed with posterior ankle impingement syndrome (PAIS) treated with arthroscopy between 2016 and 2017 by the Sports Traumatology Center of our University. Methods: Patients were evaluated with regard to the presence of associated lesions, the etiology of PAIS, and treatment outcomes using a visual analog scale (VAS) and the American Foot and Ankle Society (AOFAS) scores. All cases were treated using an arthroscopic approach to the posterior ankle. Results: Six patients presented with ankle instability and were treated with Brostrom-Gould ligament repair as an adjuvant procedure. One patient had sinus tarsi syndrome, and this space was debrided. Injury of the peroneus brevis tendon was identified in two cases, and Achilles tendinopathy was identified in one individual. Only three patients did not receive adjuvant treatment. During surgery, five cases of trigonal processes, three cases of Stieda process, one case of hallux saltans, and one case of accessory ossicle of the fibula were identified as the causes of the impingement. The mean VAS score was 1.28 (0.6-2.5), and the mean AOFAS score was 88.6 (72-100). No complications were reported. Conclusion: Arthroscopic resection of the cause of the impingement, alone or in combination with the treatment of secondary conditions, was used to effectively treat pain and reestablish function. Level of Evidence IV; Therapeutic Studies; Case series.
... 22,[31][32][33] Usually PAIS is suspected clinically, in a combination of history and careful physical examination, and confirmed with subsidiary tests. 7,25 Conventional radiographs, computed tomography, and magnetic resonance imaging are static modalities that can portray local anatomy and indirect signs of impingement but lack the dynamic capability to indicate which structure is affected and causing symptoms. 4,20,33,35 The high prevalence of os trigonum in imaging examinations also places it as potential incidental finindgs. ...
Background
Os trigonum and Stieda process are common etiologies for posterior ankle impingement syndrome (PAIS), and diagnosis is typically made by radiographs, computed tomographic, or magnetic resonance imaging. However, these static tests may not detect associated soft tissue and bony pathologies. Posterior ankle and hindfoot arthroscopy (PAHA) is dynamic, providing at least ×8 magnification with full anatomical visualization. The primary aim of this study was to report the prevalence of associated conditions seen with trigonal impingement treated with PAHA.
Methods
In this retrospective comparative study, patients who underwent PAHA for PAIS due to trigonal impingement, from January 2011 to September 2016, were reviewed. Concomitant open posterior procedures and other indications for PAHA were excluded. Demographic data were collected with pre- and postoperative diagnosis, arthroscopic findings, type of impingement, location, associated procedures, and anatomical etiologies. Trigonal impingements were divided in os trigonal or Stieda and subgrouped as isolated, with flexor hallucis longus (FHL) disorders, with FHL plus other impingement, and with other impingement lesions.
Results
A total of 111 ankles were studied—74 os trigonum and 37 Stieda. Isolated trigonal disorders accounted for 15.3% of PAIS (n = 17). Cases having associated conditions had a mode of 3 additional pathologies. FHL disorders were found in 69.4%, subtalar impingement in 32.4%, posteromedial ankle synovitis in 25.2%, posterolateral ankle synovitis in 22.5%, and posterior inferior tibiofibular ligament impingement in 19.8% of cases. Associated pathologies were observed in 58.6% of cases when FHL was not considered. Significant differences were noted comparing os and Stieda (isolated: 20.3% to 5.4%, P = .040; FHL plus others: 35.1% to 59.5%, P = .015).
Conclusion
Trigonal bone (os trigonum or Stieda) was found to cause impingement in isolation in a small proportion of cases even when the FHL was considered part of the same disease spectrum. This should alert surgeons when considering removing trigonal impingement. Open approaches may limit the visualization and assessment of associated posterior ankle and subtalar pathoanatomy, thus possibly overlooking concomitant causes of PAIS.
Level of Evidence
Level III, retrospective comparative study.
... A wide variation of occurrence has been reported in the literature (1.7-12.7%) [1]. There is some reported prevalence rate of 30% in ballet dancers, which may be attributed to repetitive forced plantar flexion. ...
... There are several possible sources of posterior ankle pain in dancers. 6,28,32 In the present cohort, persistent, or recurrent posterior ankle impingement injuries that did not undergo medical imaging may have been tendon-or bone-related, rather than true cases of capsulitis/synovitis, and dancers may experience posterior ankle pain associated with multiple coexisting tissue pathologies. 6 Although there was a high incidence and burden of posterior ankle impingement injury in females, these injuries had a lower median days' time loss when compared to bone stress of the foot and tibia. ...
OBJECTIVES: To describe the incidence rate, frequency, severity, recurrence, and burden of musculoskeletal injury in professional ballet.
STUDY DESIGN: Descriptive epidemiological (retrospective).
METHODS: Professional dancers (n = 73, 40 females, 33 males) provided consent for retrospective review of musculoskeletal injury data. Medical-attention injuries were reported to and recorded by onsite physiotherapists between January 2018 and December 2021. Time-loss injuries were any injury that prevented a dancer from taking a full part in all dance-related activities for >1 day . Injuries were classified using the OSICS-10.1 system. Injury incidence rates (IIRs; injuries/1000 h), severity, recurrence, and burden were calculated.
RESULTS: Nine hundred and fifty-three medical-attention injuries were recorded in 72 (98%) dancers at an IIR of 2.79/1000 h (95% confidence interval [CI], 2.62-2.98). 706 were time-loss injuries, which were reported in 70 dancers at an IIR of 2.07/1000 h (95% CI: 1.92, 2.23). Overuse injuries represented 53% of medical-attention injuries. The most frequently injured body area and tissue/pathology were thoracic facet joint (n = 63/953, 7%) and ankle synovitis/impingement (n = 62/953, 6%). Bone stress injuries (BSIs) were the most severe with the highest median time loss (135 days, interquartile range [IQR] 181) followed by fractures (72.5 days, IQR 132). The injuries with the highest burden were tibial BSIs (13 days lost/1000 h; 95% CI: 13, 14). Jumping and lifting were the most frequently reported injury mechanisms.
CONCLUSION: Almost all dancers required medical attention for at least one injury during the surveillance period. Approximately 74% of injuries resulted in time loss. BSIs and ankle synovitis/impingement were of high burden, and a high proportion of BSIs were recurrent. J Orthop Sports Phys Ther 2023;53(11):712-722. Epub 14 September 2023. doi:10.2519/jospt.2023.11858
... Conflict between bony and capsular ligament structures in the posterior aspect of the ankle can often lead to chronic pain, worsened by overuse in repetitive plantar flexion movements (1,2) . A Stieda process or an os trigonum may cause this impingement, which can also be due to edema of the flexor hallucis longus (FHL). ...
Objective: We present a series of patients with flexor hallucis longus tenosynovitis submitted to hindfoot endoscopy, describing clinical outcomes and reporting surgical findings and complications seen throughout the treatment. Methods: Thirty-one patients diagnosed with flexor hallucis longus tenosynovitis submitted to posterior ankle endoscopy were followed. The mean follow-up was 24 months. Patients were classified according to American Orthopaedic Foot and Ankle Society (AOFAS) and Visual Analogue Scale (VAS) scores. Patient satisfaction was measured. Results: The mean age of patients was 35.13 (Å} 10.68) years. The VAS score improved from 7.16 preoperatively to 2.16 in postoperative follow-up. The AOFAS score improved from 76.39 (Å} 5.06) preoperatively to 97.10 (Å} 3.78) in postoperative follow-up. Patients were able to return to sports activities at the same level as before surgery by a mean of 4.6 (Å} 1.27) months. One of our patients developed a complication of wound erythema in a portal, which resolved without additional treatment. Conclusion: The diagnosis of flexor hallucis longus tenosynovitis is commonly associated with a large Stieda process or os trigonum impingement, limiting participation in sports activities. In our series, the endoscopic procedure showed good results in treating this condition, promoting a swift return to sports activities. Patients further presented a good postoperative recovery with few complications. Level of Evidence IV; Therapeutics Studies; Cases Series.
... The Os trigonum Syndrome refers to pain at posterior aspect of the ankle and also leads to reduced plantar flexion movement caused by "the nutcracker-phenomenon". When an Os trigonum is present, this accessory ossicle together with surrounding soft tissues can become wedged between the tibia, talus and calcaneus and this can lead to inflammation of the involved structures [5,6]. The Os trigonum is usually seen as an individual bone, but can also be present in two or more pieces. ...
Background: The Os Trigonum Syndrome refers to pain in the posterior of the ankle and restriction of plantar flexion caused
... Magnetic resonance imaging (MRI) can be undertaken when the diagnosis is unclear, allowing evaluations of bone edema, joint effusion, synovitis, tenosynovitis, and chondral injury. Ultrasound (US) has recently gained popularity, as it can reliably and inexpensively aid in identifying the anatomical bases of PAIS [8,9], and it allows the administration of both diagnostic and therapeutic injections [10][11][12]. Nonsurgical management remains the initial approach to PAIS, and, for acute symptoms, a period of rest and protection are recommended. Conservative management-including rest, ice, the use of nonsteroidal drugs (NSAIDS), and avoidance of provocative activities-can be successful, together with shoe modifications, including heel lift orthoses to prevent dorsiflexion [13]. ...
