Magnetic resonance imaging findings associated with posterior ankle impingement syndrome are prevalent in elite ballet dancers and athletes

Imaging Findings Associated With Osteoarthritis Are Common in Dancers, and Are Rarely Symptomatic: A Systematic Review With Meta-Analysis

OBJECTIVE: To estimate the prevalence of imaging findings that may be associated with osteoarthritis (OA), and their relationship with symptoms in dancers. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: Four electronic databases were searched (PubMed, Scopus, CINAHL, SPORTDiscus) from inception to September 2023. STUDY SELECTION CRITERIA: Included studies reported joint imaging findings in dancers. We considered all study designs that investigated populations with regular participation in any form of dance, at any stage of career. DATA SYNTHESIS: Data were pooled for meta-analysis if at least 3 studies reported on the same intra-articular imaging findings, at the same joint, in a similar dance genre. RESULTS: Thirty-two studies were included. Meta-analysis was performed for the prevalence of hip, ankle, and first metatarsophalangeal joint OA, and ankle effusion. The first metatarsophalangeal joint had the highest prevalence of radiographic OA (59%). The prevalence of symptomatic OA was low (3%). The ankle (radiographic OA 41%) and then the hip (radiographic OA 19%) joint were the next most common regions to report imaging findings, with a lower prevalence of symptomatic OA seen at the ankle (2%) to pool 2 studies and hip (8%) to pool 4 studies. CONCLUSION: There was very low certainty evidence of the first metatarsophalangeal joint having the highest prevalence of imaging findings in dancers, followed by the ankle and hip joints. A lower prevalence of symptomatic OA was seen at all 3 joints. J Orthop Sports Phys Ther 2024;55(4):1-9. Epub 3 March 2025. doi:10.2519/jospt.2025.12918.

Patterns of ankle injury in soccer: MRI clues to traumatic mechanism

Understanding the traumatic mechanisms of ankle injuries in soccer is crucial for an accurate and complete MRI diagnosis. Many ankle injuries share universal mechanisms seen in other athletic activities, but certain patterns are found to be more specific and relatively unique to soccer. Ankle impingement syndromes encountered in soccer encompass a spectrum of disorders that include anterior and posterior impingement categories, with anterior impingement representing pathology relatively specific to soccer. Lateral ligamentous sprains are one of the most common injuries; however, there is a higher rate of injuries to the medial structures in soccer as compared to other sports. Ankle fractures are uncommon in soccer while bone contusions and chondral and osteochondral injuries frequently accompany ligamentous sprains. Tendon abnormalities in soccer most commonly result from overuse injuries and typically affect peroneal tendons, posterior and anterior tibialis tendons, and Achilles tendon. Acute Achilles tendon ruptures occur in both recreational players and elite soccer athletes. Tibialis anterior friction syndrome may mimic tibial stress fractures. Long-term sequelae of acute traumatic and chronic overuse ankle injuries in professional soccer players manifest as ankle osteoarthritis that is more prevalent compared to not only the general population, but also to former elite athletes from other sports. This article examines the most common and specific injuries in soccer in order of their frequency.

Validated Tools Used to Assess Musculoskeletal Injuries in Dancers: A Systematic Review

Introduction: Dance is a physically demanding art form that often results in musculoskeletal injuries. To effectively treat these injuries, standardized and reliable assessment tools designed to the dancer's needs are required. Thus, the aim of this review is to identify studies that have employed validated tools to assess musculoskeletal injuries in ballet, modern, and contemporary dancers, focusing on describing the content and psychometric quality of the tools used. Methods: This systematic review is registered at PROSPERO (CRD42022306755). PubMed, Cochrane, LILACS, Web of Science and SPORTDiscus databases were searched by two independent reviewers. Articles assessing musculoskeletal injuries with validated tools in ballet, modern and/or contemporary dancers and written in English, Portuguese, or Spanish were included. Non-peer reviewed articles, books, conference abstracts, thesis/review articles, or case design studies were excluded. The original validation studies were compiled when necessary. Two independent reviewers conducted a standardized data extraction and evaluated the methodological quality using an adapted Downs and Black checklist. Results: From the 3933 studies screened, 172 were read to verify if they met the inclusion criteria, resulting in 37 studies included accounting for 16 unique validated tools. Two were imaging exams, one was an injury classification system, and 13 were self-reported injury questionnaires. Only four injury assessment tools were validated for dancers, emphasizing the need for further validation studies for the dance population. Most of the articles (57%) achieved high-quality methodological scores and the remaining (43%) reported medium-quality scores. Conclusions: Valid, reliable, and specific tools to assess dance injuries are lacking in general. For enhanced methodological rigor in future studies, the incorporation of validated tools is recommended to improve methodological quality and facilitate cross-study comparisons. Researchers may consider conducting validation studies, involving processes such as translation into another language, validation of modifications to the original tool, or reporting reliability within the article itself.

Foot and Ankle MRI Findings in Asymptomatic Professional Ballet Dancers

Background

Previous research in sport populations has demonstrated that abnormal magnetic resonance imaging (MRI) findings may be present in individuals without symptoms or known pathology. Extending this understanding to ballet, particularly in relation to the foot and ankle, is important to guide medical advice given to dancers.

