Dance Injuries of the Foot and Ankle

Original Editor - Carin Hunter based on the course by Michelle Green-Smerdon
Top Contributors - Carin Hunter, Jess Bell, Kim Jackson, Olajumoke Ogunleye and Nupur Smit Shah

Introduction

85% of dancers will have some form of musculoskeletal injury during career and approximately 50% occur in the ankle or foot. Even injuries higher up in the chain will have an effect on the lower limb. The foot is essential to a dancer as it it their base of support and the fundamental lever to propel in dynamic manoeuvres. It is an important shock absorber and offers the ballet dancer one of their essential forms of artistic expression.

Risk Factors

• Previous injuries
• Poor rehabilitation
• Anatomical posture
• Poor training incl. low levels of muscular strength and power
• Poor lumbopelvic control
• Technical mistakes
• Execution speed
• Choreographer
• Dance style
• Shoe fit and style
• Psycho-physical condition of dancer
• Environmental factors
  • Floor type
  • Jacobs et al, 2010
  • The incidence of injuries in dancers varies from 40% to 84%. These being mostly caused by low cardiovascular conditioning, articular hyper mobility, postural deviation, alteration in the body’s center of balance
  • “realized with amateur dancers, it shows that for each 1000 hours of training, the injuries incidence diagnosed was from 0.62 to 5.6 injuries per dancers. Bearing in mind that the technical demand for a professional dancers is even higher, it is considered that this number increases drastically into the professional contest”

Acute vs overuse injuries

• Acute
  • Normally incorrect execution (improper jumps, landing) and poor technique
  • Usually an incident to report
  • Other factors such as tiredness, fatigue, loss of balance
• Overuse
  • Excessive use
  • Repeated microtrauma

Additional contributing factors

• Transitioning from Part time to Full - -time or professional ballet
• The foot can affect the knee, hip, core musculature and spine
• TURNOUT
• Biomechanical requirements (pointe and demipointe =full PF and 90 degrees MTP ext)
• Floor type
• Shoe type and fit
• The dancers body and their management
• Psychology and expectations of dancers
• One Common issue found that could lead to injury

decreased triceps surae/posterior tibialis strength and/or decreased plantar flexion active range of motion.

These deficits often contribute to faulty mechanics, including

• increased ankle inversion/eversion compensation (rolling in or out) in efforts to get en pointe and/or maintain position,
• decreased stability once there, knuckling under (excessive interphalangeal joint flexion compensation)
• and/or decreased plantar flexion rom to allow ideal positioning of body over toes.  

Anterior ankle issues

• Anterior impingement
• Anterior bone spurs (mature/retired dancer)
• Tibial stress syndrome
• Tibial stress fracture (less common)
• Anterior lig and tendon pathology esp EHL (trying to improve point, injure surrounding lig, long-term instability)
• Anterior capsule synovitis

Anterior impingement syndrome

• Agg – repetitive forced dorsiflexion (Plie)
• Educate – stretch properly and strengthen intrinsic and extrinsic musculature
• Occurring primarily secondary to the repetitive forced ankle dorsiflexion (forcing plie)
• Symptoms generally progressive
• Responds to conservative treatment but as progresses surgery is effective
• Address biomechanical faults = look higher up
• Dance movements contributing =plie, rolling ankles, forcing turnout
• Compensation=lifting up heel earlier
• Rehab = Mulligan Mobilisation with movement, Passive Accessory Movement, chair ankle rocker
• Surgery is effective if condition has progressed far enough

Posterior ankle issues

• Achilles tendinopathy
  • The prevalence of this injury in dancers is due to releves, jumps, turns, and pointe work
  • Can be caused by tying ribbons incorrectly across achilles tendon or from hard floors

Choreograper from few jumps to lots of jumps

Posterior ankle impingement syndrome

• Dancers heel
• Forced plantarflexion
• Often coincides with FHL tendinopathy
• Bony or soft tissue
• Can be operated on
• C/O pain and tenderness on the posterolateral aspect of the ankle on active plantar-flexion. Pain is exacerbated with axial loading as well as with great toe dorsiflexion as FHL pushes against the ossicles over its groove along the talus
• biomechanics check - plie, grand plie, releve
• stretch - hams, adductors, tib A, calves
• strengthen - glutes, hamstrings, adductors, abductors
• rehab- mobility crawls, isometric Single leg heel raise, eccentric single leg heel lowering