Background:
Posterior ankle impingement syndrome (PAIS) may result from flexor hallucis longus tendinopathy, compression of the posterior process of the talus from the presence of an os trigonum, soft-tissue impingement, or a combination of these. Posterior extra-articular endoscopy performed with the patient supine through the double posteromedial portals, with excision of adhesions, excision of the posterior process of the talus or an os trigonum, and decompression of the tendon of the flexor hallucis longus (FHL), can be used in athletes with PAIS.
Methods:
Thirty-four athletes with PAIS in whom conservative management had failed underwent posterior ankle endoscopy in the supine position using the double posteromedial portals. The patients were assessed pre- and postoperatively using the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner scale, and the simple visual analogue scale. Time of surgery, return to sports, patient satisfaction, and complications were recorded and analysed. The average length of postoperative follow-up was 26.7 ± 12.6 (range 24 to 72) months.
Results:
The mean Tegner activity scale score improved to 9 ± 0.2 postoperatively (p < 0.05), while the mean American Orthopaedic Foot and Ankle Society scale score improved to 96 ± 5.1 (range 87 to 100) postoperatively, with 29 of 34 patients (85.3%) achieving a perfect score of 100 (p < 0.05). The mean time to return to sports was 8.7 ± 0.7 (range 8 to 10) weeks. The complication rate was low, with no superficial wound infections or venous thromboembolism events; only two patients (5.9%) reported pain and tenderness by 3 months after the index procedure.
Conclusion:
Posterior ankle endoscopy for the resection of a posterior process of the talus or an os trigonum and decompression of the tendon of FHL is safe and allows excellent outcomes with low morbidity in athletes with PAIS.
... Por otra parte el mismo constituye un aporte al estudio de la figura de un sector que posee la mayor cantidad de trabajos vinculados al área de traumatología del deporte. (93)(94)(95)(96)(97) ...
Se realizó un estudio descriptivo, retrospectivo y transversal con el objetivo de caracterizar a bailarines profesionales del Ballet Nacional de Cuba sobre la base de los tres pilares fundamentales de la Cineantropometría. Para el mismo fueron evaluados 91 bailarines divididos en 40 hombres y 51 mujeres. Fue utilizada una muestra secundaria de 20 bailarines foráneos participantes en el circuito europeo y 1490 deportistas de las selecciones nacionales de cuba con el objetivo de comparar estas muestras con los bailarines. La investigación incluyó la estimación bicompartimental de la composición corporal a partir del método de Withers et al. (1987) y el fraccionamiento antropométrico de la masa corporal. El somatotipo fue determinado a partir del método antropométrico de Heath-Carter y la proporcionalidad a partir del modelo de Phantom adaptado. El análisis estadístico incluyo la media, desviación estándar y las pruebas de hipótesis t de Student y U de Mann-Withney .La evaluación del perfil Cineantropométrico reveló bajos estimados de grasa corporal de 7,5 y 13% para el sexo masculino y femenino respectivamente y un somatotipo promedio de 1,9; 4,8; 2,8 y 2,3; 2,6; 4,0 para uno u otro sexo. No se encontraron diferencias significativas entre los bailarines foráneos y cubano (p<0,05) solo con la excepción del pliegue del muslo (8,2 vs 15,2mm) que resaltó significativamente a favor de la bailarina cubana. Finalmente se obtuvo que el cuerpo del danzante cubano se caracteriza por niveles de adiposidad muy bajos con una estética corporal ideal para la actividad que realizan y un perfil característico de una población con altas demandas en la ejecución del ejercicio físico.
... This is supported by several studies [8,[26][27][28], while international bodies consider dancers' bone health as a topic of major concern [6]. However, unlike dance injuries and their aetiology [29,30], little is known in relation to vocational dancers' bone health (both in female and male young dancers) [15]. To our knowledge, the present study is the first to longitudinally investigate the association between bone mass accruals and nutrition energy availability in adolescent male vocational dance students. ...
Three years of study showed that female and male vocational dancers displayed lower bone mass compared to controls, at forearm, lumbar spine and femoral neck. Energy intake was found to positively predict bone mass accruals only in female dancers at femoral neck. Vocational dancers can be a risk population to develop osteoporosis.
Purpose:
To determine whether risk factors normally associated with low bone mass in athletic populations (i.e. nutrition intake, energy expenditure and energy availability) are significant predictors of bone mass changes in vocational dance students.
Methods:
The total of 101 vocational dancers (63 females, 12.8 ± 2.2 years; 38 males, 12.7 ± 2.2 years) and 115 age-matched controls (68 females, 13.0 ± 2.1 years; 47 males, 13.0 ± 1.8 years) were monitored for 3 consecutive years. Bone mass parameters were measured annually at impact sites (femoral neck, FN; lumber spine, LS) and non-impact site (forearm) using DXA. Nutrition (3-day record), energy expenditure (accelerometer), energy availability and IGF-1 serum concentration (immunoradiometric assays) were also assessed.
Results:
Female and male vocational dancers had consistently reduced bone mass at all anatomical sites (p < 0.001) than controls. IGF-1 did not differ between male vocational dancers and controls, but female dancers showed it higher than controls. At baseline, calcium intake was significantly greater in female vocational dancers than controls (p < 0.05). Male vocational dancers' fat and carbohydrate intakes were significantly lower than matched controls (p < 0.001 and p < 0.05, respectively). Energy availability of both female and male vocational dancers was within the normal range. A significant group effect was found at the FN regarding energy intake (p < 0.05) in female dancers. No significant predictors were found to explain bone mass differences in males.
Conclusion:
Our 3-year study revealed that both female and male vocational dancers displayed lower bone mass compared to controls, at both impact and non-impact sites. The aetiology of these findings may be grounded on factors different than those usually considered in athletic populations.
... Posterior ankle impingement syndrome is de ned as posterior ankle pain caused by repeated excessive plantar exion or sudden acute plantar exion of ankle, and it is mostly seen in ballet dancers, soccer and volleyball players. 1 The abnormal factors for impingement include soft tissue and bone abnormalities. 2 There are two types of treatment for posterior ankle impingement syndrome: conservative treatment and operative treatment. Conservative treatment includes taking a good rest, ice compress, oral administration of non-steroidal anti-in ammatory drugs (NSAIDs) and intra-articular injection of hyaluronate sodium. ...
Double Posterolateral Coaxial Portals has been designed by us for Endoscopic Management of Posterior Ankle Impingement. This study’s purpose was analyzed the safety and clinical efficacy of this new designed portals. Six fresh foot samples were randomly selected. The distances of two posterolateral portals to sural nerve in the neutral, dorsiflexion and plantar flexion positions were measured to evaluate the safety. The clinical efficacy of the operative approach for endoscopic management of posterior ankle impingement syndrome was prospectively analyzed, and its effectiveness and complications were evaluated. In 6 samples, the mean distances of the first and second portals to sural nerve were 2.26 ± 0.22 cm and 1.59 ± 0.12 cm in the neutral position,2.21 ± 0.21 cm and 1.55 ± 0.12 cm in the dorsiflexion 30°position, and 2.46 ± 0.29 cm and 1.73 ± 0.19 cm in the plantar flexion 30°position; thus, two portals had a big safety distance to sural nerve. Totally 38 patients received the endoscopic treatment of posterior ankle impingement syndrome with double posterolateral coaxial portals from January 2012 to December 2017. Such operative approach provided a full field of subtalar joint and posterior ankle during operation. The mean follow-up time was 28.2 (range, 24–72) months, the satisfaction rate was 94.7%; none of patients experienced complications; VAS score was decreased to 0.50 at the last visit from 5.82 before operation (P < .001), while AOFAS score was increased to 92.34 from 71.68, and the differences were both statistically significant ( P < .001); the excellent/good rate was 97.3℅. In treating posterior ankle impingement syndrome, double posterolateral coaxial portals have such advantages of good safety, miniature nerve injury, a good field of posterior ankle and subtalar joint, good clinical efficacy, and few complications, thus they are an operative approach which is reliable, effective, safe and worthy of being popularized.
... Posterior ankle impingement (PAIS) is a condition characterized by posterior ankle pain in plantar flexion. It is usually aggravated by repetitive plantar flexion and can result from either an acute injury or simple overuse (Russell et al., 2010;Sofka, 2010;Ribbans et al., 2015). Eighty-one percent of the pathologies causing PAIS were reported to be osseous in origin and os trigonum accounted for 47 % of these cases while Stieda's process accounted for only 4 % (Ribbans et al.). ...
