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Dancing on the Ceiling

Lorenz Hart concocted many witty rhymes for his college buddy Richard Rogers to set to music, but the title of their jazz standard Dancing on the Ceiling captivates the listener more than any of the actual lyrics. It’s hard to escape the fascination of this patently impossible physical feat. When the song appeared in the original 1930 London production of Rogers and Hart’s Ever Green, the cast triumphed over gravity with an upside-down set that featured a glittering chandelier rising majestically from the stage. The song’s narrative reveals a more mundane explanation for this supernatural phenomenon: The singer’s love interest dances nightly on the floor above her bedroom, his deft footsteps reverberating down through the ceiling. More figuratively, ‘‘dancing on the ceiling’’ might suggest a feeling of euphoria so intoxicating that the margins of reality become blurred. Lionel Ritchie developed this metaphor when he borrowed the title for his 1986 hit of the same name. The phrase still resurfaces whenever a writer wants to capture a sensation of intense joy or underscore the singularity of an improbable accomplishment. In Stanley Donen’s 1951 movie Royal Wedding, Fred Astaire was so enraptured by a photo of Sarah Churchill that he began to dance, first on the floor but ultimately right up the walls and across the ceiling of his hotel room. Lionel Ritchie admired Royal Wedding’s special effects so much that he asked Donen to re-create them for his own Dancing on the Ceiling music video 35 years later. Competitive athletes also may find themselves ‘‘dancing on the ceiling,’’ although in a different sense: performing at, or seemingly beyond, the limits of their capabilities. For the average competitor, this merely involves achieving a personal best performance, but the most elite athletes attempt to stretch the boundaries of all human ability as they pursue a world record or aim for a game-winning goal. For the majority of mortals, striking out Derek Jeter or Chase Utley might be an undertaking as improbable as dancing on the ceiling. Even a Hall of Fame pitcher needs to be at his best to do it. As human performance progresses, advances become asymptotic, and increments of improvement become smaller and smaller. Nevertheless, records continue to be broken, as technology, nutrition, knowledge of physiology, and serendipitous breeding push the ceiling of human potential ever higher. In sports such as swimming or track, chronographic technology has no trouble documenting minute quanta of improvement. This is not true for all athletic endeavors, however. In games such as football, soccer, or baseball, we rely on multifarious statistics to quantify the level of performance. The inherent limitations of these comparisons can lead to some impassioned arguments when questions of historical superiority arise. In medicine, we may also have difficulty quantifying functional improvements near the upper end of the performance spectrum. Many subjective outcomes instruments for measuring health and health-related quality of life have been developed and validated. When the limitations of such instruments prevent them from documenting incremental improvement at the higher end of function, they are said to exhibit a ceiling effect. You might say that high-functioning patients are dancing on the ceiling of the outcomes instrument, their true ability level bumping up against the artificial limit imposed by the measuring scale itself. These effects can be problematic in sports medicine, in which optimal athletic performance is an integral component of daily living. It is not really surprising that routine outcome scores are inadequate for measuring the functional recovery of elite athletes following injury treatment. Conway et al recognized this problem when they published their classic report in 1992 on repair and reconstruction of the ulnar collateral ligament (UCL) of the elbow in throwing athletes. Using what became known as the Conway scale, they classified the results as excellent if the athlete was able to return to play at the same or a higher level, good if he was able to compete at a lower level, fair if only recreational play was possible, and poor if play was impossible. Other authors have attempted to pinpoint the level of recovery in professional athletes even more precisely using performance statistics to describe the quality of function following surgery. In this issue of The American Journal of Sports Medicine, Domb et al report the results of UCL reconstruction of the elbow in professional baseball players using the recently validated Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow score. The authors’ goal was to go beyond merely documenting return to play, by distinguishing athletes who were playing with pain from those who were playing pain-free or not playing at all because of pain. It is interesting to note that even the players who were playing without pain scored lower than a control group who had never been injured, a finding that suggests subtle residual impairment even after successful surgery. This contrasts somewhat with Gibson et al, who found that performance statistics, such as earned run average and walks and hits per inning pitched, did not deteriorate in pitchers who had successfully returned to Major League Baseball after UCL reconstruction. It is often forgotten that validation of an outcomes instrument is not absolute but specific for a particular The American Journal of Sports Medicine, Vol. 38, No. 8 DOI: 10.1177/0363546510378616 2010 American Orthopaedic Society for Sports Medicine