Calf Endurance and Achilles Tendon Structure in

Classical Ballet Dancers

Jennifer A. Zellers, P.T., D.P.T., Katrina van Ostrand, P.T., M.P.T., and
Karin Grävare Silbernagel, P.T., A.T.C., Ph.D.

U
Abstract nspecified tendon injury including misdiagnosis,4 inappropri-
Optimal lower leg function is critical for has been reported to ac- ate levels of activity modification,5 as
ballet dancers to meet their occupational count for 17% of injuries in well as biochemical and mechanical
requirements. Achilles tendon injury is professional ballet dancers and is of aspects of tendon loading and re-
particularly detrimental to ballet dancers. particular concern given the extreme pair.6-8 For dancers, the duration of re-
While standardized measures have been physicality of their occupation.1 In a covery from tendon injury combined
validated and incorporated into clinical study on ballet dancers of the Royal with pressure to return to full dance
practice for use in people with Achilles Swedish Opera House by Nilsson activity can potentially complicate
tendon injury, normative ranges specific
and coworkers, incidence of Achilles the healing trajectory. At the level of
to the dancer population have not been
described. The purpose of this pilot tendinopathy was found to have been a professional dance company, long
study was to observe the performance present in 6.2% of female and 4.4% leaves of absence can pose a signifi-
of pre-professional ballet students and of male members of the company over cant financial burden.9
professional ballet dancers on a well- the 5 year study period.2 Similarly, Devices that guide treatment,
established test battery for lower leg Comin and colleagues reported an rehabilitative strategy, and return to
functional performance as well as ultra- incidence of Achilles tendon injury of activity decision making commonly
sonographic evaluation of the structure 5% over a 24 month period in a study used in other populations of athletes
of their Achilles tendons. The dancers of dancers in the English Royal Ballet.3 have generally not been applied to
in this study had significantly shorter While found to be less common than dancers. It is reasonable to expect
Achilles tendons than non-dancers (p = flexor hallucis longus and peroneal that dancers would perform differ-
0.016). Dancers demonstrated signifi-
tendinopathy, Achilles tendon injury ently on these tests and measures
cantly higher maximum heel-rise height
on the heel-rise test for calf endurance led to longer sick leaves than other than the athletes for whom they were
(p < 0.001) but performed significantly foot and ankle tendon conditions.2 originally intended. Prior studies have
less work than non-dancers (p = 0.014). Nilsson and coworkers report that reported differences in mechanism of
The results of this study support the use a partial Achilles tendon rupture re- injury, severity of symptoms, type of
of the heel-rise test as a tool for screening sulted in the retirement of one dancer, pathology (tendinous versus muscu-
and to guide rehabilitation. and Achilles tendinopathy accounted lar), and duration of recovery from
for sick leaves of 10 to 12 weeks.2 hamstring injury between dancers
This prolonged recovery time and sprinters.10-12 Such differences
frame is a common feature of tendon are generally based on assessment of
injury. There are many suggested rea- three components of tendon injury:
sons for the long recovery duration, structural abnormalities of the ten-
don, changes in tendon function, and
Jennifer A. Zellers, P.T., D.P.T., Program in Biomechanics and Movement Science, patient self-perception of pain and
Katrina van Ostrand, P.T., M.P.T., Sports Physical Therapy Residency Program, symptoms. Utilizing a standardized,
and Karin Grävare Silbernagel, P.T., A.T.C., Ph.D., Department of Physical comprehensive test battery is crucial
Therapy, University of Delaware, Newark, Delaware. in diagnosing tendon problems as
Correspondence: Jennifer A. Zellers, P.T., D.P.T., Department of Physical Therapy, different aspects of each patient’s
University of Delaware, 540 South College Avenue, Newark, Delaware 19713; tendon injury will resolve at different
jzellers@udel.edu. rates. This can lead to the common
Copyright © 2017 J. Michael Ryan Publishing, Inc.