PAIS in Ballet

• In some sports - required periodically and suddenly in a passive manner (by external force, e.g., soccer during certain forms of kicking) or briefly in an active manner (e.g., gymnastics and other artistic sports),
• In Ballet -  required in a controlled, persistent, extreme, active, and fully weightbearing manner.
• When kicking a ball, the talo-crural and subtalar joints are non-weightbearing; hence, there is no tendency for the talus (talo-crurally) and calcaneus (subtalarly) to slide posteriorly and add to the impingement. Second, when kicking, the calcaneus is not pulled up by the triceps surae. That this is important is biomechanically logical and is illustrated by the fact that in PAIS testing (plantar flexion test) the pain will mainly be provoked if the calcaneus is pressed up simultaneous

Lateral ankle issues

• Lateral ankle sprains (common)
• Cuboid subluxation issues (rotational strain to bone following other issues)
• Sinus tarsi
• Peroneal tendon overuse and retinaculum stress

Lateral ankle sprain

• Dancer relies on feedback and stability from lateral lig
• biomechanics check – first position pile, releve, passe. Alignment in demipointe or pointe
• stretch -  hams, quads, adductors, iliopsoas, calves
• Strengthen - glutes, dorsiflexors, everters
• rehab- aggressive strengthening and proprioception, side plank tbd clamshell, SLB tap front around to back, resisted PF with eversion

Toe issues

• Hallux Valgus
• Hallux Riditis
• Bunions
  • Strengthening intrinsic foot muscles
  • Correct alignment and toe spacers
• Sesmoiditis
• Metatarsalgia
• 5th metatarsal fracture/ Dancers fracture/lisfrank fracture
• Hammer toe
• Blisters
• Ingrown toe nails

Hallux rigidis

FHL = primary dynamic stabiliser of medial ankle in pointe and demi pointe

• biomechanics check - parallel, first position, passe
• stretch -iliopsoas, quads, adductors, calves
• Strengthen - glutes, hamstrings, adductors, abductors
• rehab-toe/ankle rocker w toe spacer, big toe flexion and extension, isometric theraband toe abduction, curl/flex with theraband, toe abduction, toe separation

Sesmoiditis

• Embedded within the FHB tendon and articulate with the plantar surface of the first metatarsal head
• Function – stabilise first MTPJ and improve power of the FHB tendon
• Technical errors – rolling in, pronation, forcing turnout
• Collapsed arches = more pressure on sesmoids
• SX – pain under first MT head on plantar forefoot, tenderness should move distally with DF of great toe
• Agg – Taking off and landing jumps esp without plie, rolling into Releve/demi pointe (more stressful than en pointe), walking with toe out gait/ in turn out
• RX – padding to off-load area, use of stif soled shoes outside class (more support), assess and correct alignment, takes months to resolve
• stretch - hams, glutes, adductors, roll calves
• Strengthen - glutes, hams, adductors, iliopsoas, intrinsic foot muscles
• rehab- tbd clamshells, foam roll ball squeeze leg lowering, prone hamstring curl to hip extension

5th metatarsal fracture

Dancers fracture, non –operative, twisting injury, differentiate to jones fracture (occurs further down the base, repetitive stress = surgery)

• stretch -hams, glutes, iliopsoas, adductors, roll calves
• Strengthen - glutes, hams, adductors, iliopsoas
• rehab-side plank hip adduction, foam roll quadruped donkey kicks, quadruped car wheel

Plantar fasciitis

• This injury is often associated with repetitive jumping which is why it has such a high prevalence in dancers
• biomechanics check - plie, developpe, gait
• stretch -iliopsoas, quads, adductors, calves
• Strengthen -glutes, abductors, deep rotators
• rehab- chair SL bridges, SL heel raises on stairs, ankle/toe rockers, strapping

Foot and Ankle Care

• POINTEWORK SHOULD BE PROGRESSED SLOWLY AND ONLY COMMENCED ONCE READY/SCREENED
• FOOT ALIGNMENT SHOULD BE MONITORED THROUGHOUT THE JUMPING SECTION WITH NO UNDUE PRONATION OF THE FOREFOOT
• SIMPLE BALANCE EXERCISES SHOULD BE INCLUDED
• INTRINSIC FOOT EXERCISES
• CALF EXERCISES AND STRETCHED
• WALK WITH NORMAL ANGLE OF GAIT TO OFFLOAD HIP ROTATORS, ie, not in turned out position