Purpose

To assess foot and ankle MRI scans in asymptomatic ballet dancers focusing on bone marrow edema and the posterior ankle and to investigate whether these MRI findings would become symptomatic within 1 year.

Study Design

Case series; Level of evidence, 4.

Methods

In total, 31 healthy dancers (62 feet/ankles; 15 male and 16 female; age, 26.5 ± 4.3 years) who were dancing in full capacity were recruited from an elite professional ballet company. Orthogonal 3-plane short tau inversion recovery imaging of both feet and ankles was obtained using 3T MRI and the images were reviewed using a standardized evaluation form by 2 musculoskeletal radiologists. Injuries in the company were recorded and positive MRI findings were assessed for correlation with any injuries requiring medical attention during the subsequent 12 months.

Results

A total of 51 (82%) of the 62 feet and ankles had ≥1 area of bone marrow edema. The most common locations of bone marrow edema were the talus (n = 41; 66%), followed by first metatarsal (n = 14; 23%). Os trigonum and Stieda process were seen in 5 (8%) and 8 (13%) ankles, respectively. Among them, 2 os trigona showed bone marrow edema. Fluid in the anterior and posterior talocrural joints and the subtalar joint was observed in 48%, 63%, and 63% of these joints, respectively. Fluid around foot and ankle tendons was observed, with the most prevalent being the flexor hallucis longus tendon (n = 13; 21%). Two dancers who had positive findings on their MRI subsequently developed symptoms during the next 12 months.

Conclusion

Positive MRI findings are commonplace in the foot and ankle of asymptomatic professional ballet dancers. The majority do not result in the development of symptoms requiring medical attention within 12 months. Careful interpretation of MRI findings with the dancer's clinical picture is required before recommending activity modification or further intervention.

The Pediatric Ankle: Normal Variations and Maturation-Dependent Pathology

The pediatric ankle can present a broad range of normal variation and pathology unique to certain stages of development. Understanding the expected age ranges of ossification and fusion about the ankle is essential to provide accurate diagnoses regarding skeletal integrity. This conclusion has been well characterized radiographically and is supported by cadaveric research.The range of appearances on magnetic resonance imaging has also been well described. Knowledge about the structure of the periosteum and perichondrium aids in image interpretation as well as explaining typical injury patterns. The expected appearance of the physis and regional bone marrow signal is also of utmost importance.Ultrasonography is a valuable tool in pediatric musculoskeletal imaging but is limited when there is concern for intra-articular pathology. Computed tomography tends to be reserved for preoperative evaluation. We describe normal variation and maturation-dependent pathology of the pediatric ankle with an emphasis on imaging considerations.

Single-Leg Heel Raise Capacity is Lower, and Perceived Ankle Instability is Greater, in Dancers and Athletes With Posterior Ankle Impingement Syndrome

OBJECTIVE

To compare clinical assessment findings between elite athletic populations with and without a clinical diagnosis of posterior ankle impingement syndrome (PAIS).

DESIGN

Cross-sectional case-control study.

SETTING

Elite ballet and sport.

PARTICIPANTS

Ten male and female professional ballet dancers and athletes with a clinical diagnosis of PAIS and were matched for age, sex, and activity to 10 professional ballet dancers and athletes without PAIS.

INDEPENDENT VARIABLES

Posterior ankle pain on body chart and a positive ankle plantarflexion pain provocation test.

MAIN OUTCOME MEASURES

Single-leg heel raise (SLHR) endurance test, range of motion testing for weight-bearing ankle dorsiflexion, passive ankle plantarflexion, and first metatarsophalangeal joint dorsiflexion, and Beighton score for generalized joint hypermobility. Participants also completed the Cumberland Ankle Instability Tool (CAIT) questionnaire.

RESULTS

The group with PAIS achieved significantly fewer repetitions on SLHR capacity testing ( P = 0.02) and were more symptomatic for perceived ankle instability according to CAIT scores ( P = 0.004).

CONCLUSIONS

Single-leg heel raise endurance capacity was lower, and perceived ankle instability was greater in participants with PAIS. The management of this presentation in elite dancers and athletes should include the assessment and management of functional deficits.

Foot pain in children and adolescents: a problem-based approach in musculoskeletal ultrasonography

Various etiologies and risk factors contribute to foot pain in children and adolescents, including conditions such as Kohler's disease, Sever's disease, Iselin's disease, rigid flat foot, accessory navicular, Freiberg's disease, sesamoiditis, os trigonum syndrome, and more. High-frequency musculoskeletal ultrasonography can show both the bone surface and the surrounding soft tissue clearly from various angles in real-time, thereby providing a higher level of detail that is helpful for identifying the etiology of foot pain and monitoring disease progression compared with other imaging modalities. This review provides an overview of the epidemiology, pathophysiology, clinical manifestations and characteristic ultrasonographic findings of select foot pain conditions in children and adolescents.

Musculoskeletal Injury in an Australian Professional Ballet Company, 2018-2021: 953 Medical-Attention and 706 Time-Loss Injuries Over 4 Years

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.

Posterior Ankle Impingement Syndrome Clinical Features Are Not Associated With Imaging Findings in Elite Ballet Dancers and Athletes

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.