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Subtalar subluxation in ballet dancers
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ABSTRACTS
when the foot is supporting the body weight.' This paper has not re-invented the arch; it provides good evidence that we can safely forget about it.
Menetrey J, Fritschy D, Subtalar subluxation in ballet dancers. A m J Sports Med 1999; 27: 143-149. Many orthopaedic surgeons will be unfamiliar with the concept of subtalar subluxation. The authors of this paper report that this was described by Broca from Paris in 1853. The authors point out that subtalar subluxation is common in ballet dancers. Their paper gives a useful review of the literature on foot problems in ballet dancers and refers to various publications by Hamilton, Quirk and Sommarco. Menetrey and Fritschy found that there was a surprisingly high incidence of this condition. They had studied 60 dancers from one ballet company during an entire season. Subtalar subluxation was reported in 25 of these dancers and represented 10.5% of all reported injuries. Recurrent episodes were reported in 10 of the 25 dancers. It is well known that there is a strong interosseous ligament between the talus and calcaneum and this is a major factor in achieving stability at the subtalar joint. The authors point out that the calcaneo-fibular ligament is also important in maintaining subtalar stability. When the foot is in plantar flexion this ligament becomes lax and no longer protects against subluxation of the subtalar joint. A position of plantarflexion of the ankle is of course common during ballet. The authors also point out than many ballet dancers have generalized joint laxity and also there may be laxity of the calcaneo-fibular ligament due to previous ankle injuries. All their patients gave a history of previous ankle sprains. It appears that the high incidence of this injury in this ballet company may have been the result of a new teacher, who asked the dancers to repeatedly perform jumps on pointes and demi pointes. As a result of the subluxation, the dancer reported a sharp pain in the anterior aspect of the ankle and a sensation of forward displacement of the foot. Subsequently there was restriction of ankle and subtalar movement followed by the development of tenderness and swelling at the talo-navicular joint. It seems clear that subluxation of the subtalar joint is associated with a corresponding subluxation in the talo-navicular joint.
Unfortunately, there is no detailed account of imaging for this injury. However, it is reported that only 25% of the patients had an abnormality of the talo-navicular joint on radiographs. This abnormality is difficult to appreciate on the figures shown. However, the figures shown do indicate that subluxation of the subtalar joint can occur and can be reduced. The authors comment that attempts using CT scan and MRI scan to confirm the diagnosis were unsuccessful. A method of reducing the subluxation is described. This involves putting the patient into a prone position with the knee flexed at 90 ° and then applying upward traction of the hands and at the same time manipulating the foot. It is stated that successful reduction was usually audible, and with experience it may be obtained at the first attempt. Rehabilitation is surprisingly rapid. Taping is applied followed by physiotherapy treatment and dancing is resumed after 3 or 4 weeks. Chronic subluxation is also described and is also easily reduced. Apparently both acute and chronic subluxations are completely rehabilitated after 6 weeks. Rather mysteriously, it is stated that in cases of chronic subluxation that Achilles tendinitis dominates the patient's symptoms and that the Achilles tendinitis may be treated after reduction of the subtalar subluxation. There is a certain amount of speculation in this paper, especially involving the role of the tibialis posterior in producing the subluxation. The authors regard the condition as being analogous to the 'locked cuboid', which may be a cause of pain and spasm in the athlete's foot. Subtalar subluxation may not only be a cause of temporary incapacity for the dancer, but may also predispose to the development of subtalar arthritis in the long term.
Frey C, Feder KS, Di Giovanni C. Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int 1999; 20: 185-191. This article gives a brief resum6 of the technique of subtalar arthroscopy. With the use of a 2.7-mm arthroscope the technique is not excessively difficult and a middle portal is recommended for inspection of the sinus tarsi. The authors had performed 49 such procedures between 1989 and 1996. © 1999 BlackwellScienceLtd, Foot and Ankle Surgery, 5, 203-205
ABSTRACTS
when the foot is supporting the body weight.' This paper has not re-invented the arch; it provides good evidence that we can safely forget about it.
Menetrey J, Fritschy D, Subtalar subluxation in ballet dancers. A m J Sports Med 1999; 27: 143-149. Many orthopaedic surgeons will be unfamiliar with the concept of subtalar subluxation. The authors of this paper report that this was described by Broca from Paris in 1853. The authors point out that subtalar subluxation is common in ballet dancers. Their paper gives a useful review of the literature on foot problems in ballet dancers and refers to various publications by Hamilton, Quirk and Sommarco. Menetrey and Fritschy found that there was a surprisingly high incidence of this condition. They had studied 60 dancers from one ballet company during an entire season. Subtalar subluxation was reported in 25 of these dancers and represented 10.5% of all reported injuries. Recurrent episodes were reported in 10 of the 25 dancers. It is well known that there is a strong interosseous ligament between the talus and calcaneum and this is a major factor in achieving stability at the subtalar joint. The authors point out that the calcaneo-fibular ligament is also important in maintaining subtalar stability. When the foot is in plantar flexion this ligament becomes lax and no longer protects against subluxation of the subtalar joint. A position of plantarflexion of the ankle is of course common during ballet. The authors also point out than many ballet dancers have generalized joint laxity and also there may be laxity of the calcaneo-fibular ligament due to previous ankle injuries. All their patients gave a history of previous ankle sprains. It appears that the high incidence of this injury in this ballet company may have been the result of a new teacher, who asked the dancers to repeatedly perform jumps on pointes and demi pointes. As a result of the subluxation, the dancer reported a sharp pain in the anterior aspect of the ankle and a sensation of forward displacement of the foot. Subsequently there was restriction of ankle and subtalar movement followed by the development of tenderness and swelling at the talo-navicular joint. It seems clear that subluxation of the subtalar joint is associated with a corresponding subluxation in the talo-navicular joint.
Unfortunately, there is no detailed account of imaging for this injury. However, it is reported that only 25% of the patients had an abnormality of the talo-navicular joint on radiographs. This abnormality is difficult to appreciate on the figures shown. However, the figures shown do indicate that subluxation of the subtalar joint can occur and can be reduced. The authors comment that attempts using CT scan and MRI scan to confirm the diagnosis were unsuccessful. A method of reducing the subluxation is described. This involves putting the patient into a prone position with the knee flexed at 90 ° and then applying upward traction of the hands and at the same time manipulating the foot. It is stated that successful reduction was usually audible, and with experience it may be obtained at the first attempt. Rehabilitation is surprisingly rapid. Taping is applied followed by physiotherapy treatment and dancing is resumed after 3 or 4 weeks. Chronic subluxation is also described and is also easily reduced. Apparently both acute and chronic subluxations are completely rehabilitated after 6 weeks. Rather mysteriously, it is stated that in cases of chronic subluxation that Achilles tendinitis dominates the patient's symptoms and that the Achilles tendinitis may be treated after reduction of the subtalar subluxation. There is a certain amount of speculation in this paper, especially involving the role of the tibialis posterior in producing the subluxation. The authors regard the condition as being analogous to the 'locked cuboid', which may be a cause of pain and spasm in the athlete's foot. Subtalar subluxation may not only be a cause of temporary incapacity for the dancer, but may also predispose to the development of subtalar arthritis in the long term.
Frey C, Feder KS, Di Giovanni C. Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int 1999; 20: 185-191. This article gives a brief resum6 of the technique of subtalar arthroscopy. With the use of a 2.7-mm arthroscope the technique is not excessively difficult and a middle portal is recommended for inspection of the sinus tarsi. The authors had performed 49 such procedures between 1989 and 1996. © 1999 BlackwellScienceLtd, Foot and Ankle Surgery, 5, 203-205