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Ankle sprain: the most frequent acute trauma among dancers

Updated: Nov 24, 2020

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The orthopedic pathologies that afflict the dancers are mainly chronic in nature or from functional overload: they are linked, in fact, to the repetition of the same movement for many hours a day until the tolerance threshold of the bone and muscle-tendon structures involved is exceeded. The distortion of the ankle trauma represents, in this context, a sort of exception: in all statistical surveys concerning dancers, the distosions are reported as the most frequent and often least considered from a technical and rehabilitative point of view. Distortion means the set of injuries to the capsuloligamentous structures that cover an articulation that occur due to a sudden stress of the articulation itself in an unusual direction of movement or due to an excessive degree of mobility. It is useful to remember that both the joint capsule and the ligaments are composed of fibrous connective tissue and that, within them, there are numerous position receptors (proprioceptors) that are responsible for the perception in the brain of the position of the ankle in space and therefore, obviously, an individual's ability to maintain balance.

From the skeletal point of view, the ankle (or tibio-tarsal articulation) is composed of the two malleoli - tibial and peroneal - which form a kind of "pincer", called precisely malleolar forceps, in which the cylindrical body of the talus is articulated ( one of the seven bones of the tarsus, ie of the back of the foot); from the apex of each malleolus it originates a ligament that branches out, like a fan, on the bones of the tarsus and which is responsible for the stability of the joint (internal collateral ligament and external collateral ligament). The thickness of the two ligaments, however, is decidedly different: in the inner part of the ankle, the ligaments are very robust while, in the outer part, the external collateral ligament is formed by three relatively thin bundles of which the most anterior, called the peronate ligament- Anterior talus, is extremely important to maintain ankle stability in the relevé. Precisely because of the shape of the bones that compose it, the ankle is able to perform only flexion and extension movements (as in the alternation plié-relevé) and, any stress of the joint in another direction, predisposes to distortion : since the two malleoli are not symmetrical, the foot "yields" more easily with the fingertips pointing towards the center of the body (trauma in inversion) and the trauma almost always affects the most anterior portion of the external collateral ligament, ie the ligament peroneal-anterior talar. The ankle distortion can occur during the descent from a jump or from a relevé; poor control of the alignment of the lower limb, both in parallel and in dehors, can favor the incorrect support of the foot on the ground. Many distortions occur at the end of the lesson and / or tests: in these cases fatigue can be considered an important risk factor; other causes that can predispose to ankle sprains are poor control of the peroneal muscles, the presence of a rigid hallux (which predisposes to supporting the foot in supination), the execution of overly complex overhangs, the floor too rigid, etc.

However, of all the risk factors, those that should be taken into consideration in the dance hall are, above all, the technical defects: the poor ability of the dancer to correctly distribute the load between the five heads of the metatarsus (on the demi-pointe) or between the first three fingers (on the tips), the risk of incurring distortive traumas clearly increases. Normally the ankle sprains are classified in three degrees: the first degree distortion, or slight distortion, is characterized by the stretching of the ligament, with the interruption of a small number of bundles that compose it; in the second degree distortion, or medium distortion, the lesion of a fair number of bundles is highlighted, so that the ligament is partially interrupted; the third degree lesion, or severe distortion, is characterized by the complete interruption of the affected ligament. Fortunately, this latter type of injury is relatively rare and most of the dancer's distortions can be classified as mild or medium. The diagnosis of ankle sprain is mainly clinical - the presence and extent of swelling, painful points on palpation, presence of any signs of instability - and, through a simple visit, in most cases it is also possible to establish the extent of the lesion . Radiographic examination is advisable to exclude the concomitance of complications such as tear fracture of the base of the fifth metatarsal (linked to the abrupt contraction of the short peroneal muscle in an attempt to avoid distortion trauma).

The urgent treatment of ankle sprain involves the local application of ice and the raising of the limb to reduce edema and pain; the immobilization of the joint by means of a bandage, an anklet or a brace, allows the damaged ligament fibers to restore their continuity. The use of the plaster cast is rare and we try to avoid it as it greatly slows down the recovery time of the activity; surgical reconstruction of ligaments, in the event of complete interruption, is still a fairly controversial topic: most orthopedists, however, tend towards non-invasive treatment even of third-degree distortions which, if well rehabilitated, may be able to heal without sequelae. In this regard, it seems important to underline that very often the dancers underestimate the importance of the distortive trauma: they do not respect the recommended rest times or even arbitrarily remove the bandages or tutors applied by the doctor or physiotherapist to be able to return, as quickly as possible possible, to their daily lessons. Because of this type of behavior, often the healing of the distortion is not complete either from the anatomical point of view or from the functional one: the affected ankle thus becomes the weak point of the chain and at the first distortion many others can follow, due to trauma of less and less entity. Another aspect that is often overlooked is the importance of rehabilitative treatment: this will not only restore ankle mobility after the rest or immobilization period, but will also have the far more important task of reactivating the proprioceptive role of the injured ligament . The disappearance of pain and the possibility of freely moving the ankle and foot do not represent the reliable signs of a complete healing of the ligamentous lesion: the feeling of "weak ankle" that many dancers report to the resumption of lessons after a distortive trauma, is not other than a sign of poor control of the area previously affected by the trauma. The proprioceptive rehabilitation of the ankle involves the use of instability platforms (from simple tablets to the most complex instruments connected to the computer) on which one trains to maintain the monopodalic support; only after having reactivated this type of skill will the dancer be able to return to his own dance class, complete with relevé, jumps and turns.

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