Toe Flexor Strength, Flexibility and Function and Flexor Hallucis Longus Tendon Morphology in Dancer

NewsBot · Sep 23, 2015

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Toe Flexor Strength, Flexibility and Function and Flexor Hallucis Longus Tendon Morphology in Dancers and Non-Dancers
K. Michael Rowley, Danielle N. Jarvis, Toshiyuki Kurihara, Yu-Jen Chang, Abbigail L. Fietzer, Kornelia Kulig
Medical Problems of Performing Artists: Volume 30 Number 3: Page 152 (September 2015)

Tendinopathy of the flexor hallucis longus (FHL), colloquially referred to as "dancer?s tendinitis," is a common condition in dancers and attributed to high demand on this muscle in positions of extreme ankle plantarflexion and metatarsophalangeal (MTP) flexion and extension. Despite such a high prevalence, there has been little research into preventative or nonsurgical interventions. As a means to identify potential targets for prevention and intervention, this study aimed to characterize toe flexors in dancers by measuring strength, flexibility, function, and FHL tendon morphology. Dancers (n=25) were compared to non-dancers (n=25) in toe flexor isometric strength, first MTP joint range of motion, foot longitudinal arch flexibility, balance ability, endurance during modified heel raises without use of the toes, and FHL tendon thickness, cross-sectional area, and peak spatial frequency. Significant differences were found in functional first MTP joint extension (dancers 101.95?, non-dancers 91.15?, p<0.001), balance ability during single-leg stance on the toes (dancers 11.43 s, non-dancers 5.90 s, p=0.013), and during modified heel raises (dancers 22.20 reps, non-dancers 28.80 reps, p=0.001). Findings indicate that dancers rely on toe flexors more than non-dancers to complete balance and heel raise tasks. Efficacy of using this modified heel raise task with the toes off the edge of a block as a means to train larger plantarflexors and as a nonsurgical intervention should be studied in the future. Improving interventions for FHL tendinopathy will be impactful for dancers, in whom this condition is highly prevalent.
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NewsBot · Nov 18, 2015

Assessment of female ballet dancers' ankles in the en pointe position using high field strength magnetic resonance imaging.
Russell JA, Yoshioka H
Acta Radiol. 2015 Nov 13. pii: 0284185115616295

BACKGROUND:
The en pointe position of the ankle in ballet is extreme. Previously, magnetic resonance imaging (MRI) of ballet dancers' ankles en pointe was confined to a low field, open MR device.
PURPOSE:
To develop a reproducible ankle MRI protocol for ballet dancers en pointe and to assess the positions of the key structures in the dancers ankles.
MATERIAL AND METHODS:
Six female ballet dancers participated; each was randomly assigned to stand en pointe while one of her feet and ankles was splinted with wooden rods affixed with straps or to begin with the ankle in neutral position. She lay in an MR scanner with the ankle inside a knee coil for en pointe imaging and inside an ankle/foot coil for neutral position imaging. Proton density weighted images with and without fat suppression and 3D water excitation gradient recalled echo images were obtained en pointe and in neutral position in sagittal, axial, and coronal planes. We compared the bones, cartilage, and soft tissues within and between positions.
RESULTS:
No difficulties using the protocol were encountered. En pointe the posterior articular surface of the tibial plafond was incongruent with the talar dome and rested on the posterior talus. The posterior edge of the plafond impinged Kager's fat pad. All participants exhibited one or more small ganglion cysts about the ankle and proximal foot, as well as fluid accumulation in the flexor and fibularis tendon sheaths.
CONCLUSION:
Our MRI protocol allows assessment of female ballet dancers' ankles in the extreme plantar flexion position in which the dancers perform. We consistently noted incongruence of the talocrural joint and convergence of the tibia, talus, and calcaneus posteriorly. This protocol may be useful for clinicians who evaluate dancers.
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NewsBot · May 5, 2018

Specialized properties of the triceps surae muscle‐tendon unit in professional ballet dancers
M M Moltubakk M M Magulas F O Villars O R Seynnes J Bojsen‐Møller
The Scandinavian Journal of Medicine & Science in Sports

