Ankle sprains are prevalent in dancers (Liebler 1976). Too often treated as insignificant, these injuries can have a major impact on a dancer’s life and ability to perform. It is important to understand how the ankle joint is constructed and how these injuries occur.
The talus is the part of the ankle on which the tibia, or shinbone, rests. It is relatively wide in the front and narrow in the back (Inman 1976). The talus fits into the ankle mortise, which is a niche formed by the end of the fibula and tibia (figure 4.1).
The medial aspect of the ankle has three very strong ligaments, the deltoid ligaments. These are rarely sprained. There are also three major ligaments on the lateral side of the ankle. The anterior talofibular ligament (ATF) runs from the fibula to the talus in a horizontal fashion. When a dancer is in the demi-pointe position the ATF becomes vertical instead of horizontal. This provides mechanical stability and prevents the foot from supinating (Gould, Seligson, and Gassman 1980). The ATF also gives rotational stability to the ankle (Gould, Seligson, and Gassman 1980), preventing the talus from rotating out of its mortise, especially on outside turns. Despite, or perhaps because of,its stabilizing role, the ATF ligament is most commonly involved in minor ankle sprains.
Muscles also aid in stabilizing the ankle joint. The most important of these are the peroneal muscles, which run from the top of the fibula down the outside of the lower leg. The peroneus longus then runs along the side of the ankle and inserts under the ball of the great toe, or hallux. The peroneus brevis inserts into the base of the fifth metatarsal. On the medial side of the leg, the tibialis posterior muscle originates from underneath the calf muscle and sends its tendon around the medial malleolus, inserting on the inner aspect of the midfoot. When the foot is on demi-pointe the narrow rear part of the talus is in the mortise, and thus there is little or no mechanical (bony) stability in this position (Sammarco 1982). In high demi-pointe there is some stability gained from the locking of the calcaneus against the posterior aspect of the tibia. When the ankle is dropped even a few degrees out of a very high demi-pointe, the responsibility for stabilizing the ankle falls predominantly on the ATF ligament and the peroneal and posterior tibial muscles, which form a yoke around the ankle.
Perhaps the most important cause of ankle sprains is inadequate rehabilitation of previous ankle sprains, since these injuries are often taken too lightly. Another is poor technique in landing from jumps, particularly with the foot supinated (Hardaker et al. 1988). Certain dance steps seem to carry a higher risk for ankle sprains, such as the entrechat six (Hamilton 1982). At the end of a long day, when fatigue is a factor, rehearsing new, unfamiliar, or advanced steps can also be a very real threat. Dancers must stay attuned to the workings of their bodies to know what their limits are and when those limits are reached. Other disorders, such as hallux rigidus (arthritis of the great toe joint) can cause a sickling in of the foot when attempting relevé, which may predispose to ankle sprains. Dance surfaces that are hard or uneven or steeply raked may be a factor as well (Seals 1983).
Ankle sprains are usually classified into three grades, grade 1 being the mildest and grade 3 the most severe (and fortunately the least common). The amount of pain experienced is not a reliable indicator in diagnosing the degree or severity of an ankle sprain. A grade 1 sprain means there has been partial tearing of the fibers in the ligaments of the muscles, while a grade 2 involves a more severe tear. A grade 3 is a complete disruption or tearing of one or more of the ligaments. The ankle develops what is called a “talar tilt sign”; when the ankle is placed under a lateral stress the talus tilts and opens up, creating a gap laterally. This can be measured and diagnosed by means of a stress X ray in which the ankle is manipulated to simulate stress under normal movement conditions (Hamilton 1982). A talar tilt sign during this test indicates a complete rupture of the calcaneofibular ligament, which normally assists with lateral stability of the ankle. Clinically, a grade 3 sprain of the ATF ligament is confirmed when there is a positive “drawer sign”: That is, when the tibia is stabilized and the heel is pulled forward, there is an anterior shifting of the talus out of the mortise joint.
The first aid treatment for ankle sprains is rest, ice, compression, and elevation (RICE). This minimizes the bleeding and swelling that occur in and about the ankle joint following the sprain. Controlling the swelling significantly reduces recovery time. For first- and second-degree sprains an air-cast or gel-cast ankle brace is very useful. This consists of two plastic shells containing air- or gel-filled bladders, which are arranged on either side of the ankle and held in place by a flat stirrup that fits inside the shoe and by straps wrapped around the ankle. With each step and release the bladders cause a change of pressure, which helps force out some of the swelling. Theconstruction of the brace prevents painful pronation and supination while still allowing for nearly full flexion and extension. The dancer wearing this device is able to bear weight earlier, walk more naturally, and return to activities in less time (Hamilton 1982).