64 https://doi.org/10.12678/1089-313X.21.2.64
 Journal of Dance Medicine & Science • Volume 21, Number 2, 2017 65

problem of relying heavily on sub- tests for dancers would provide useful naire (VISA-A) upon acceptance into
jective complaints to guide clinical guidance for clinicians in determining the study. This is a valid and reliable
decision making and overlooking what is typical performance in this measure of self-reported symptoms
overall functional performance of the population. specific to individuals with Achilles
musculotendinous unit.13 The aim of this study was to de- tendinopathy. 24 The non-dancers
Diagnostic ultrasound (US) imag- scribe the Achilles tendon structure completed the Physical Activity Scale
ing is commonly used to diagnose and plantar flexor function of classical to measure general activity level.25-27
Achilles tendon injury. Characteristic ballet dancers compared to non-danc- This is a questionnaire involving a
changes in the tendon, including ers using established, clinical Achilles score of 1 to 6 with 1 being “hardly
thickening of the tendon and areas tendon examination methods. any physical activity” and 6 being
of hypoechogenicity, are seen in in- “hard or very hard exercise regularly
dividuals with mid-portion Achilles Material and Methods and several times a week.”25 Subjects
tendinosis. 14 Ultrasound can also Healthy non-dancers and ballet danc- were instructed to avoid any heavy
distinguish bony changes that can ers from the local community were re- exertion prior to the day of data collec-
occur in the context of insertional cruited for this study. To be included, tion, and collections were scheduled
tendinopathy. Furthermore, changes participants had to be 16 to 35 years for days when the dancers did not
in Achilles tendon length have been of age, and the dancers had to engage have scheduled classes or rehearsals.
found to be of concern in individuals in ballet classes more than 3 days a Tendon geometry was assessed via
following Achilles tendon rupture.15-17 week at or above the pre-professional B-mode ultrasound imaging utilizing
The use of ultrasound as a prognostic level. Individuals were excluded if a a standard ultrasound with extended
indicator of individuals at risk for current Achilles tendon problem was field of view capability at 10 MHz
developing Achilles tendon symptoms limiting their ability to function fully. (GE LOGIQ*e, GE Healthcare,
has been investigated with conflicting Ultimately, 20 subjects, both male (N Wauwatosa, WI, USA). Images were
results.3,18 In a study of elite soccer = 2 in each group) and female (N = 8 taken using acoustic coupling gel and
players, increased tendon thickness in each group), were included in the a linear transducer. Extended field of
was a positive predictor of develop- study: 10 dancers and 10 non-dancers. view images were taken of the Achilles
ment of Achilles tendon symptoms No statistically significant differences tendon in the long axis from the cal-
during the course of a season. 18 were observed between groups with caneus to the myotendinous junction
Conversely, a study of professional regard to age, height, weight, or sex. of the gastrocnemius. Measurements
ballet dancers found focal hypoechoic All subjects provided informed con- of Achilles length were taken from
changes, but not tendon thickness, sent prior to inclusion, and the study the calcaneal notch, or most proximal
were related to development of symp- was approved by the University of insertion of the Achilles tendon, to the
toms.3 These conflicting results point Delaware Institutional Review Board. gastrocnemius myotendinous junc-
to the need for establishing differences All subjects were screened with a tion as well as the most distal insertion
between structural characteristics of clinical examination to ensure tendon of the soleus.28 Short axis images of
tendon in dancers compared to non- health. Clinical exams and testing the Achilles tendon immediately distal
dancers. protocols were all completed by this to the soleal insertion were collected
Another component of the overall study’s investigators, who are licensed using a standoff pad and were then
patient picture is the tendon’s func- physical therapists. The clinical exam exported to ImageJ where the tendon
tional performance. In non-dancer consisted of palpation of the inser- was traced for calculation of the cross-
populations, functional testing, in- tion, medial and lateral retrocalcaneal sectional area.
cluding jump and heel-rise tests, have bursal areas, and the mid-portion of Functional capacity of the calf
been described to evaluate patient the Achilles tendon.21,22 Pain on palpa- musculature was evaluated using the
function over time as well as to guide tion as well as any subjective findings heel-rise test. This test has been shown
return to play decision making. 19 of tendon thickening were recorded. to be a reliable and valid measure of
Normative values for such testing Dorsiflexion range of motion was calf endurance in individuals with
and milestone criteria for return to measured using an inclinometer po- healthy as well as injured Achilles
training and performance, however, sitioned on the tibia in standing with tendons.29 In this test, subjects begin
have not been reported for dancers. the knee both extended and flexed.23 by standing barefoot in single leg
In jumping tasks, alterations have Tendon health was also evaluated stance on a 10° incline board. Two
been described in lower extremity via B-mode diagnostic ultrasound fingers are placed against the wall
movement patterns in dancers with imaging, and any sign of tendon in front of the subject for balance.