This study compared professional ballet dancers (n=10) to non‐stretching controls (n=10) with the purpose of comparing muscle and tendon morphology, mechanical, neural and functional properties of the triceps surae and their role for ankle joint flexibility. Torque‐angle and torque‐velocity data were obtained during passive and active conditions by use of isokinetic dynamometry, while tissue morphology and mechanical properties were evaluated by ultrasonography. Dancers displayed longer gastrocnemius medialis fascicles (55 ± 5 vs 47 ± 6 mm) and a longer (207 ± 33 vs 167 ± 10 mm) and more compliant (230 ± 87 vs 364 ± 106 N·mm−1) Achilles tendon compared to controls. Greater passive ankle dorsiflexion range of motion (40 ± 7 vs 17 ± 9°) was seen in dancers, resulting from greater fascicle strain and greater elongation of the muscle. Peak electromyographic (EMG) activity recorded during passive stretching was lower in dancers, and at common joint angles, dancers displayed lower EMG amplitude and lower passive joint stiffness. No differences between groups were seen in maximal isometric plantar flexor torque, isokinetic peak torque, angle of peak torque or work. In conclusion, the greater ankle joint flexibility of professional dancers seems attributed to multiple differences in morphological and mechanical properties of muscle and tendinous tissues, and to factors related to neural activation.
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NewsBot · Oct 11, 2018

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How does ballet training alter ankle tendinous morphology and hemodynamics in asymptomatic pre-professional dancers? An ultrasonographic study.
Shih WS et al
J Sci Med Sport. 2018 Sep 28.

OBJECTIVES:
Among symptomatic dancers, sonographic abnormalities are common. Whether asymptomatic dancers have any abnormalities remains unknown. Some dancers became cyanosis over distal feet after ballet training. The hemodynamic changes at the feet in ballet are not clearly understood.

DESIGN:
Cross-sectional study.

METHODS:
In 25 dancers and 14 non-dancers, B-mode ultrasonography was used to measure cross-sectional areas (CSA) of tendons of deep posterior compartment muscles. Doppler ultrasonography was used to measure peak velocity (Vpeak) of posterior tibial artery in three ankle postures: the neutral position, passively and forced actively plantar flexion (en pointe). The big toe oxygen saturation was recorded in neutral position and during 1-min en pointe. Single-leg standing heel rise test was performed to represent the muscle function.

RESULTS:
The CSA of FHL was larger in dancers (0.26cm2 [0.20, 0.30] vs 0.21cm2 [0.17, 0.24], p<0.01), while other tendons were not different (all p>0.05). Higher Vpeak was recorded in passively plantar flexion than in neutral position (p<0.01, in both groups). The blood flow was undetectable during en pointe, more frequently in dancers (54.9% vs 14.3%, p<0.01). Oxygen saturation decreased during en pointe more prominently in dancers (85% [80, 90] vs 94% [84, 97], p<0.01). There was no significant difference in muscle function.

CONCLUSIONS:
US showed the FHL tendon thickening and en pointe-related vascular compromise in pre-professional dancers, even when they are asymptomatic.
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NewsBot · Jul 19, 2019

Relationship between the architecture and function of ankle plantar flexors with Achilles tendon morphology in ballet dancers
Guilherme S.NunesaBruna MarianaTessarinaRodrigoScattone SilvabFábio ViadannaSerrãoa
Human Movement Science Volume 67, October 2019, 102494

Highlights
•Torque and muscle architecture partially explain Achilles tendon thickness.
•Torque and fascicle length partially explain Achilles tendon echogenicity.
•Ankle torque seems to be important for prevention of Achilles tendon alterations.
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Achilles tendinopathy is the most frequent foot overuse injury in ballet dancers and knowledge of clinically modifiable factors related to tendon structure in a population at risk, such as ballet dancers, would be important for the development of preventive programs. Therefore, the present study aimed to assess relationships of gastrocnemius muscle architecture and ankle plantar flexors function with Achilles tendon morphology in ballet dancers. Fifty-four measures from 27 ballet dancers were collected. Tendon morphology (thickness, echogenicity, hypoechoic areas and neovascularisation) and muscle architecture (thickness, pennation angle and fascicle length) were evaluated using ultrasonography; ankle plantar flexors torque was evaluated using hand-held dynamometry, flexibility was evaluated in maximal weight-bearing ankle dorsiflexion position using inclinometer, and endurance was evaluated using the heel rise test. Ankle plantar flexors torque and medial gastrocnemius muscle architecture (thickness, pennation angle and fascicle length) are associated with Achilles tendon thickness in ballet dancers (r2 = 0.24, p = 0.008). Ankle plantar flexors torque and medial gastrocnemius muscle fascicle length are also associated with the echogenicity of the Achilles tendon (r2 = 0.13, p = 0.03). These findings call attention to the potential importance of ankle plantar flexors muscle force in healthy ballet dancers for the prevention of alterations in Achilles tendon structure.
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NewsBot · Feb 22, 2021