Rehabilitation aims at restoring full range of motion, the normal levels of strength and endurance, and position sense, or proprioception. In many cases exercises are addressed to these rehabilitative principles or goals simultaneously. An attempt should always be made to rehabilitate the dancer in as functional a manner as possible (Molnar 1988). It is very important to maintain overall body flexibility and strength while the dancer is injured and recuperating. Allowing the entire body to become deconditioned due to an injury of a specific part is a common problem in any sport and one that is easily avoidable. In the case of ankle injuries, swimming is an excellent solution, or a ballet barre may be done in the water (Hardaker et al. 1988).
Flexibility of the Achilles tendon must be restored through stretching, as the Achilles often becomes tight following an ankle sprain. Strengthening the peroneal muscles can be done most effectively by using a Theraband, which is a broad elastic or rubber band in varying resistance degrees, each color coded. The band can be wrapped around the balls of both feet so that when the feet are opened up to a V shape, keeping the heels together, the band applies the desired resistance. This should be done with the feet pointed as well as flexed, because the peroneal muscles come into play primarily when the foot is up on demi-pointe and must be rehabilitated in that position.
The yoke muscles, that is, the peroneal and posterior tibialis muscles, can also be strengthened effectively using manual resistance. Holding the foot, the therapist (or the dancer himself or herself) will resist movement in two different diagonals, referred to by physical therapists as “close pack” and “loose pack” (Molnar 1988). The diagonals are from dorsiflexion with supination (up and in) to plantarflexion with pronation (down and out), and the opposite, dorsiflexion with eversion or pronation (up and out) to plantarflexion with supination (down and in). Resisting these movements in a smooth but progressively intense fashion has an advantage over the Theraband in that it rehabilitates the muscles in more directional planes.
Within the substance of the ankle ligaments and joint capsule lie sensory nerve endings called proprioceptive endings. These nerve endings transmit position information to the brain, directing muscle control about the ankle to maintain stability. When the ankle is sprained, these pathways are often disrupted and must be restored through functional rehabilitation. The wobble-type board is an excellent means of doing this; one can construct this device by simply affixing a half round dowel or half of a hard wooden ball to the underside of a piece of plywood about a foot and a half square (0.14 m2). It can be used initially in a seated position with no weight bearing and then with progressive weight bearing. A more sophisticated version of this device is called the BAPS, or biomechanical ankle platform system, manufactured by Camp International. The BAPS has five different-sized hemispheres that screw to the underside of the board. The board is designed to accommodate the difference in range of motion between pronation and supination. There are mechanisms for adding weights in different positions around the foot and ankle to provide progressive resistive exercises in addition to proprioceptive rehabilitation (Molnar 1988). The BAPS board is also useful for rehabilitation of knee injuries.
Molnar, in her article “Rehabilitation of the Injured Ankle” (1988), outlines a number of ankle rehabilitation exercises (with photographs), as does Micheli in The Sports Medicine Bible (1995). The reader may wish to consult these references for more detailed information.
A sensible plan for rehabilitation is essential to full recovery. The following 7- to 10-day program is designed primarily for mild ankle sprains. More serious grades would use a similar progression but with greater length between the stages.
Day 1: Apply ice with elevation and compression; no weight bearing; air cast or gel cast.
Day 2: Do active exercises for ankle and foot two to three times a day; ice after each period; conditioning exercises for entire body, and walking when necessary with air cast. See chapter 13, pages 176-177, figure 13.6a-d.
Day 3: Massage elevated lower leg, stroking upward toward heart; swimming and pool exercises; resistive exercises for ankle two to three times a day; walking with air cast. See chapter 13, page 178, figures 13.9a-c and 13.10.
Day 4: Stretch to normal range of motion; increase resistance exercises; use balance board; continue use of ice after exercise.
Day 5: Warm up foot and ankle; contrast baths (alternating immersion of the leg to just below knee level in warm or hot and then cold water, for 20 minutes each); barre work, slowly with foot in tape; strength and flexibility exercises, then ice.
Day 6: Continue body conditioning exercises; resistance exercises for ankle; full barre, all speeds; walk in pointe shoes, but no work on pointe.
Days 7-10: Begin small jumps and turns; resisted balance positions; rehearsals and slow pointe work (Hamilton and Molnar 1983).
One further comment about third-degree (complete) sprains: There is some controversy among dance orthopedists as to how these injuries are to be managed. Some feel that conservative or “closed” management is adequate (Norris 1988a, 1988b), whereas others favor “open” or surgical repair (Hamilton 1982). It is, however, agreed that if a reconstructive procedure is necessary to stabilize a joint, the peroneal tendons should not be sacrificed to serve as a reinforcement. The peroneal tendons are too important for stability en pointe to be sacrificed (Gould, Seligson, and Gassman 1980).