The aim of our study was to determine the prevalence and the anatomical variations of the posterolateral tubercle of talus in relation to sex on CT imaging. A total of 1478 ankle CT scans was retrospectively reviewed for the different anatomical variants of the posterolateral tubercle of talus, the type and size of os trigonum. Normal sized lateral tubercle was found in 46.1 %, an enlarged posterolateral tubercle (Stieda’s process) in 26.1 %, os trigonum in 20.5 % and almost absent tubercle in 7.3 %. A statistically higher prevalence of Stieda’s process was found in males while os trigonum was higher in females (p<0.05). Among feet with os trigonum, 25.7 % were non-articulating and identified as a separate bone located posterior to the posterolateral tubercle of talus and 74.3% of os trigonum were identified as fused to the posterolateral tubercle by synchondrosis or syndesmosis. Additionally, 17.5 % of os trigonum were associated with intact lateral tubercle, 53.5 % were considered as part of the lateral tubercle and 29.0 % were without a lateral tubercle. According to its size, 22.8 % of os trigonum were smaller than 0.5 cm, 55.4 % were between 0.5 and 1cm, and 21.8 % were larger than 1 cm. No significant differences were found between the different types/sizes of os trigonum according to gender (p>0.05). The posterolateral tubercle of talus and its accessory ossicle, the os trigonum, could vary morphologically. The data of this study could be helpful in understanding the clinical problems that could be associated with some of these variants.
... Some studies have focused mainly on orthopaedic surgery interventions. Foot surgery has often been described [17][18][19][20] in relation to such injuries as metatarsal fractures, ankle impingement or tendinopathies. Surgical vs conservative management of fractures in dancers has also been described [21][22][23]. ...
Background
The unique repetitive nature of ballet dancing, which often involves transgressing endurance limits of anatomical structures, makes dancers prone to injury. The following systematic review aims to assess the effectiveness of physiotherapy interventions in the treatment of injuries in ballet dancers.
Methods
The review was performed in line with the PRISMA statement on preferred reporting items for systematic reviews and meta-analyses. Six electronic databases (PubMed, Ovid Embase, Cochrane, Medline, PEDro, Google Scholar) were queried. The study populations comprised active ballet dancers and/or ballet school attendees with acute and chronic injuries and those with persistent pain. There were no restrictions regarding age, sex, ethnicity or nationality. The Modified McMaster Critical Review Form for quantitative studies was used to assess the methodological quality of the studies reviewed in accordance with the relevant guidelines.
Results
Out of the total of 687 articles subjected to the review, 10 met the inclusion criteria. Diverse physiotherapeutic interventions were described and effectiveness was assessed using different parameters and measurements. Overall, the results indicate that physiotherapy interventions in ballet dancers exert a positive effect on a number of indices, including pain, ROM and functional status.
Conclusions
Due to the small amount of evidence confirming the effectiveness of physiotherapeutic interventions in ballet dancers after injuries and methodological uncertainties, it is recommended to improve the quality of prospective studies.
... Diagnosis of FHL tendinitis/tenosynovitis is typically made clinically, although ultrasound and MRI are useful for precise diagnosis (3,5,17,18). Dancers typically complain of pos-terior ankle pain and/or clicking during releve and tendu (Fig. 1). ...
The purpose of this study was to report on a series of dancers who had undergone Flexor Hallucis Longus (FHL) tenolysis/tenosynovectomy after having failed conservative management. Institutional human subjects committee approval was obtained prior to initiating this study. This study is a retrospective case series of 58 dancers and 63 ankles who underwent FHL tenolysis/tenosynovectomy via an open posteromedial approach by a single surgeon between 1993 to 2017. All patients were interviewed and charts reviewed. Collected variables included: preoperative and postoperative pain levels, time to return to dance, and subjective satisfaction with the procedure. Age, primary dance form, level of dance were determined. Mean preoperative pain level decreased significantly postoperatively. Mean time to return to dance was 7.1 weeks. There was a 98% (62/63) return to dance at some level while 97% (61/63) of patients returned to dance symptom-free. There were no neurovascular or other major complications. Minor complications included stiffness at follow-up (6.3%, 4/63), superficial wound infection (3.1%, 2/63), and hypertrophic scar (4.8%, 3/63). Over 97% (61/63) of dancers considered the procedure a success and 98% (62/63) of dancers would repeat the procedure. This is one of the largest series reported of isolated FHL tenolysis/tenosynovectomy in dancers who have failed nonoperative management. Satisfactory pain relief and return to dance with a low complication rate may be expected from this surgical procedure. The results of this study can be used to help dancers and their providers make informed decisions about treatment in isolated FHL tendinitis.
Level of Clinical Evidence: 4
... Posterior ankle impingement (PAIS) is a condition characterized by posterior ankle pain in plantar exion. It is usually aggravated by repetitive plantar exion and can result from either an acute injury or simple overuse (Ribbans, Ribbans, Cruickshank, & Wood, 2015;Russell, Kruse, Koutedakis, McEwan, & Wyon, 2010;Sofka, 2010). Eighty-one percent of the pathologies causing PAIS were reported to be osseous in origin and os trigonum accounted for 47% of these cases while Stieda's process accounted for only 4% (Ribbans et al., 2015). ...
The aim of our study was to establish the prevalence of the different anatomical variants of the posterolateral tubercle of talus on CT imaging. 1478 ankle CT scans were retrospectively reviewed for the different anatomical variants of the posterolateral tubercle of talus, the type and size of os trigonum. Normal sized lateral tubercle was found in 46.1%, an enlarged posterolateral tubercle (Stieda’s process) in 26.1%, os trigonum in 20.5% and almost absent tubercle in 7.3%. A statistically higher prevalence of Stieda’s process was found in males while os trigonum was higher in females (p<0.05). Among feet with os trigonum, 25.7% were non-articulating and identified as a separate bone located posterior to the posterolateral tubercle of talus and 74.3% of os trigonum were identified as fused to the posterolateral tubercle by synchondrosis or syndesmosis. Additionally, 17.5% of os trigonum were associated with intact lateral tubercle, 53.5% were considered as part of the lateral tubercle and 29.0% were without a lateral tubercle. According to its size, 22.8 % of os trigonum were smaller than 0.5 cm, 55.4% were between 0.5 and 1cm, and 21.8% were larger than 1 cm. No significant differences were found between the different types/sizes of os trigonum according to gender (p>0.05). The posterolateral tubercle of talus and its accessory ossicle, the os trigonum, could vary morphologically. The data of this study could be helpful in understanding the clinical problems that could be associated with some of these variants.
... It is usually aggravated by repetitive plantar exion and can result from either an acute injury or simple overuse (11)(12)(13). PAIS pathology can be due to osseous, soft tissue lesions and variations in anatomy (14). The most important anatomical variations that can predispose patients to the development of PAIS are an os trigonum and Stieda process (15). ...
Background: The most important anatomical variations of the posterolateral talar tubercle that can predispose patients to development of posterior ankle impingement syndrome (PAIS) are an os trigonum and Stieda process. The aim of this study was to elucidate the prevalence of different anatomical variants of posterolateral talar tubercle on CT imaging, their prevalence in patients with PAIS, and to evaluate the risk posed by these anatomical variants to PAIS.
Methods: 1478 ankle CT scans were retrospectively reviewed for the different anatomical variants of the lateral talar tubercle, the type and size of os trigonum. In addition, these anatomical differences were assessed in a subgroup of patients with PAIS.
Results: Normal sized lateral tubercle was found in 46.1%, Stieda’s process in 26.1%, os trigonum in 20.5% and almost absent tubercle in 7.3%. A statistically higher prevalence of Stieda’s process was found in males while os trigonum was higher in females (p<0.05). In patients with PAIS, the most common variant was os trigonum (48.8%), followed by Stieda process (34.1%). Patients with Stieda process were 1.5 times more likely to have PAIS, and patients with os trigonum were 4.4 times more likely to have PAIS. PAIS was observed in 20.8% of patients with os trigonum. Fused forms of os trigonum (by cartilage) and sizes larger than 1cm were associated with a higher risk of occurrence of PAIS (OR 2.10 and OR 1.96 respectively)(p<0.05).
Conclusion: Patients with os trigonum, followed by Stieda process were more likely to have PAIS compared to other anatomical variants of lateral talar tubercle.
... Debemos evaluar patologías importantes o malformaciones como el hallux valgus o los pies cavos que dificultarían la practica deportiva, o podrían variar la biomecánica del movimiento del pie, como en el zapateado, (Echegoyen, Aoyama, & Rodríguez, 2013;J. Russell, 2008) o en el caso de las puntas (Ritter, 2008), por tanto puede provocar lesiones (J. A. Russell, Kruse, Koutedakis, McEwan, & Wyon, 2010). Las alteraciones morfológicas pueden causar disfunciones en las cadenas cinéticas y ser causa de lesiones en pie y tobillo de bailarines (Macintyre, 2000). ...