Effects of a “toes-off” modified heel raise on muscle coordination in non-dancers, dancers, and dancers with flexor hallucis longus tendinopathy
K. MichaelRowleyaHai-Jung SteffiShihaKristenTrainaaBrookeWinderbPamelaMikkelsenaKorneliaKuliga
Clinical Biomechanics; Volume 83, March 2021, 105287

Highlights
•Most healthy dancers decreased toe flexor activity during toes-off heel raises.
•Dancers with tendinopathy showed varying responses in the toes-off condition.
•The modification may be useful in unloading toe flexors in some healthy dancers.
•Cueing or tactile facilitation may be needed to optimize rehabilitation strategies.
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Background
Tendinopathy of the flexor hallucis longus, commonly called “dancer's tendinitis”, is a prevalent injury among female ballet dancers. Limited success of non-surgical interventions leads to many dancers undergoing tenolysis surgeries with risks and recovery times that can be detrimental to a dance career. The purpose of this study was to evaluate lower limb kinematics and muscle coordination during a modified traditional heel raise exercise where the toes hang off the edge of the support surface. We hypothesized this would decrease activation of the flexor hallucis longus and increase activation of larger plantarflexors.

Methods
Healthy non-dancers (n = 11), healthy dancers (n = 10), and dancers with flexor hallucis longus tendinopathy (n = 9) performed traditional (“toes-on”) and modified (“toes-off”) heel raises with kinematic and electromyographic instrumentation of the lower leg.

Findings
Participants maintained ankle excursion with the toes-off modification, while metatarsophalangeal joints had reduced excursion and greater excursion variability. Most healthy dancers (9/10) decreased flexor hallucis longus activation as predicted, but dancers with flexor hallucis longus tendinopathy showed a variable response with some decreasing activation (3/9) but others increasing activation up to 4-times. There were no changes in activation of other plantarflexors. Across groups, intrinsic foot muscle activation decreased with the toes-off modification.

Interpretation
The toes-off modification decreased flexor hallucis longus activation in most of the healthy dancers but was insufficient to shift muscle coordination from the flexor hallucis longus to larger plantarflexors in dancers with flexor hallucis longus tendinopathy. Future work should investigate clinical cues or modifications to this “toes-off” heel raise intervention.
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NewsBot · Mar 4, 2021

Kinematic Analysis of the Coupling Between Calcaneal Eversion and Ankle Dorsiflexion in a Contemporary Dancer's Demi-Plié
Anna Schrefl, Rolf van de Langenberg, Andrea Schärli
Med Probl Perform Art. 2021 Mar;36(1):45-53

Background: Dancing requires a high range of motion in the foot as well as a good shock-absorbing system formed by the foot and ankle joints. Although there is a broad consensus in dance that excessive calcaneal eversion can cause injury and should be avoided, calcaneal eversion is discussed controversially in the dance literature. An increased research focus on the biomechanics of dance, particularly research pertaining to the foot and ankle joints, might help to resolve this controversy.

Objectives: The study's main purpose was to generate hitherto lacking kinematic data of calcaneal eversion in a dancer's demi-plié.

Methods: Thirty-two contemporary dancers performed three trials in two different conditions: demi-plié in parallel and in turned-out positions. The motion capture system FASTRAK was used to measure calcaneal eversion and foot and lower leg alignment during demi-plié.

Results: Maximal calcaneal eversion in turned-out demi-pliés was 3.36°±4° and total range of motion (i.e., maximal minus minimal angle) of calcaneal eversion was 3.73°±1.42°, where the large standard deviations indicate substantial variability across participants. Calcaneal eversion was significantly different between turned-out (3.36°±4°) and parallel (1.17°±4.06°) demi-pliés, as was the alignment of the lower leg and foot, where the lower leg tracked more medially relative to the foot during turned-out pliés. Crucially, both the magnitude of calcaneal eversion and its temporal coupling with ankle dorsiflexion were highly variable across participants.

