Cover Page
The handle http://hdl.handle.net/1887/58767 holds various files of this Leiden University dissertation.
Author: Rietveld, A.B.M.
Title: Performing arts medicine with a focus on Relevé in Dancers
Issue Date: 2017-11-28
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APPENDIx (14-19)
• Summary
•
Nederlandse samenvatting
•
Acknowledgements / Dankwoord
• Biography
•
Curriculum vitae (Nederlands)
•
List of publications / Bibliografie
232
Testing muscle power of peroneus brevis in a dancers’ foot Tenor saxophone with support hook
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APPENDIx (14-19)
• Summary
•
Nederlandse samenvatting
•
Acknowledgements / Dankwoord
• Biography
•
Curriculum vitae (Nederlands)
•
List of publications / Bibliografie
233
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14 Summary
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14 In chapter one a general introduction is given of Performing Arts Medicine. Since Performing
Arts Medicine is a relative young sub-specialty in The Netherlands, a concise historical overview deserves a place in chapter two. This includes a short background of the Medical Centre for Dancers and Musicians (MCDM) in the Haaglanden Medical Centre (HMC) in The Hague, The Netherlands, and the introduction of “PASSION-MD”, a 25 years cohort study containing the clinical data of the thousands of dancer- and musician-patients consulting the MCDM since 1993.
The thesis is written in four parts:
In Part 1 orthopaedic Performing Arts Medicine, limited to dancers and musicians and from an orthopaedic perspective, is introduced with general ideas and some specific thoughts about aetiology, prevention, rehabilitation, and conservative treatment.
In Part 2 the results of treatment of limited and painful relevé in dancers due to posterior ankle impingement syndrome (PAIS) and flexor hallucis longus (FHL) tendinopathy are studied.
In Part 3 limited and painful relevé in dancers, due to some structural deformities and specific, miscellaneous and rare forefoot and tarsal conditions, is discussed (Freiberg’s disease, accessory navicular and tarsal coalitions) .
Part 4 contains a general discussion, guidelines for clinical studies in dancers and musicians, suggestions for future research and general recommendations for Performing Arts Medicine in The Netherlands .
Part 1
In chapter three an overview of Dance Medicine and Musicians’ Medicine is given from an orthopaedic perspective. Causes and treatment of injuries in dancers are explained. As a general principle the physician must respect the passion of the dancer and avoid the advice to stop dancing. Making the diagnosis in musicians’ injuries is quite often only possible by examining the patient while playing his or her musical instrument. Extensive explanation, advice, and relative rest supported by mental practice are effective in overuse injuries in musicians.
The subject of chapter four is prevention and rehabilitation of complaints in musicians and dancers. The physical and psychological problems that can befall performing artists are summarised and an insight into their prevention is provided. The second half of this chapter offers insights in dance specific graded rehabilitation and access to a dance-specific structured rehabilitation program.
14 Summary Summary 14
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Chapter five focusses on (orthopaedic) dance medicine, studying and describing aspects of aetiology of common dance injuries. The incidence of symptomatic hyperpronation resulting in prescription for orthotics was 30% in a retrospective study of 2,427 dancers’ charts in the Medical Centre for Dancers and Musicians.
In a prospective study among 24 new dancer-patients with possibly hyperpronation-related symptoms, the clinical severity of hyperpronation was linearly related to the calcaneal angle . It was concluded that grading the clinical severity of a dancer’s hyperpronation is reliable.
Healthcare providers working with dancers should be aware of the presence of hyperpronation, its relation to compensatory turnout techniques, and association with injuries in the foot, ankle, knee, hip, and low back. The most common related diagnosis was patellofemoral pain.