El acceso a los estudios oficiales de Danza, se realizan mediante pruebas de aptitud en los Conservatorios Profesionales de Danza de España y realizadas por profesores de Danza que evalúan aptitudes rítmicas, expresivas y psicomotrices y por otra parte, médicos que realizan una evaluación de las características físicas. La selección de los alumnos se realiza en función de los resultados de estas pruebas. Se analiza en este documento cuales son las características principales que rigen las calificaciones. El tribunal evaluador está formado por profesionales de danza, y se quiere averiguar si existen diferencias entre las diferentes especialidades a la hora de calificar. No han sido encontrados estudios acerca de pruebas específicas para realizar dicha evaluación. Se analizan los ítems de la prueba de aptitud según el profesorado de Enseñanzas de Régimen Especial de Danza, y según las diferentes especialidades que posean con respecto al elemento de la evaluación. Para cumplimentar los objetivos del estudio, datos cuantitativos y cualitativos fueron recogidos con la aplicación de una encuesta ad hoc (n= 27). Los resultados indican que, mientras el profesorado de danza clásica priorizó calificaciones en el ítem peso/talla, morfología del pie y extensión de piernas, los docentes de danza española y flamenco concedieron mayor importancia a la evaluación de la morfología de las piernas y aspectos de ritmo y expresión, mientras que los de la especialidad de contemporáneo destacaron con más importancia la calificación de la morfología de la columna y la pelvis. Los resultados muestran diferencias estadísticamente significativas en la distribución de las calificaciones de determinados ítems de evaluación. Abstrac. Access to official studies in dance is granted following dance aptitude tests in Spanish Professional Conservatories of Dance, performed by dance teachers who evaluate rhythmic, expressive and psychomotor skills and doctors physicians who perform an assessment of the physical characteristics. The selection of students is based on the results of these tests. The aim is to know if there are differences among teachers who evaluate according to their specialty in dance (Ballet, Flamenco, Contemporary or Spanish dance) and the main features determining their ratings. No studies have been found on tests to conduct such evaluations. To complete the objectives of the study, quantitative and qualitative data were collected through the administration of a test (n=27). The results indicate that, while the classical dance teacher prioritized weight/height, foot morphology and leg flexibility, teachers of Spanish dance and flamenco granted greater importance to the evaluation of the morphology of the legs and aspects of rhythm and expression. Teachers of contemporary dance emphasized ratings of spine and pelvis morphology.
... If the os trigonum is present, it is usually entrapped and narrowed under the thick tendon sheath. Stenosing tenosynovitis of the FHL with involvement of the os trigonum has been reported as a major pathologic finding [1][2][3][4]. ...
We report a rare case of massive accumulation of fluid in the flexor hallucis longus tendon sheath with stenosing tenosynovitis and os trigonum. A 34-year-old woman presented to our hospital with pain and swelling in the posteromedial aspect of the left ankle joint after an ankle sprain approximately 8 months earlier. There was tenderness at the posteromedial aspect of the ankle, and the pain worsened on dorsiflexion of the left great toe. Magnetic resonance imaging revealed massive accumulation of fluid around the flexor hallucis longus tendon. We removed the os trigonum, performed tenosynovectomy around the flexor hallucis longus, and released the flexor hallucis longus tendon via posterior arthroscopy using standard posterolateral and posteromedial portals. At 1 week postoperatively, the patient was asymptomatic and able to resume her daily activities. There has been no recurrence of the massive accumulation of fluid around the flexor hallucis longus tendon as of 1 year after the surgery. To our knowledge, this is a rare case report of extreme massive effusion in the flexor hallucis longus tendon sheath with stenosing tenosynovitis and os trigonum treated successfully by removal of the os trigonum, tenosynovectomy around the flexor hallucis longus, and release of the flexor hallucis longus tendon via posterior ankle arthroscopy.
... Lateral ankle instability was previously linked to mechanisms leading to PAIS [17]. Some reports explained the pathophysiology of os trigonum syndrome; for example, in a lateral ankle sprain, the talus can rotate more anteriorly under the tibial plafond, resulting in the ossicle impingement between the posterior edge of distal tibia and the talus [22,24]. ...
Purpose
Os trigonum syndrome is a rare condition, often affecting athletes. A paucity of data exists on the incidence of os trigonum syndrome in nonathletic population. The study aimed to determine the incidence and clinical characteristics of os trigonum syndrome in nonathletic patients with sprained ankles.
Methods
The sample consisted of 798 adolescent and adult patients that attended the emergency department or Foot and Ankle Clinic with acute ankle sprain. Lateral and/or oblique lateral radiographs of the feet were screened for the presence of os trigonum in relation to age and gender. A cohort of 163 patients with os trigonum was followed up prospectively over a 48-month period to correlate the presence of the os trigonum with patient symptomatology.
Results
Os trigonum was found in 20.4% (163/798) of sprained ankles. Patients aged 18–35 exhibited most os trigonum [42.3% (69/163)], with higher incidence in females. 5.5% (9/163) of the os trigonum patients developed an os trigonum syndrome after a standard treatment of an ankle sprain [3.8% (3/78) of males and 7.1% (6/85) of females]. Females aged between 18 and 35 years had higher incidence of os trigonum syndrome compared to males of a similar age.
Conclusion
Os trigonum syndrome should be suspected in nonathletic patients with an ankle sprain unresponsive to standard treatment. About 1.1% of acute ankle sprain patients develop an os trigonum syndrome. This finding can help identify the source of a patient’s symptoms, leading to an accurate diagnosis, appropriate treatment and reducing the potential chronic symptoms.
... Posterior impingement syndrome occurs due to repetitive plantarflexion of the foot ( Russell et al. 2010). It occurs due to the entrapment of soft tissue and bony process between inferior surface of tibia and trochlear surface of talus with superior surface of calcaneus (Milan 1994). ...
ABSTRAK Kecederaan buku lali adalah kejadian yang biasa berlaku dalam mana-mana aktiviti sukan. Tujuan utama kajian adalah untuk menjelaskan anatomi buku lali, mekanisma kecederaan yang berkaitan dengan aktiviti sukan, keabnormalan secara kongenital atau variasi anatomi yang berkaitan dengan kecederaan buku lali serta perbincangan rawatan secara efektif. Suatu tinjauan perpustakaan telah dijalankan untuk mengetahui kecederaan buku lali yang berlaku akibat daripada pelbagai aktiviti sukan. Kami mendokumenkan semua sukan yang melibatkan kecederaan pada sendi buku lali. Anatomi pelbagai struktur bahagian tapak kaki dan keterlibatannya dalam kecederaan dibincangkan dengan teliti. Pengetahuan anatomi tentang kecederaan buku lali boleh memberi manfaat untuk diagnosis akan datang dan bagi tujuan rawatan. ABSTRACT Ankle injuries are commonly seen in various sports. The main aim of the present review was to highlight the normal anatomy of the ankle, mechanism of injuries related to sports, congenital abnormalities or anatomical variations related to ankle injury and discuss its effective management. A review of literature was done to determine the ankle injuries which occur as a result of various sports related activities. We documented all sports which involved injury to the ankle joint. The anatomy of various structures in the sole of foot and their involvement in injuries were discussed at length. The anatomical knowledge of ankle injury may be beneficial for future diagnosis and treatment purpose.
INTRODUÇÃO: O treinamento excessivo, incorreto, mal planejado ou inexistente pode levar a lesões crônicas, como a fratura por stress no tornozelo e tendinites, frequentes em bailarinas clássicas, causadas pelo alto número de repetições exigido para aperfeiçoamento da performance, bem como as entorses, bursites de tornozelo e tendinite de Aquiles. OBJETIVO: revisar a literatura quanto a lesões de tornozelo em bailarinas clássicas a fim de nortear profissionais, praticantes, professores e pesquisadores sobre as lesões e possíveis prevenções. MÉTODOS: Foi realizada uma revisão de literatura, tendo como critérios de inclusão os estudos publicados em revistas científicas indexadas, principalmente nos últimos 10 anos, nos idiomas pré-estabelecidos (inglês e português), que se referiam a lesões no tornozelo de bailarinos clássicos. Foram excluídos os artigos que não descreviam lesões relacionadas as articulações do tornozelo e pé. As buscas dos artigos científicos foram feitas na base de dados eletrônica Pubmed e Lilacs com os seguintes descritores de assunto: ankles AND injuries AND ballet AND dancer. Para selecionar as referências pertinentes ao tema pesquisado, inicialmente foram utilizadas as combinações simples desses termos, em inglês ou português e em seguida, a pesquisa foi refinada de acordo com as opções que a base de dados oferecia para tal procedimento RESULTADOS: O presente estudo deixou claro, a prevalência de possíveis lesões no tornozelo de praticantes de ballet clássico, bem como seus fatores causadores. No entanto, a motivação ao realizar esta revisão de literatura, foi o baixo número de pesquisas mostrando a relação entre o ballet clássico e as lesões nos tornozelos de seus praticantes, bem como o despreparo sobre questões anatômicas, biomecânicas e fisiológicas por parte dos profissionais que conduzem a formação nesta modalidade. Devido ao elevado período em que as bailarinas clássicas permanecem na posição en pointe (flexão plantar extrema), aumenta-se o grau de lesões nesta articulação. Segundo o levantamento bibliográfico, as principais lesões encontradas nos tornozelos de bailarinos clássicos foram: distensões, tendinite de aquiles, síndrome do impacto posterior, anterior e ântero-lateral do tornozelo, luxação e sub-luxação do tornozelo, fraturas por estresse no tornozelo e bursite no tornozelo. Contudo, a entorse de tornozelo é a lesão traumática mais frequente no ballet clássico, ocorrendo quando o bailarino sobe na ponta, perde o equilíbrio e cai sobre o pé ou, em aterrissagem inadequada. Ocorrendo tanto em movimentos de hiper flexão quanto de hiperextensão dos tornozelos. Devem ser realizados exercícios de fortalecimento para os músculos dorsiflexores, plantiflexores, inversores e eversores, principalmente gastrocnêmios, sóleo e tibial anterior, a fim de aumentar, tanto o fortalecimento muscular quanto a estabilidade articular, prevenindo o alto número de lesões na articulação do tornozelo. CONCLUSÃO: Miríade é o número de pesquisas sobre ballet e seus componentes de risco, no entanto, poucas pesquisas sobre a relação do ballet clássico e as lesões nos tornozelos de seus praticantes têm sido realizadas. Assim, concluímos que os bailarinos clássicos, enquanto um grupo ocupacional, tem recebido pouca atenção na literatura médica, tornando-se necessária a investigação de programas de prevenção de lesões em seus tornozelos e pés.