Conclusions: Average calcaneal eversion is a poor indicator of the role calcaneal eversion plays in the demi-plié of contemporary dancers. Rather, the temporal coupling between calcaneal eversion and ankle dorsiflexion needs to be considered.
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NewsBot · Jun 21, 2021

Flexor Hallucis Longus Tenolysis/Tenosynovectomy in Dancers
Elizabeth I. Barchi, M.D. et al
JFAS: June 20, 2021

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.
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NewsBot · Jul 25, 2021

Flexor Hallucis Longus Tenolysis/Tenosynovectomy in Dancers
Elizabeth I Barchi et al
J Foot Ankle Surg. 2021 Jun 20

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 and 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, and 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.
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NewsBot · Aug 15, 2022

The Effect of Foot Deformity and First Metatarsophalangeal Joint Plantar Pain on Performance in DanceSport Athletes
Zijian Liu et al
Children 2022, 9(8), 1169; https://doi.org/10.3390/children9081169

Background: Adolescent DanceSport athletes who regularly dance in high heels have a higher possibility of developing hallux valgus deformity and foot pain. We believe that the occurrence of foot disorders may change the loading on their feet, which thus affects the athletic performance of those adolescents. Methods: A total of 63 adolescent DanceSport athletes (16 boys, 47 girls) were included. The plantar pain in the first metatarsophalangeal (1st MTP) joint was evaluated using a questionnaire, and the hallux valgus angle was evaluated using digital photographs (HVAp). The loading values of the plantar pressure while performing relève on demi-pointe were measured using sensor sheets. The participating boys and girls were analyzed separately. Results: The results showed that female adolescent DanceSport athletes with the 1st MTP joint plantar pain showed a decrease in the loading distribution and plantar pressure percentage on the hallux and an increased loading distribution and pressure distribution of the metatarsal head as the HVAp increased. Conclusion: Among adolescent DanceSport athletes with plantar pain in the 1st MTP joint and a large HVAp, the loading manner of the foot may have changed, which may be associated with a decrease in the toe function and performance
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NewsBot · Nov 19, 2022

Investigation of the Relationship Between the Morphology of the Toe Flexor Muscles in Ballet Dancers and the Postural Stability During Standing on Demi-Pointe: A Cross-Sectional Study
Ishihara, Honoka et al
Journal of Dance Medicine & Science, Volume 26, Number 4, December 2022, pp. 205-212(8)

Introduction: This study investigated how toe flexor muscles are related to postural stability in 11 ballet dancers and 12 non-dancers.
Methods: Toe flexor strength (TFS), cross-sectional areas (CSA) of the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, flexor hallucis longus (FHL), and flexor digitorum longus, and center of pressure (COP) displacement during single-leg demi-pointe were measured. Correlations between toe flexor strength and COP displacement and between CSA and COP displacement within each group were calculated using Pearson's correlation coefficient or Spearman's correlation coefficient.
Results: The dancers showed smaller COP displacement than the non-dancers (p < 0.05). Toe flexor strength in dancers was moderately negatively correlated with COP displacement in the anterior-pos- terior direction (r = -0.54, p < 0.01) and total COP displacement (r = -0.57, p < 0.01). Only the CSA of the FHL in dancers exhibited a significant negative correlation with COP displacement in the anterior-posterior direction (r = -0.42, p < 0.05) and total COP displacement (r = -0.52, p < 0.01).
Conclusion: The present study found a relationship between the toe flexor strength and COP displacement and CSA of toe flexor muscles and COP displacement during one-legged demi-pointe standing. These results suggest that the development of the toe flexor muscles may be involved in the balance control of dancers.
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NewsBot · Jul 1, 2023

Flexor hallucis longus tendon morphology in dancers clinically diagnosed with tendinopathy
Pamela Mikkelsen et al
J Ultrasound. 2023 Jun 25.

Purpose: The unique demands of dance technique make dancers more prone to certain pathologies especially of the foot and ankle. Flexor hallucis longus (FHL) tendinopathy, colloquially known as "dancer's tendinopathy," is common in dancers and not well studied. The purpose of this study was to assess if morphological alterations in tendon structure occur as an adaptive response to dance activity by comparing the FHL tendon in dancers to non-dancers, and if pathology further alters tendon morphology in dancers clinically diagnosed with tendinopathy.

Methods: Three groups of ten participants were recruited (healthy non-dancers, healthy dancers, and dancers with FHL tendinopathy). Ultrasound images of the FHL tendons were analyzed for macromorphology by measuring the tendon thickness. The micromorphology was analyzed by determining the peak spatial frequency radius of the tendon. Our study did find increased tendon proper and composite tendon thickness in dancers with tendinopathy but no difference between asymptomatic dancers and non-dancers.

Results: There was no significant difference in micromorphology found between any of the groups. As expected, dancers with tendinopathy demonstrated increased composite tendon and tendon proper thickness however, there was no evidence of adaptive thickening of the FHL tendon as might be expected for the dance population. There was also no evidence of micromorphological changes in the presence of clinically diagnosed FHL tendinopathy.

Conclusion: Because of the limited normative data for this pathology, these results can help improve diagnosis and therefore treatment for dancers to decrease the impact of this injury on their careers
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