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The prevalence and clinical significance of sonographic tendon abnormalities in asymptomatic ballet dancers: a 24-month longitudinal study
  1. Jules Comin1,
  2. Jill L Cook2,
  3. Peter Malliaras1,
  4. Moira McCormack3,
  5. Michelle Calleja4,
  6. Andrew Clarke4,
  7. David Connell5
  1. 1Imaging @ Olympic Park, Melbourne, Victoria, Australia
  2. 2Primary Health Care, Monash University, Melbourne, Victoria, Australia
  3. 3Royal National Ballet, London, UK
  4. 4Department of Radiology, Royal National Orthopaedic Hospital, London, UK
  5. 5Department of Medical Imaging, Monash University, Melbourne, Victoria, Australia
  1. Correspondence to Dr Jules Comin, Imaging @ Olympic Park, 60 Olympic Boulevard, Melbourne 3002, Australia 3002; julescomin{at}


Introduction Sonographic abnormalities of the achilles and patellar tendons are common findings in athletes, and tendinopathy is a common cause of pain and disability in athletes. However, it is unclear whether the sonographic changes are pathological or adaptive, or if they predict future injury.

We undertook a cohort study to determine what sonographic features of the achilles and patellar tendons are consistent with changes as a result of ballet training, and which may be predictive of future development of disabling tendon symptoms.

Methods The achilles and patellar tendons of 79 (35 male, 44 female) professional ballet dancers (members of the English Royal Ballet) were examined with ultrasound, measuring proximal and distal tendon diameters and assessing for the presence of hypoechoic change, intratendon defects, calcification and neovascularity. All subjects were followed for 24 months for the development of patellar tendon or achilles-related pain or injury severe enough to require time off from dancing.

Results Sonographic abnormalities were common among dancers, both male and female, and in both achilles and patellar tendons. Disabling tendon-related symptoms developed in 10 dancers and 14 tendons: 7 achilles (3 right, 4 left) and 7 patellar (2 right, 5 left). The presence of moderate or severe hypoechoic defects was weakly predictive for the development of future disabling tendon symptoms (p=0.0381); there was no correlation between any of the other sonographic abnormalities and the development of symptoms.

There was no relationship between achilles or patellar tendons’ diameter, either proximal or distal, with an increased likelihood of developing tendon-related disability.

Conclusion The presence of sonographic abnormalities is common in ballet dancers, but only the presence of focal hypoechoic changes predicts the development of future tendon-related disability. This suggests that screening of asymptomatic individuals may be of use in identifying those who are at higher risk of developing tendon-related disability, which may in turn allow targeted modifications of training or other preventative regimens.

  • Achilles tendon
  • Ankle injuries
  • Measurement
  • Tendons
  • Ultrasound

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