Ankle impingement is a broad term that encompasses both anterior and posterior ankle joint abnormalities of both bony and soft-tissue pathologies. It could also occur with combinations of both anterior and posterior joint pathologies that present simultaneously. The exact etiology behind ankle impingement syndromes might not be well understood. Generally, causative theories range from repetitive microtrauma and repetitive impaction injury to degenerative joint diseases’ post-traumatic or malunion causes. Irrespective of the etiology, broadly the affected individual might complain of joint swelling, stiffness, pain, and eventual dysfunction. Impingement syndromes are readily appreciated by thorough history taking and adequate clinical examination. The different anatomical and pathological impingement syndromes can be diagnosed by various radiological investigations. In some instances, ultimately a local infiltrative diagnostic injection might be very useful to confirm the diagnosis, but in some cases, it might also help to alleviate the presenting symptoms, becoming an adequate therapeutic tool.
Recognition, evaluation, and management of foot and ankle stress fractures are key, especially in an athletic population as it can cause long absences from performance. These can present in all bones of the human body, but they appear to be more common in the lower limb, especially over foot and ankle.Therefore, a high index of suspicion without delay in further investigation is mandatory in the athlete. Additionally, treatment consists mostly of activity modification and relative rest.Surgery can be indicated in case of a “high-risk” fracture pattern that is potentially prone to diastasis and/or displacement.This chapter focuses on the specific foot and ankle stress fractures in athletes and presents the evidence-based clinical examination pearls and best management for an early and safe return to play.KeywordsStress fracturesFoot and ankleTrack and fieldAthlete risk factorsReturn-to-play
The ankle sprain incidence in sports has been reported between 0.324 and 9 per 1000 h of activity [1, 2], with a variability that is most likely due to different definitions of injury and population. In football for example, increased ankle sprain rates have been reported in older players, dominant leg, during competition, and at the end of each half of a game [3]. Historically, the ankle used to be the most common location of injury in professional football players (around 30% of total injuries). However, more recent studies suggest a lower ankle injury rate, accounting for 10–15% of all injuries [4–6]. Approximately 60% of ankle sprains occur as a result of player contact [7, 8] and the overall ankle sprain recurrence rate is between 4% and 29% [3, 7, 8].KeywordsSyndesmosisHigh ankle sprainInstabilityClinical assessmentAnkle injuryAthlete
Posterior ankle impingement is a common cause of ankle pain. Among the pathologic contributors to the development of this condition, attention must be paid to the several ligaments located in the posterior ankle compartment. Given their proximity to the tibia, they are in some cases at risk of impingement when the talus and the calcaneus approximate each other during extreme plantar flexion. This chapter deals with some of these ligaments, focusing on their role in the development of posterior ankle impingement.KeywordsAnklePosterior impingementPosterior talofibular ligamentFlexor retinaculumPosterior talocalcaneal ligamentFibulotalocalcaneal ligament
Objective:
To assess the association between clinical features and magnetic resonance imaging (MRI) findings in posterior ankle impingement syndrome (PAIS) and to compare the prevalence of imaging findings between participants with and without a clinical diagnosis of PAIS.
Design:
Case-control study.
Setting:
Elite ballet and sport.
Participants:
Eighty-two male (54%) and female participants comprising ballet dancers (n = 43), cricket fast bowlers (n = 24), and football (soccer) players (n = 15).
Independent variables:
Clinical: posterior ankle pain on body chart, passive plantarflexion pain provocation test. Patient-reported outcome measures: Oslo Sports Trauma Research Center Overuse Injury Questionnaire, Foot and Ankle Ability Measure Sports subscale.
Main outcome measures:
Imaging findings including posterior ankle bone marrow edema, os trigonum (± bone marrow edema, and increased signal at synchondrosis), Stieda process (± bone marrow edema), talocrural and subtalar joint effusion-synovitis size, flexor hallucis longus tendinopathy, and tenosynovitis identified as present or absent on 3.0-Tesla MRI.
Results:
Imaging findings were not associated with posterior ankle pain or a positive ankle plantarflexion pain provocation test. Imaging findings were not associated with patient-reported outcome measures. Imaging findings did not differ between PAIS-positive and PAIS-negative groups. Os trigonum and Stieda process were prevalent despite clinical status.
Conclusions:
The lack of association between imaging findings and clinical features questions the role of imaging in PAIS. Clinicians should rely primarily on clinical assessment in the diagnosis and management of patients with PAIS.
Posterior ankle impingement syndrome is mainly seen in ballet dancers and frequently associated with specific movements in ballet such as pointe and demi pointe in which the whole-body weight is applied to the maximally plantar flexed ankle. We performed arthroscopic debridement for two dedicated ballet dancers on the intervening soft tissue causing PAIS. In both cases, T2-weighted MRI revealed low-signal intensity of meniscus-like soft tissue without abnormal osseous findings, connecting from the posterior side of the talus to Kager's fat pad. To examine the intervening soft tissue in detail, we performed histological evaluation by hematoxylin and eosin staining, Safranin O fast green staining, and immunohistochemistry for type I collagen and type II collagen. Hematoxylin and eosin staining showed that there was cartilage-like tissue including chondrocyte-like cells in contact with fibrous tissue. The extracellular matrix in the cartilage zone was consistently stained by Safranin O staining and type II collagen without any staining with type I collagen. These findings suggested that the meniscus-like soft tissue appearing as low-signal intensity on MRI at the posterior side of talus included hyaline-like cartilage. To the extent of our knowledge, these were rare cases of hyaline-like cartilage generation causing PAIS in ballet dancers, which might be associated with ballet specific movements resulting in chondrogenesis.
Background
The authors aimed to evaluate the functional outcomes of endoscopic resection and debridement of symptomatic os trigonum and associated inflammatory changes including the flexor hallucis longus (FHL) pathologies.
Methods
A prospective interventional study was conducted including 28 patients with 32 symptomatic os trigonum in the period from January 2010 to March 2016. The mean age of patients was 23.6 yr (range, 12 to 45 yr). All patients completed a minimum follow-up of 5 yr. Outcomes were assessed by the 100-mm visual analogue scale (VAS), American Orthopedic Foot and Ankle Society score (AOFAS), and the postoperative complication rate.
Results
Endoscopic examination revealed tibiotalar and subtalar hypertrophic synovitis in 14/32 and 13/32 patients, respectively. A small bony prominence encroached upon the FHL in 3/32 patients, 18/32 patients had FHL tenosynovitis, and the FHL tendon was constricted at its entry point into the tarsal tunnel requiring release of the flexor retinaculum in one patient. The mean AOFAS and the VAS scores significantly improved at final follow-up. The degree of improvement of AOFAS and the VAS scores was greater for the posterior ankle impingement group than the os trigonum fracture group. All patients experienced no major complications.
Conclusions
Posterior endoscopic excision of a symptomatic os trigonum is safe, feasible, and has excellent results in patients with various sporting or occupational activities. The degree of improvement is greater for patients without os trigonum fracture.
Level of Evidence
Level IV.
Objective
To report the prevalence of MRI features commonly associated with posterior ankle impingement syndrome in elite ballet dancers and athletes and to compare findings between groups.Materials and methodsThirty-eight professional ballet dancers (47.4% women) were age- and sex-matched to 38 elite soccer or cricket fast bowler athletes. All participants were training, playing, and performing at full workload and underwent 3.0-T standardised magnetic resonance imaging of one ankle. De-identified images were assessed by one senior musculoskeletal radiologist for findings associated with posterior ankle impingement syndrome (os trigonum, Stieda process, posterior talocrural and subtalar joint effusion-synovitis, flexor hallucis longus tendon pathology and tenosynovitis, and posterior ankle bone marrow oedema). Imaging scoring reliability testing was performed.ResultsPosterior talocrural effusion-synovitis (90.8%) and subtalar joint effusion-synovitis (93.4%) were common in both groups, as well as the presence of either an os trigonum or Stieda process (61.8%). Athletes had a higher prevalence of either os trigonum or Stieda process than dancers (74%, 50% respectively, P = 0.03). Male athletes had a higher prevalence of either os trigonum or Stieda process than male dancers (90%, 50% respectively, P = 0.01), or female athletes (56%, P = 0.02). Posterior subtalar joint effusion-synovitis size was larger in dancers than athletes (P = 0.02). Male and female dancers had similar imaging findings. There was at least moderate interobserver and intraobserver agreement for most MRI findings.Conclusion
Imaging features associated with posterior impingement were prevalent in all groups. The high prevalence of os trigonum or Stieda process in male athletes suggests that this is a typical finding in this population.