Chapter six concentrates on aspects of conservative treatment in dancers. The usage and effectiveness of orthotics in the management of symptomatic hyperpronation among dancers was investigated in a prospective cohort study of 24 consecutive dancer-patients who were prescribed orthotics for new symptoms related to hyperpronation. Orthotics were found to decrease the medial longitudinal arch angle (i.e. correction of hyperpronation) significantly during static stance with the orthotic in place and give a 26% decrease in pain from the day of orthotics prescription to follow-up. In a retrospective study among 105 participating dancers 67% wore orthotics at the time of follow-up for six days per week and 7.5 hours per day. It is concluded that the dancers in this study demonstrated a high rate of compliance in obtaining and wearing their orthotics and experienced a significant decrease in pain.
Part 2
The subject of part two is the result of treatment of limited and painful relevé in dancers due to posterior ankle impingement syndrome (PAIS or dancer’s heel) and / or flexor hallucis longus (FHL) tendinopathy (dancer’s tendinitis).
Dancing on pointe and relevé require extreme plantar flexion of the talo-crural joint and may lead to PAIS. PAIS is a painful, usually limited plantar flexion of the ankle joint, due to soft tissue impingement or a bony impediment. PAIS often coincides with FHL tendinopathy behind the medial malleolus. Both injuries are common in dancers and can appear in isolation as well.
In persistent complaints the bony impediment is removed, the tunnel of the FHL tendon is released, or a combination of these procedures is performed by open surgery.
Chapter seven is a systematic search, which was undertaken in October, 2016, to evaluate the results of conservative and operative treatment (both open and endoscopic) of PAIS and
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Summary
FHL tendinopathy in dancers. Twenty-seven retrospective studies with levels of evidence four and five reported the results of operative treatment in 376 ankles in 324 dancers. Both open (n = 344) and endoscopic (n = 32) procedures were effective and safe and there was no difference between both groups in final outcome or mean time to return to dance. However the endoscopic procedure has been studied in too few dancers to allow any evidence-based recommendations.
Isolated PAIS, PAIS combined with FHL tendinopathy and isolated FHL injuries seem different pathological entities, and more research, preferably with a prospective design and including dance-specific baseline characteristics and outcome scores, is needed to:
• find out in which cases early operative management should be considered or avoided,
• define the place of endoscopic surgery of PAIS and FHL tendinopathy in dancers and
• predict which pathology implicates worse outcomes or delay in return to dance.
Only six publications reported the results of conservative treatment in 33 ankles of 28 dancers, not allowing any evidence-based recommendations.
Chapter eight presents the results of open surgery. Outcomes of treatment by open surgery for PAIS and FHL tendinopathy have been described in small series of dancers only. We extracted data from clinical files and operative reports of the Medical Centre for Dancers and Musicians and defined success rate as an outcome score based on patient satisfaction extracted from the clinical files at the date of discharge from outpatient follow-up. Until October 2016, 148 dancers underwent 190 open procedures for PAIS, FHL, or a combination. In 91% of cases patients reported a “better” or “much better” postoperative outcome. It was concluded that the open surgical treatment of PAIS and FHL tendinopathy in dancers has a high success-rate, and can be considered a successful standard operative approach in dancers.
In chapter nine the open and the endoscopic approaches for the operative treatment of PAIS and FHL tendinopathy in dancers were compared. In 2000 an endoscopic surgical technique was introduced. To date there is no evidence of the superiority of the open or the endoscopic surgical technique for the treatment of PAIS and FHL tendinopathy in dancers. We compared the first 20 consecutive open procedures with the first 19 consecutive endoscopic procedures in dancers only, all operated by the author. The direct postoperative morbidity in the endoscopic group was less favourable. Although the two small groups of dancers, the retrospective character of this descriptive cohort study, and several limitations did not allow firm conclusions or statistical analysis of subgroups, in this study the open approach seemed to be better than the endoscopic approach in the surgical treatment of PAIS and FHL tendinopathy in dancers. It
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was concluded that more research is needed to determine the place of endoscopic surgery in the surgical treatment of PAIS and FHL tendinopathy in dancers.
Part 3
Chapter 10 draws attention to Freiberg’s disease in dancers. Freiberg’s disease is an osteonecrosis of the second metatarsal head, which can severely limit a dancer’s relevé.