Achilles tendinopathy.20 These com- pathology, such as fusiform tendon A linear encoder (MUSCLELAB™,
plex movements are challenging to thickening or areas of hypoecho- Ergotest Innovation A.S., Norway) is
measure in a quantifiable way that is genicity, were recorded. Subjects taped to their heel, and the system is
practical for the clinician. Therefore, completed the Victorian Institute of calibrated. The subject then performs
describing the use of simple, clinical Sport Assessment-Achilles Question- unilateral heel rises until fatigue. A
66 Volume 21, Number 2, 2017 • Journal of Dance Medicine & Science

Table 1 Clinical Examination Standing Dorsiflexion Range of Motion

Dancers (N = 10) Non-dancers (N = 10) P-value
Knee extended 39.1° (10.2°) 39.3° (6.0°) 0.923
Knee flexed 43.9° (7.7°) 42.3° (6.9°) 0.512
All values listed as Mean (SD).

metronome set at 60 beats per min- and mode of 5 on the physical activity 18.4 (1.75) cm, compared to the non-
ute is provided to assist the subject in scale indicating moderate amounts of dancers’ 20.2 (2.6) cm (p = 0.016).
performing 30 heel-rises per minute. exercise, multiple times per week, on There were no statistically significant
The subject is instructed to perform as average. differences in the length to the soleus
many heel-rises as possible as high as between groups with the dancers and
possible. The tester discontinues the Ultrasound Imaging non-dancers averaging 4.8 (1.4)
test if the subject demonstrates any The dancers demonstrated signifi- cm and 5.3 (1.7) cm, respectively
of the following signs of fatigue that cantly shorter Achilles length to the (p = 0.333). Achilles tendon cross-
they are unable to correct with verbal gastrocnemius, with a mean (SD) of sectional area was also not statistically
cueing: inability to keep the standing
knee straight, inability to maintain
pace, or a heel rise height of less than
2 cm. Strong verbal encouragement
is provided to the subject throughout
the heel-rise test. For the purpose of
this study, data extracted for analysis
included number of repetitions, maxi-
mum heel rise height, and total work
performed (body weight multiplied by
total distance traveled).
For the purposes of data analysis,
each lower extremity was considered
a separate data point (20 extremities
in each group). Comparisons between
dancer and non-dancer cohorts were
analyzed using a one-way analysis of
variance (ANOVA) test. Pearson cor-
relational analysis was performed to
determine the relationship between Figure 1 Total work (J) performed on heel-rise test in dancers and non-dancers. *In-
maximum heel-rise height and Achil- dicates statistical significance, p < 0.05.
les tendon length for the combined
cohorts with each tendon representing
a single data point. The level of statisti-
cal significance was set at p < 0.05.
Results
There were no statistically signifi-
cant differences in range of motion
between dancers and non-dancers
(Table 1). There were no clinically
meaningful differences in VISA-A
scores between groups, with dancers
reporting a mean (SD) of 95.0 (7.2)
and non-dancers a mean (SD) of
97.6(3.63) out of 100. These scores
indicate that neither group had pain
or symptoms from their Achilles
tendons. The group as a whole dem- Figure 2 Relationship between maximum heel-rise height and Achilles tendon length
onstrated a mean (SD) of 4.9 (0.94) for all subjects.
 Journal of Dance Medicine & Science • Volume 21, Number 2, 2017 67

different between groups with dancers would be required when en pointe. flexion as an individual advances in
averaging 0.41 (0.10) cm and non- Furthermore, subtle adjustments may ballet training, there is an advantage
dancers 0.43 (0.13) cm (p = 0.693). be performed with the deep posterior for individuals with shorter Achilles
lower leg musculature, particularly the tendons.
Heel-Rise Test flexor hallucis longus, when en pointe. The strength of this study is in
One dancer presented with symptoms Prior studies have suggested that the the methods utilized to assess lower
consistent with posterior lower leg soleus works along with the muscles leg performance and Achilles tendon
compartment syndrome and request- of the deep lower leg compartment structure. Continued utilization of
ed not to perform the heel-rise test. to control the demi-pointe position standardized procedures that are easily
Therefore, she was not included in this in ballet dancers.30 In combination, translated into clinical practice will
portion of testing. The dancer cohort these findings point to the importance help with developing evidence-based
demonstrated a significantly higher of loading the Achilles tendon in mid- practice guidelines for this popula-
mean (SD) maximum heel rise height ranges in dancers with Achilles tendon tion of artist-athletes. The heel-rise
of 16.5 (0.75) cm compared to 13.3 dysfunction. Anecdotally, dancers test should be investigated further as
(1.8) cm in non-dancers (p < 0.001). with Achilles tendon problems may a potential screening tool for tendon
Dancers performed significantly fewer perceive less difficulty with maintain- health and calf musculature function.