Background
Posterior ankle impingement syndrome (PAIS) is a common and debilitating condition, commonly affecting people who participate in activities that involve repetitive ankle plantarflexion. The relationship between clinical and imaging findings in PAIS has not been established.
Purpose
To investigate the relationship between clinical and imaging features in PAIS by reviewing the literature comparing symptomatic patients to asymptomatic controls.
Material and Methods
A systematic literature search was performed to identify all English-language articles that compared imaging features in patients diagnosed with PAIS to imaging in an asymptomatic control group.
Results
A total of 8394 articles were evaluated by title and abstract, and 156 articles were read in full text. No articles compared imaging findings to an asymptomatic control group, thus no articles met the inclusion criteria.
Conclusion
This systematic review found no published research that compared the imaging findings of people diagnosed with PAIS to asymptomatic people. Until this information is available, imaging features in people with posterior ankle impingement should be interpreted with caution.
Purpose
The purpose of this study was to identify and characterize various causes of delay in the diagnosis of posterior ankle impingement syndrome (PAIS) in pediatric patients.
Methods
IRB approved prospective study of patients under 18 years who underwent arthroscopic surgery for the diagnosis of posterior ankle impingement after failed conservative treatment at a tertiary children's hospital. Radiographic findings were compared with an age-matched control group. Descriptive and inferential statistics were employed.
Results
47 patients (61 ankles), mean age 13 years, had an average 14 months delay in diagnosis of PAIS from the initial presentation. 33 (70%) patients had seen multiple medical providers and given other diagnoses. 9 (19%) patients participated in ballet or soccer, and 16 (34%) patients had unrelated associated foot and ankle diagnoses. 25 (41%) of 61 ankles did not have pain on forced plantar flexion; all 61(100%) ankles had tenderness to palpation over the posterior ankle joint line. Radiographs were reported to be normal in 37/52 (71%) ankles, while MRI report did not mention the diagnosis in 20/41 (49%) studies. There was a significant difference in the MRI findings in the patient population when compared to the control group. Indication for surgery was failed conservative treatment. All 61 ankles had posterior ankle impingement pathology confirmed visually during arthroscopy. At average 15 months follow-up, there was significant improvement pre- to post-operatively (p < 0.001) for both pain VAS (6.9 to 0.9) and AOFAS ankle-hindfoot scores (65 to 94).
Conclusion
Multiple clinical and imaging factors can lead to delayed diagnosis of posterior ankle impingement. An increased awareness about the features of PAIS is needed amongst medical providers involved in treating young patients.
Neben akuten Verletzungen können auch chronische Beschwerden am Sprunggelenk oder der Achillessehne die Trainings- und Wettkampffähigkeit beeinträchtigen. Zuletzt sind die Behandlungsstrategien bei tendinopathischen Beschwerden in den Fokus der Rehabilitation gerückt. Dieses Kapitel gibt einen Überblick über die Diagnostik- und Therapieprinzipien bei akuten und chronischen Beschwerden im Bereich des Sprunggelenkes und der Achillessehne.
Pain in the foot and ankle is common in sports, resulting from a variety of conditions. It is essential for radiologists and other physicians dealing with athletes to know the range of therapeutics for these conditions, as well as the resulting imaging appearance. This chapter will outline the major treatment modalities for common injuries and other conditions affecting the athlete, ranging from fractures, ligament injuries, cartilage injury and osteochondral lesions, impingement, tendon treatment, painful ossicles, fasciopathy, coalitions, plantar plate tears and Morton neuromas.
Posterior ankle pain is a common complaint, and the potential causative pathologic processes are diverse. The constellation of these numerous etiologies has been collectively referred to as posterior ankle impingement syndrome. The pain associated with posterior ankle impingement is caused by bony or soft tissue impingement of the posterior ankle while in terminal plantar flexion. This condition is most frequently encountered in athletes who participate in sports that involve forceful, or repetitive, ankle plantar flexion. This article discusses the associated pathology, diagnosis, conservative treatment, and surgical techniques associated with flexor hallucis longus and posterior ankle impingement syndrome.
Background
Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.
Objective
To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.
Materials and methods
Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.
Results
Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager’s fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).
Conclusion
PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.
Background
The os trigonum is an accessory bone that is not fully fused with the talus during secondary ossification, and is one of the risk factors of posterior malleolus impact syndrome. The purpose of this study was to classify the os trigonum and to guide the diagnosis and treatment of related clinical diseases.
Material/Methods
Ankle computed tomography (CT) scans of 586 Chinese patients between October 2014 and October 2018 were reviewed. CT images of 1011 ankle joints were reconstructed to evaluate the classification of the os trigonum and the measurement of anatomical parameters.
Results
The incidences of os trigonum in 3 groups were determined as type I (1.9%), type II (10.5%), and type III (14.7%). The macro-axis of type II (0.89±0.31) cm was significantly larger than with type I (0.65±0.24 cm) and type III (0.74±0.23 cm) (p<0.05).The minor axis of similar of type I (0.41±0.23 cm) was significantly shorter than that of type II (0.58±0.32 cm) and type III (0.55±0.16 cm) (p<0.05).The distance from os trigonum to calcaneal tubercle was significantly different than that of type I (1.33±0.52 cm), type II (1.67±0.55 cm), and type III (1.84±0.45 cm) (p<0.05).
Conclusions
This study showed that os trigonum has a high incidence. Type I was the least common, the volume of type II was larger, and type III was more common. The anatomical parameters of each type may improve treatment of related diseases and the further development of ankle arthroscopic surgery.
We treated 52 patients with impingement of the anterolateral soft tissues of the ankle by arthroscopic debridement. All had a history of single or multiple inversion injuries, without instability. One half had negative stress radiographs (stable group), while the others were positive (unstable group). Their mean age was 31 years and there were 35 men and 17 women. The results were assessed at a mean follow-up of 30 months.
Three patients (6%) had a fair result, while 49 (94%) had an excellent or good outcome. No difference was found in the final results between the two groups (p > 0.05). We conclude that anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle.
1. The carpus and tarsus are subject to the same types of anomalous development.
2. Congenital anomalies may or may not be hereditary; they may be bilateral or unilateral; and they may undergo pathological changes.
3. Teratological data are commonly misused for the fabrication of unsubstantiated phylogenetic speculations.
4. Four types of anomalies must be distinguished: (a) extensive abnormalities; (b) fusions; (c) accessoria; (d) bipartitions.
5. Carpal absences are usual in the "paraxial hemimelias". Duplications and absences are found in polymelic conditions (double foetus, symmelia, partial limb duplication).
6. Congenital carpal or tarsal fusions may occur between almost any two elements, and probably arise as an absence of joint cavitation, and chondrification of the embryonic "interzone". Lunatotriquetral fusion is the most frequent type in the hand; its relation to an accessory ossicle seems to be gratuitous. "Peroneal spastic flat-foot" is generally due to talocalcaneal or calcaneonavicular fusion.
7. Many accessory ossicles have been described a number have been found in the embryo. Postnatal pathological origins in some instances must also be kept in mind, however. It is not practicable at present to distinguish "accessory" from "sesamoid" bones. Many accessory bones exhibit "bilocation", that is, they may occur either at or as a process on one of the major elements. It is suggested that the terminology of the accessoria be standardized in agreement with current anatomical nomenclature.
8. Although most divisions of bones are traumatic in origin, a few cases seem to be congenital. Bipartite scaphoid probably arises from two mesenchymal or cartilaginous centers, and the division is at the waist. Bipartite medial cuneiform is divided into dorsal and plantar parts. Endocrine factors may be operative in some cases of bipartition, as in hypothyroid epiphyseal dysgenesis, characterized by multiple ossific foci.
Ballet is an exquisitely sophisticated and elegant art form. However its seeming ease and gracefulness belie the underlying physical stress. Much of a dancer's ability is reliant on favourable anatomy, strength and flexibility. Their foot mechanics, training and performing techniques are unique and thus they present with particular injury patterns. The following paper aims to address these differences and provide an approach to assessing and treating foot and ankle injuries in the ballet dancer.
The epidemiology of dance injuries requires further study, in order to properly implement effective health interventions. This study aimed to pilot injury surveillance tools to assess the incidence of injuries in adolescent pre-professional dancers and identify the intrinsic and extrinsic risk factors associated with dance injuries. The study involved a prospective, cohort design. A population of adolescent dancers at a liberal arts high school dance program in Natick, Massachusetts, was studied over the nine-month school year in 2000/2001. Intrinsic risk factors, including anatomical characteristics, past medical history, menstrual history, and dance experience, were assessed with a pre-participation history and orthopedic physical exam. The extrinsic risk factors, including training, fatigue, stress, shoes, and calcium intake, were assessed with surveys completed every two weeks by the dancers. Study outcomes were: 1) self-reported injuries (SRIs), 2) reported injuries (RIs) assessed by a physical therapist in the school clinic, 3) duration of injuries, and 4) severity of injuries. Descriptive statistics and univariate analyses were performed on each risk factor. Thirty-nine of 55 dancers participated in the study. The average age was 15.3 years, and 85% of the dancers were female. The return rate for the biweekly surveys was 90%. Over one school year, there were 112 self-reported injuries, averaging 2.8 SRIs per dancer, and 71 reported injuries assessed by the physical therapist, averaging 1.4 RIs per dancer. Consistent with other studies, the most common locations for injuries were ankles, lower leg/calf, and back, usually caused by overuse, muscle strains, and sprains. Although the female dancers reported dancing significantly more hours (3.3 hours per day) than the males (2.7 hours/day), the males had a higher injury rate of SRIs (8.4 injuries/1,000 exposure hours of dancing vs. 4.1 injuries/1,000 hours) as well as RIs (5.5 injuries/1,000 hours vs. 2.6 injuries/1,000 hours). Older age and male sex were risk factors associated with SRIs and RIs. Most risk factors were found not to be statistically associated with the number of SRIs or RIs. Self-reported injuries occur frequently in pre-professional student dancers, who seek medical care in more than half the cases. Health professionals involved with dancers should be familiar with posterior ankle and low back problems. The rates of injuries appear almost twice as high in male dancers than female dancers. The main limitations to this study were small sample size and misclassification, recall, and reporting biases. With the information and tools of this pilot study, a multi-center study can be carried out to better assess risk factors on a larger dance population. Further research should aim to standardize injury definitions and classifications.