Previously published reports of successful surgical outcomes would, for a dancer, result in an unacceptable loss of dorsiflexion of the second metatarso-phalangeal joint. This first case report of Freiberg’s disease in a dancer serves to discuss the orthopaedic and artistic implications of managing the disease in a young, active, adolescent dancer. A new surgical treatment involving modification of Mann’s cheilectomy, normally used for hallux rigidus, is presented. The operation corrected the patient’s pain, completely normalised the aberrant relevé, allowed her to resume dance training within three weeks, and return to full dance activity within three months.
The subject of chapter 11 is tarsal coalitions in dancers. Tarsal coalitions, a fusion between two or more bones of the tarsus, are a rare entity in dancers and may easily be missed. We describe the presentation, types, and treatment of tarsal coalitions in seven dancers diagnosed in the MCDM between 2008 and 2011. The presenting complaints include a limited and painful relevé.
Physical examination reveals a stiff subtalar joint in all cases. In all, six of our dancers with a tarsal coalition were able to continue dancing. Treatment in dancers depends on the type and extent of the coalition. In calcaneo-navicular coalition early resection of the bar is our treatment of choice, based on historic literature and our success with three patients. In our opinion the only option for talo-calcaneal coalition in dancers is conservative management. We recommend to perform the simple “heel-tip test” in every dance-screening.
In chapter 12 the accessory navicular in dancers is studied. The accessory navicular, or os tibiale externum, is an accessory bone on the medial side of the navicular of the foot at the insertion of the posterior tibial tendon. It can cause obvious hyperpronation, medial foot pain, and a limited and painful relevé in dancers. Six dancers (10 feet) were treated in the MCDM for a symptomatic accessory navicular Type II. Five of them (eight feet) underwent surgery, two unilaterally and three bilaterally (at the same time). All five had an excellent result. Simple excision of a symptomatic accessory navicular Type II seems to be a good choice in dancers.
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Part 4
Chapter 13 contains the general discussion and gives future perspectives and
recommendations. Performing Arts Medicine in The Netherlands is a young sub-specialty and is slowly progressing through the different levels of Evidence Based Medicine. This thesis aims to add some pieces of clinical knowledge and experience to this exciting field.
After explaining some treatment strategies used in the MCDM, including a stepped care - approach used in the chronic, overuse-type injuries, some conclusions of the different chapters are summarized.
Insufficient description of dance related base line characteristics and the inconsistent use of different outcome scores, as encountered in most studies found in the systematic review, prompted the author to formulate guidelines for clinical studies in dance and musicians’
medicine, including a proposal for seven standardized levels of Return to dance (RtD), a qualitative functional outcome measure, universally applicable to all dance forms (not only ballet).
The research presented in the different chapters of this thesis made clear how clinical research still has to be developed in orthopaedic dance-medicine, and probably in performing arts medicine in general. Several research questions arise from the articles in this thesis. For that matter, additional research on the painful and limited relevé in dancers due to forefoot problems, like hallux rigidus and sesamoid injuries. Clinical research within the PASSION-MD database (as described in chapter two) is approved by an independent ethics committee and is available for evaluation by clinical researchers in Performing Arts Medicine.
In general clinical (comparative) cohort studies are recommended with dance- or music-specific baseline characteristics, which have to be succinctly defined in order to reduce heterogeneity of the diagnosis, but also are in need of validated functional, dance- resp. music-specific outcome scores in order to compare treatment strategies across patient groups but also internationally.
Nowadays several young scientists are doing clinical research in different fields of Performing Arts Medicine in The Netherlands, hopefully resulting in PhD dissertations in the near future.
To foster Performing Arts Medicine in The Netherlands attention must be given to specialised healthcare and prevention for dancers and musicians, clinical studies and scientific research, education, training and stimulating awareness, public relations and close cooperation with the Dutch Performing Arts Medicine Association (NVDMG).
Summary
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