repetitions compared to non-dancers ing the en pointe position than with The primary limitation of this study
with means (SD) of 19.7 (3.6) and “rolling up” to full or demi-pointe or is the small sample size; however,
32.5 (8.29), respectively (p < 0.001). with jumping tasks. since significant differences were seen
Despite performing higher heel rises, The triceps surae muscles have been between groups, these differences
dancers performed 1,643 (492) joules estimated to contribute 65% to 85% would likely occur in a larger sample.
of work, which was significantly less of total plantar flexion torque.31,32 The Additionally, the small number of
total work compared to 2,241 (786) tibialis posterior, flexor hallucis longus, male dancers is limiting given that
joules of work in non-dancers (p = and flexor digitorum longus comprise male and female dancers are subjected
0.014; Fig. 1). Maximum heel rise the deep posterior compartment of the to different demands in classical bal-
height was negatively correlated to lower leg and contribute to plantar let. This study also investigated only
Achilles tendon length to the gastroc- flexion torque. The relative contribu- the performance of primarily pre-
nemius for both groups combined (R tion of the triceps surae versus the deep professional ballet students, and the
= -0.384, p = 0.017; Fig. 2). compartment has been found to dif- findings may not be generalizable
fer between individuals, activity, and to other dance forms or a cohort of
Discussion presence or absence of Achilles tendon professional-level ballet dancers. Fu-
This is the first study that has applied injury.33,34 While not formally assessed, ture studies to characterize heel-rise
standardized measures of lower leg increased muscle volume and develop- test performance of dancers at varying
function to a population of ballet ment of the flexor hallucis longus was skill levels—likely separating findings
dancers. The results of this study observed via B-mode ultrasound imag- of male and female dancers—as well
indicate that healthy, classically- ing in the dancer cohort. This suggests as across genres will be helpful in es-
trained ballet students have lower that differences in the requirements of tablishing normative values for these
calf endurance as measured by total ballet activities may result in changes populations.
work performed on the heel-rise test in contribution of the triceps surae and These findings have several clinical
and shorter Achilles tendons from the deep compartment musculature, implications for clinicians involved in
the calcaneal insertion to the gastroc- particularly the flexor hallucis longus.35 the care of dancers. Weakness in the
nemius myotendinous junction than Dancers were found to have shorter calf may be an area of preventative
non-dancers. Achilles tendons when compared to care for dancers; however, prospective,
It is surprising that the dancers per- non-dancers. It is possible that this is interventional studies are required to
formed only 74% the amount of work the result of a selective versus adaptive determine the efficacy of a preventa-
of the non-dancers given the amount process. Studies in individuals fol- tive calf-strengthening program. This
of time dancers spend in plantar flexed lowing Achilles tendon rupture have study also supports the concept that
positions. Dancers did demonstrate found heel rise height to be inversely dancers may require modification of
significantly higher maximum heel- related to Achilles tendon length.17 return-to-activity criteria with regard
rise height during the heel-rise test The results of this study indicate that to calf strength measures. The heel-rise
but performed significantly fewer shorter Achilles tendons are related to test would be a clinically useful tool
repetitions than the non-dancers. a higher heel-rise height in individuals to inform return-to-dance decision
These findings suggest that the Achil- with healthy Achilles tendons, though making and may be useful to include
les tendon and triceps surae may have this correlation is not as strong as that in pre-season screening of dancers.
decreased levels of demand when seen in people post-Achilles tendon Given that differences in recruit-
weightbearing in an isometric fashion rupture.17 Therefore, because there ment of the triceps surae and flexor
in fully plantar flexed positions, as is a need for higher levels of plantar hallucis longus are likely between
68 Volume 21, Number 2, 2017 • Journal of Dance Medicine & Science

dancers and non-dancers, it would 5. Visnes H, Hoksrud A, Cook J, Bahr Rehabil Technol. 2015 Apr:2(2):49-
be beneficial to continue to investi- R. No effect of eccentric training on 55.