Ballet dancers frequently stand on the tips of their toes in the en pointe and demi-pointe positions, resulting in compression of the posterior structures of the ankle during repeated plantar flexion of the foot, producing the talar compression syndrome. This mechanism may result in posterior block or impingement of an os trigonum or Stieda's process. When the dancer attempts to force the foot into plantar flexion, the os trigonum or the Stieda's process may be impinged between the calcaneus and the posterior edge of the tibia. Pain and tenderness are localized at the posterolateral aspect of the ankle behind the peroneal tendons. In nondancing members of the population, these conditions are usually asymptomatic. It is the requirement of the classical dance for a well-pointed foot that produces symptoms. We are reporting up to 7 years follow-up of six professional ballet dancers in whom we removed the os trigonum for symptomatic talar compression syndrome, caused by the trauma of the en pointe position of toe dancing. Two patients had bilateral operations. All six patients returned to professional dancing within a few months and remained asymptomatic. The anatomy of this condition is reviewed, as well as the diagnosis and treatment.
Two patients presented with painful heels. The first was relieved by excision of the os trigonum from each heel. The second was relieved by local steroid injection. The os trigonum is not always an insignificant roentgenographic finding, and fracture of the posterior process of the talus does occur and may in time resemble an os trigonum.
Abstract
PURPOSE: To evaluate the results for patients treated arthroscopically for anterolateral soft tissue impingement syndrome, to determine the factors affecting the outcome, and to report on a synovial shelf.
TYPE OF STUDY: Retrospective clinical review.
METHODS: Forty-one patients underwent operative arthroscopy for anterolateral impingement of the ankle between 1990 and 2001; the mean follow-up was 83.7 months (range, 21 to 152 months). There were 25 men and 16 women with an average age of 33.2 years (range, 15 to 63 years). All patients reported a history of inversion injury to the ankle. The most frequent preoperative complaints were tenderness localized to the anterolateral aspect of the ankle, swelling, crepitation, and pain at weight-bearing. All patients had failed to respond to at least 3 months of conservative treatment. The results were assessed according to Meislin's criteria and the American Orthopaedics Foot and Ankle Society (AOFAS) scoring table. For statistical analysis, the Mann-Whitney U test was used where appropriate and the significance was set at P < .005.
RESULTS: According to Meislin's criteria, there were excellent results in 21 patients, good in 16, fair in 2, and poor in 2. The mean AOFAS score was 89.6 points (range, 60-100) at follow-up. Four different soft tissue pathologies causing impingement were described. It has been statistically shown that cartilage damage located at the anterolateral region of the ankle and not advanced to the subchondral bone, and repeated inversion injuries had negative effects on clinical results at long-term follow-up.
CONCLUSIONS: The arthroscopic diagnosis and treatment of anterolateral soft tissue impingement is a safe and effective method. Any combination of associated intra-articular pathologies, such as a chondral lesion or a new inversion injury of the ankle, after the arthroscopic procedure resulted in a poor outcome.
LEVEL OF EVIDENCE: Level IV, Therapeutic Study.
Purpose of the studyThe purpose of this work was to describe the posterior ankle impingement syndrome and to present a retrospective analysis of results after surgical treatment in 21 patients with a mean five years follow-up.
Os trigonum impingement is a cause of posterior ankle pain in ballet dancers and other athletes who forcibly point their feet. It must be distinguished from other causes of posterolateral ankle pain. A course of nonsurgical therapy is recommended as the initial treatment. In those cases where conservative treatment fails, good results have been obtained by surgical excision of the accessory ossicle. Both lateral and medial surgical approaches are described.
Talar stress injury was diagnosed in a 16-year-old ballerina who frequently danced en pointe, a position in which the subtalar joint is locked with the heel and forefoot in varus position. After completing a 6-week non-weightbearing period as prescribed, the patient wore a removable walker boot for 2 weeks. During this period, she underwent non-weightbearing exercise and symptoms resolved. She avoided prohibited movements for 2 weeks; during the next 6 months, she gradually returned to full dance activity. When last seen at follow-up 4 months later, the patient remained pain-free. During en point dancing, the force of full weightbearing is probably transmitted through the talus and thus predisposes it to stress fracture from repetitive loading.
Easy access of medical attention was provided to advanced students in a pre-professional ballet school. During a 20-month period 38 of 54 students between the ages of 12 and 19 reported 194 musculoskeletal complaints. The type and location of these complaints were compared to 1,353 injuries, in a comparable age group evaluated in a sports/dance medicine clinic. The incidence rates of musculoskeletal complaints among the students and the injuries found in the clinic population were similar. The similar injury rates suggest that the students' complaints were early manifestations of the injuries that required formal medical care, thus indicating that information on the management of these injuries when provided to dancers may constitute a preventative measure and result in a decrease in the number of these injuries that advance to the stage where formal medical care is necessary.
Injuries of the deltoid ligament are uncommon and frequently missed. The treating surgeon needs to understand the surgical, magnetic resonance imaging (MRI), and arthroscopic anatomy of the medial malleolar-talar articulation and deltoid ligament complex, both in the normal and abnormal settings. A careful history, physical examination, and diagnostic testing are needed to make the correct diagnosis of deltoid ligament injuries. Stress radiographs and MRI scans are particularly helpful in delineating the extent of the injury and in detecting other associated injuries as well. Acute repairs are only done when the medial clear space cannot be reduced. Chronic deltoid injuries can be treated with arthroscopic evaluation and debridement, but if a complete tear is found, open repair is necessary. In a chronic situation where the torn deltoid ligament cannot be repair, a free flexor digitorum longus graft or a split posterior tibial tendon augmentation can be used to reconstruct the deltoid ligament. A high index of suspicion is necessary to assist in the diagnosis and treatment of this challenging problem.
(C) 2000 Lippincott Williams & Wilkins, Inc.
1. Previous papers on the subject of the os trigonum are reviewed.
2. Evidence is produced to show that the posterior part of the talus normally develops from separate centres.
3. An explanation is given for the presence in adults of separate ossicles (the so-called os trigonum) in one or both ankles and for the variety of shapes adopted by them.
4. Contrary to opinions expressed by previous writers, these ossicles may give rise to symptoms.
A typical disease entity in dancers is the posterior ankle impingement syndrome. After unsuccessful conservative therapy, 24 dancers with an average age of 21.9 years (16–34 years) were treated in the same way using an open surgical technique. Functional assessment of the surgical outcome was made after an average of 26.2 months (18–34 months) using a modified version of the clinical score. A very good outcome was achieved in 13 patients (54%), and a good or satisfactory outcome in five patients each (21% each). One patient (4%) had a poor outcome. The widely used term `os trigonum syndrome' is not recommended, as it is too readily associated with a therapeutically relevant pathological finding, i.e. one requiring surgical treatment. Rather, we recommend the use of the term `posterior ankle impingement', in which the cause of impingement should also be stated in all cases.
Posterior impingement syndromes of the ankle have been well described in the literature. It is most commonly associated with a prominent or fractured posterior talar process, an os trigonum or fibrotic scar tissue [Foot Ankle Int 15 (1994) 2; J Bone Joint Surg Am 78 (1996) 1491; Foot Ankle 11 (1991) 404]. There have been few reports of isolated posteromedial impingement lesions and those reported discuss findings of mechanical impingement resulting from disorganised scar tissue or ligament damage [Arthroscopy 9 (1993) 709; Am J Sports Med 29 (2001) 550]. We present two cases of posteromedial impingement of the ankle resulting from an isolated accessory bony lesion, causing symptoms distinct from fibrotic scar tissue impingement or the os trigonum syndrome.
Acute or repetitive trauma to the ankle can result in painful restriction of movement caused by impingement of soft tissue and osseous structures. Ankle impingement syndromes are classified according to their anatomic relationship to the tibiotalar joint. This article reviews the relevant anatomy, etiology, and clinical features of ankle impingement syndromes, and demonstrates the potential imaging findings and discusses management of each for these conditions.
