Lower Extremity Injury Patterns in Elite Ballet Dancers: Ultrasound/MRI Imaging Features and an Institutional Overview of Therapeutic Ultrasound Guided Percutaneous Interventions

Abstract

Background

Altered biomechanics from repetitive microtrauma, such as long practice hours in en pointe (tip of the toes) or demi pointe (balls of the feet) predispose ballet dancers to a multitude of musculoskeletal pathologies particularly in the lower extremities. Both ultrasound and magnetic resonance imaging (MRI) are radiation-sparing modalities which can be used to confidently evaluate these injuries, with ultrasound (US) offering the added utility of therapeutic intervention at the same time in experienced hands.

Questions/Purposes

The purposes of this paper were: (1) to illustrate the US and MRI features of lower extremity injury patterns in ballet dancers, focusing on pathologies commonly encountered at a single orthopedic hospital; (2) to present complementary roles of both ultrasound and MRI in the evaluation of these injuries whenever possible; (3) to review and present our institutional approach towards therapeutic ultrasound-guided interventions by presenting explicit cases.

Methods

Online searches were performed using the search criteria of “ballet biomechanics” and “ballet injuries.” The results were then further narrowed down by limiting articles published in the past 15 years, modality (US and MRI), anatomical region (foot and ankle, hip and knee) and to major radiology, orthopedics, and sports medicine journals.

Results

Performing ballet poses major stress to lower extremities and predisposes dancer to several musculoskeletal injuries. These can be adequately evaluated by both US and MRI. US is useful for evaluating superficial structures such as soft tissues, tendons, and ligaments, particularly in the foot and ankle. MRI provides superior resolution of deeper structures such as joints, bone marrow, and cartilage. In addition, US can be used as a therapeutic tool for providing quick symptomatic improvement in these athletes for who “time is money”.

Conclusion

Performing ballet may cause major stress to the lower extremities, predominantly affecting the foot and ankle, followed by the knee and hip. US and MRI play complementary roles in evaluating various orthopedic conditions in ballet dancers, with US allowing for dynamic evaluation and guidance for interventions.

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Disclosures

Conflict of Interest

Razia Rehmani, MD, Yoshimi Endo, MD, Phillip Bauman, MD, William Hamilton, MD, Hollis Potter, MD and Ronald Adler, MD, PhD have declared that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by the any of the authors.

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Correspondence to Razia Rehmani MD.

Electronic supplementary material

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ESM 7. A 27-year-old ballet dancer with lateral ankle pain. Dynamic cine clip imaged in short axis to the peroneal tendons with the patient actively circumducting at the level of the ankle shows intrasheath subluxation of the two tendons with respect to each other as well as subluxation onto and beyond the fibular tip with provocative maneuvers, reflecting laxity of the Q3 superior peroneal retinaculum. (AVI 50409 kb)

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ESM 8. Cine images before and after surgery similarly demonstrate smoother motion of the FHL tendon after surgical release with active plantar and dorsiflexion of the big toe. (AVI 22014 kb)

ESM 9

ESM 9. Cine images before and after surgery similarly demonstrate smoother motion of the FHL tendon after surgical release with active plantar and dorsiflexion of the big toe. (AVI 24623 kb)

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Rehmani, R., Endo, Y., Bauman, P. et al. Lower Extremity Injury Patterns in Elite Ballet Dancers: Ultrasound/MRI Imaging Features and an Institutional Overview of Therapeutic Ultrasound Guided Percutaneous Interventions. HSS Jrnl 11, 258–277 (2015). https://doi.org/10.1007/s11420-015-9442-z

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Keywords

  • ballet
  • ultrasound
  • MRI
  • foot and ankle
  • hip
  • tendon
  • ligament
  • osseous
  • labrum
  • corticosteroid and PRP