gate this relationship. It may be that jumper’s knee in volleyball players 16. Suydam SM, Buchanan TS, Manal
subclinical changes in the Achilles during the competitive season: a K, Silbernagel KG. Compensatory
tendon and triceps surae function randomized clinical trial. Clin J Sport muscle activation caused by tendon
Med. 2005 Jul;15(4):225-32. lengthening post-Achilles tendon
could contribute to overuse of the 6. Khan KM, Cook JL, Bonar F, et al. rupture. Knee Surg Sports Traumatol
flexor hallucis longus and develop- Histopathology of common tendi- Arthrosc. 2015 Mar;23(3):868-74.
ment of tendinopathy. Muscular nopathies: update and implications 17. Silbernagel KG, Steele R, Manal
recruitment of the triceps surae versus for clinical management. Sports K. Deficits in heel-rise height and
deep compartment musculature may Med. 1999 Jun;27(6):393-408. Achilles tendon elongation occur in
also vary between tasks such as relevé 7. Thomopoulos S, Parks WC, Rifkin patients recovering from an Achilles
and sauté. Studies investigating these DB, Derwin KA. Mechanisms of tendon rupture. Am J Sports Med.
relationships will help inform clinical tendon injury and repair. J Orthop 2012 Jul;40(7):1564-71.
decision making when rehabilitating Res. 2015 Jun;33(6):832-9. 18. Jhingan S, Perry M, O’Driscoll G,
dancers with lower leg tendinopathies. 8. Lavagnino M, Wall ME, Little D, et al. Thicker Achilles tendons are a
et al. Tendon mechanobiology: cur- risk factor to develop Achilles tendi-
rent knowledge and future research nopathy in elite professional soccer
Conclusion opportunities. J Orthop Res. 2015 players. Muscles Ligaments Tendons
A standardized test battery used to Jun;33(6):813-22. J. 2011 Dec 29;1(2):51-6.
evaluate lower leg function found 9. Garrick JG, Requa RK. Ballet inju- 19. Silbernagel KG, Gustavsson A,
pre-professional ballet dancers to have ries: an analysis of epidemiology and Thomeé R, Karlsson J. Evaluation
less calf endurance than non-dancers. financial outcome. Am J Sports Med. of lower leg function in patients
Additionally, dancers presented with 1993 Jul-Aug;21(4):586-90. with Achilles tendinopathy. Knee
shorter Achilles tendons than non- 10. Askling C, Saartok T, Thorstensson Surg Sport Traumatol Arthrosc. 2006
dancers. These findings indicate that A. Type of acute hamstring strain af- Nov;14(11):1207-17.
fects flexibility, strength, and time to 20. Kulig K, Loudon JK, Popovich
the occupational requirements of return to pre-injury level. Br J Sports JM, et al. Dancers with Achilles
ballet dancers may change the recruit- Med. 2006 Jan;40(1):40-4. tendinopathy demonstrate altered
ment of the lower leg musculature and 11. Askling CM, Tengvar M, Saartok lower extremity takeoff kinematics.
select for individuals with anatomical T, Thorstensson A. Acute first-time J Orthop Sports Phys Ther. 2011
variations that allow them to achieve hamstring strains during high-speed Aug;41(8):606-13.
a high heel-rise. These findings point running: a longitudinal study includ- 21. Silbernagel KG, Thomee R, Thomee
to the importance of collecting nor- ing clinical and magnetic resonance P, Karlsson J. Eccentric overload
mative data in larger, representative imaging findings. Am J Sports Med. training for patients with chronic
populations of elite artist-athletes on 2007 Feb;35(2):197-206. Achilles tendon pain—a randomised
standardized test batteries to guide 12. Askling CM, Tengvar M, Saartok T, controlled study with reliability
screening, rehabilitation, and return- Thorstensson A. Proximal hamstring testing of the evaluation meth-
strains of stretching type in different ods. Scand J Med Sci Sport. 2001
to-dance decision making. sports: injury situations, clinical and Aug;11(4):197-206.
magnetic resonance imaging charac- 22. Maffulli N, Kenward MG, Testa V,
References teristics, and return to sport. Am J et al. Clinical diagnosis of Achilles
1. Byhring S, Bø K. Musculoskeletal Sports Med. 2008 Sep;36(9):1799- tendinopathy with tendinosis. Clin
injuries in the Norwegian National 804. J Sport Med. 2003 Jan;13(1):11-5.