Injuries to the lateral ligament complex of the ankle are common problems in acute care practice. We believe that a well-developed knowledge of the anatomy provides a foundation for understanding the basic mechanism of injury, diagnosis, and treatment, especially surgical treatment, of lateral collateral ankle ligament injury. To address this issue we performed this review with regard to the anatomy of the lateral collateral ankle ligaments. Clin. Anat. 21:619-626, 2008. (C) 2008 Wiley-Liss, Inc.
Sixteen patients underwent surgical excision of an im pinging ossicle through a posterior lateral approach. Twelve of these patients (15 ankles) were available for followup and were retrospectively surveyed at an av erage of 28 months after surgery. There were 9 women and 3 men. Nine were professional ballet dancers and 3 were students of advanced ballet schools. Preoper ative symptoms included pain localized to the posterior ankle, limitation of motion, weakness, swelling, or neu rologic changes associated with dance activities. All patients were severely hampered in their dance partic ipation and had failed nonsurgical therapies.
Postoperatively, all patients followed an aggressive rehabilitation protocol. All had improvement in their impingement symptoms; eight (67%) still had occa sional discomfort. All professional dancers returned to unrestricted dance activity. The mean time to full activity was 3 months. One patient had a superficial wound infection requiring antibiotic treatment and another suf fered a transient tibial nerve neurapraxia. Both of these complications resolved without sequelae.
We conclude that posterior ankle impingement in ballet dancers, caused by an os trigonum and resistant to nonsurgical therapies, is effectively treated with sim ple excision of the offending structure.
The cases of nine patients with ununited fracture of the posterior process of the talus were reviewed. The most common mechanism of injury was forced plantarflexion. All patients had pain in the posterior ankle region. Common physical findings included tenderness between the lateral malleolus and the Achilles tendon and pain on forced plantarflexion. Of the radiographic imaging modalities used, ⁹⁹ Tc bone scan was found to be the most helpful in diagnosis.
All nine patients eventually underwent surgical excision at a mean period of 9.4 months post injury. At average follow-up of 27 months after surgery (range 7–69 months), six of nine patients had good or excellent results with respect to pain relief and return to function. There were two complications of sural neuroma formation, one of which resulted in severe persistent pain after surgery.
Based on these findings, we believe the differential diagnosis of chronic posttraumatic ankle pain should include fracture of the posterior process of the talus. Furthermore, excision of an ununited fragment through a lateral approach, taking care to preserve and protect the sural nerve, should lead to the return of painless function in the majority of cases.
The os trigonum syndrome, a musculoskeletal ankle disorder causing posterior ankle pain, is an entity that may present as numerous disorders. To accurately diagnose and treat the syndrome, its anatomy, origin, nomenclature, and biomechanics must be thoroughly understood. For this purpose, a review of recent literature is presented.
Twenty-eight principal dancers and soloists from America's two most famous ballet companies were examined for anthropometric measurements, including flexibility, muscle strength, and joint range of motion. Both male and female dancers were flexible, but not hypermobile, and did not differ significantly from each other. Marked differences were found between the range of motion of the hip and ankle in the dancers and the norms for the general population. The increased external rotation of the hip in women was accompanied by a loss in internal rotation, resulting in an increased range of motion with an externally rotated orientation. The men, however, lost more internal rotation than they gained in external rotation. These data raise the possibility of a torsional component to the turned-out hip position in elite female professional ballet dancers. In addition, significant anatomic differences separate elite dancers of both sexes from the normal population.
Thirteen Swedish National classic ballet dancers were surgically treated for an "os trigonum syndrome."Their main symptom was an impingement pain in the hind foot while actively plantarflexing the ankle during ballet dancing. The surgical procedure included excision of an os trigonum or a prominent lateral posterior process of the talus, together with division of the flexor hallucis tendon sheath if it was thickened. This procedure was safe and resulted in return of the dancers to the same level of ballet dancing within 5 to 10 weeks.
Seven patients who had pain in the anterior aspect of the ankle were found to have a thickened distal fascicle of the anteroinferior tibiofibular ligament. Each patient had a history of an inversion sprain of the ankle followed by chronic pain in the anterior aspect of the ankle. The thickened distal fascicle was resected without loss of stability of the ankle. Five patients needed débridement of an area of abraded hyaline cartilage on the anterolateral aspect of the talus. Six patients were followed for a mean of thirty-nine months (range, twenty-four to fifty-nine months). Four of them had no pain in the ankle or limitation in activities, and two reported marked improvement, with only occasional pain in the ankle related to overuse. A separate distal fascicle of the anteroinferior tibiofibular ligament is present in most human ankles and can be a cause of talar impingement, abrasion of the articular cartilage, and pain in the anterior aspect of the ankle. Resection of this ligament usually will alleviate the pain caused by the impingement.
The os trigonum is a frequently encountered accessory bone of the foot. It is located at the posterior aspect of the talus, and may appear either as a separate ossicle or fused to the talus. The separate ossicle may represent an accessory bone or a fracture of the posterior process (also called the trigonal process) of the talus. The author reviews the mechanism of injury and the diagnosis and treatment. A case report of a fracture of the trigonal process is presented.
Three anatomic specimens of os trigonum from skeletally immature patients demonstrated anatomic continuity of the cartilage containing the ossicle with the body of the talus, with a synchondrosis being present between the two ossifying regions. The os trigonum may be considered a developmental analogue of a secondary ossification center similar to the posterior calcaneal apophysis (although there are obvious histologic differences). The chondro-osseous border of the synchondrosis may be injured either as a chronic stress fracture or, less frequently, as an acute fracture, comparable to the injury patterns involving the accessory navicular.
A survey of injuries to dancers was commissioned by the National Organisation of Dance and Mime. Questionnaires asking about chronic and recent injuries were sent to 188 dancers and completed by 141 dancers from seven professional ballet and modern dance companies in the United Kingdom (75% response rate). It was found that of the 141 dancers, 67 (47%) had experienced a chronic injury and 59 (42%) an injury in the previous six months that had affected their dancing. A high proportion of injuries to the soft tissues had not responded to treatment. With correct treatment such injuries should usually heal completely. Dancers are aware of the high rate of injuries and also of procedures that might help to prevent injury--for example, dancing on floors that are sprung and in warmer studios; teachers' and choreographers' awareness of a dancer's limitations and the need for rest and adequate treatment when an injury occurs.
The pathomechanics of dance injury are explained. Specific injuries are included, such as fractures, ankle sprains, anterior impingement syndrome, posterior impingement syndrome, flexor hallicus longus tendinitis, Achilles tendinitis, and stress fractures.
The author discusses the diagnosis and both conservative and surgical methods of treating this problem common to professional ballet dancers.
The theatrical dancer is a unique combination of athlete and artist. The physical demands of dance class, rehearsal, and performance can lead to injury, particularly to the foot and ankle. Ankle sprains are the most common acute injury. Chronic injuries predominate and relate primarily to the repeated impact loading of the foot and ankle on the dance floor. Contributing factors include anatomic variation, improper technique, and fatigue.
Early and aggressive conservative management is usually successful and surgery is rarely indicated. Orthotics play a limited but potentially useful role in treatment Following treatment, a structured rehabilitation program is fundamental to the successful return to dance.
Dancing is not dangerous; however, dancers must recognize their limitations and learn to do the best they can with what they have to work with. This article discusses some of the more common acute and chronic foot and ankle problems in dancers for the benefit of the treating physician.
Ballet dancers frequently stand on the tips of their toes in the en pointe and demi pointe positions, resulting in compression of the posterior structures of the ankle during repeated plantar flexion of the foot, producing the talar compression syndrome. This mechanism may result in posterior block or impingement of an os trigonum or Stieda's process. When the dancer attempts to force the foot into plantar flexion, the os trigonum or the Stieda's process may be impinged between the calcaneus and the posterior edge of the tibia. Pain and tenderness are localized at the posterolateral aspect of the ankle behind the peroneal tendons. In nondancing members of the population, these conditions are usually asymptomatic. It is the requirement of the classical dance for a well-pointed foot that produces symptoms. We are reporting up to 7 years' followup of six professional ballet dancers in whom we removed the os trigonum for symptomatic talar compression syndrome, caused by the trauma of the en pointe position of toe dancing. Two patients had bilateral operations. All six patients returned to professional dancing within a few months and remained asymptomatic. The anatomy of this condition is reviewed, as well as the diagnosis and treatment.
Three groups of apparently normal developmental variants in extremities as they appear on radiographs are presented. In contrast to the widely held view that these are of no clinical significance, these ossicles may, in fact, be responsible for symptoms. The first group consists of ossicles which, from the very onset, may represent the sequelae of repetitious trauma. The second group is composed of normal variants in which the presence of a congenital synchondrosis may predispose to injury as a result of chronic repetitious trauma. The third group consists of ossicles that may result in local and premature degenerative changes. The use of radionuclide bone scanning, which provides physiologic as well as morphologic information, is crucial in evaluating the significance of these ossicles in the symptomatic patient.
Radiographs of the hip and lower extremities of 52 professional ballet dancers were evaluated. Among the various abnormalities, some similar to those found in athletes, were specific patterns of stress hypertrophy of the femora, tibiae, fibulae, and the first 3 metatarsal bones, and multiple stress fractures of the femoral necks and tibiae. This group of findings is sufficient to identify the classical ballet dancer.