Ballet: a prospective cohort study. 13. Silbernagel KG, Thomeé R, Eriksson 23. Barton CJ, Bonanno D, Levinger P,
Scand J Med Sci Sports. 2002 BI, Karlsson J. Full symptomatic re- Menz HB. Foot and ankle charac-
Dec;12(6):365-70. covery does not ensure full recovery teristics in patellofemoral pain syn-
2. Nilsson C, Leanderson J, Wykman A, of muscle-tendon function in pa- drome: a case control and reliability
Strender L-E. The injury panorama tients with Achilles tendinopathy. Br study. J Orthop Sports Phys Ther.
in a Swedish professional ballet com- J Sports Med. 2007 Apr;41(4):276- 2010 May;40(5):286-96.
pany. Knee Surg Sports Traumatol 80; discussion 280. 24. Robinson JM, Cook JL, Purdam C,
Arthrosc. 2001 Jul;9(4):242-6. 14. Kader D, Saxena A, Movin T, Maf- et al. The VISA-A questionnaire: a
3. Comin J, Cook JL, Malliaras P, fulli N. Achilles tendinopathy: some valid and reliable index of the clinical
et al. The prevalence and clinical aspects of basic science and clinical severity of Achilles tendinopathy. Br
significance of sonographic tendon management. Br J Sports Med. 2002 J Sports Med. 2001 Oct;35(5):335-
abnormalities in asymptomatic Aug;36(4):239-49. 41.
ballet dancers: a 24-month longitu- 15. Carmont MR, Grävare Silbernagel 25. Grimby G. Physcial activity and mus-
dinal study. Br J Sports Med. 2013 K, et al. The Achilles tendon rest- cle training in the elderly. Acta Med
Jan;47(2):89-92. ing angle as an indirect measure of Scand Suppl. 1986 Jan;711:233-7.
4. Leadbetter WB. Cell-matrix response Achilles tendon length following 26. Nilsson-Helander K, Silbernagel
in tendon injury. Clin Sports Med. rupture, repair, and rehabilitation. KG, Thomeé R, et al. Acute Achil-
1992 Jul;11(3):533-78. Asia-Pacific J Sport Med Arthrosc les tendon rupture: a randomized,
 Journal of Dance Medicine & Science • Volume 21, Number 2, 2017 69

controlled study comparing surgical ment of heel-rise endurance with the 33. Finni T, Hodgson JA, Lai AM, et al.
and nonsurgical treatments using ability to detect functional deficits Muscle synergism during isometric
validated outcome measures. Am J in patients with Achilles tendon plantar flexion in achilles tendon
Sports Med. 2010 Nov;38(11):2186- rupture. Knee Surg Sports Traumatol rupture patients and in normal sub-
93. Arthrosc. 2010 Feb;18(2):258-64. jects revealed by velocity-encoded
27. Olsson N, Silbernagel KG, Eriksson 30. Tanabe H, Fujii K, Kouzaki M. Joint cine phase-contrast MRI. Clin
BI, et al. Stable surgical repair with coordination and muscle activities of Biomech (Bristol, Avon). 2006
accelerated rehabilitation versus non- ballet dancers during tiptoe. Motor Jan;21(1):67-74.
surgical treatment for acute Achilles Control. 2017 Jan;21(1):72-89. 34. Finni T, Komi PP V, Lepola V. In vivo
tendon ruptures: a randomized 31. van Zandwijk JP, Bobbert MF, human triceps surae and quadriceps
controlled study. Am J Sports Med. Harlaar J, Hof AL. From twitch to femoris muscle function in a squat
2013 Dec;41(12):2867-76. tetanus for human muscle: experi- jump and counter movement jump.
28. Ryan ED, Rosenberg JG, Scharville mental data and model predictions Eur J Appl Physiol. 2000 Nov;83(4-
MJ, et al. Test-retest reliability and for m. triceps surae. Biol Cybern. 5):416-26.
the minimal detectable change for 1998 Aug;79(2):121-30. 35. Rowley K, Jarvis D, Kurihara T, et
achilles tendon length: a panoramic 32. Gregor RJ, Komi PV, Browning RC, al. Toe flexor strength, flexibility and
ultrasound assessment. Ultrasound Järvinen M. A comparison of the function and flexor hallucis longus
Med Biol. 2013 Dec;39(12):2488- triceps surae and residual muscle tendon morphology in dancers and
91. moments at the ankle during cycling. non-dancers. Med Probl Perform
29. Silbernagel KG, Nilsson-Helander J Biomech. 1991;24(5):287-97. Art. 2015 Sep;30(3):152-6.
K, Thomeé R, et al. A new measure-