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Dancer's Tendonitis

Original Editor - Puja Gaikwad

Top Contributors - Puja Gaikwad, Lania-Schane Smith, Vidya Acharya, Wanda van Niekerk, Kim Jackson and Alexandra Stead  

Introduction

Ballet Dancer-En Pointe Position.

The ankle is one of the most commonly injured body areas in dance.[1] Incidences of injury to the ankle-foot complex scale from 27% to 49% of total injuries in ballet, modern, flamenco, and tap dancers.[2][3] Flexor Hallucis Longus (FHL) tendonitis (also known as Dancer’s tendonitis) is a common condition seen due to the repetitive and intense demands of dance, which place significant stress on tendons. FHL tendonitis commonly arises from repetitive plantarflexion and dorsiflexion of the foot, and can significantly impact a dancer's ability to perform, leading to extended periods away from training and performances.[4][5]

The repercussions of FHL tendonitis extend beyond the immediate pain; it can disrupt a dancer’s progress, affect their technique, and potentially hinder their career.[5] Early diagnosis and effective management are crucial to minimising downtime and ensuring a successful return to dance. Understanding and addressing this common injury can help dancers maintain their physical health and performance levels.

Relevant Anatomy

FHL

The Flexor Hallucis Longus (FHL) muscle arises from the posterior and distal two-thirds of the fibula, the interosseous membrane of the limb and the intermuscular septa.[6] It is distal and lateral to the muscle belly of the flexor digitorum longus (FDL) and deep to the soleus and gastrocnemius.[6] The Flexor Hallucis Longus (FHL) muscle is pennate in shape, meaning its fibres are arranged in a feather-like pattern and converge toward the tendon. The FHL tendon then courses posterior to the talus and beneath the medial retinacular structures at the posteromedial ankle, where it is enclosed in a synovial sheath and traverses a fibro-osseous tunnel between the medial retinaculum and the lateral tubercles of the talus.[6] As the FHL tendon continues towards the arch of the foot, it passes beneath the sustentaculum tali, which is a bony ledge on the calcaneus that helps support and guide the tendon.[6]

Knot of Henry

The Flexor Hallucis Longus (FHL) tendon is a component of the tarsal tunnel, situated posterior to the neurovascular bundle within this space. [7][8][9] As the FHL tendon traverses the arch of the foot, it crosses over the Flexor Digitorum Longus (FDL) tendon at a region known as the 'knot of Henry,' positioning itself on top of the FDL tendon.[8] [7][9] At this crossing point, the FHL tendon lies dorsal to the medial edge of the plantar fascia.[9] The tendon continues forward, passing between the two sesamoid bones of the first metatarsophalangeal (MTP) joint, where it is covered by the intersesamoid ligament, and finally inserts at the base of the distal phalanx of the great toe.[9] The FHL tendon interacts with three key retinacular structures: the tarsal tunnel, the knot of Henry, and the intersesamoid ligament. These interactions can create points of potential compression and stress, which may contribute to tendon injuries such as tendonitis.[7][9]

Causes

While the accurate cause of FHL tendon injury is debated, it is thought that constriction occurs at the fibro-osseous tunnel in the posterior ankle in and around the tarsal tunnel, the Knot of Henry in the midfoot or intersesamoid ligament.[10] This pseudo- entrapment generates repetitive microtrauma, and usually occurs due to gradual wear and tear associated with overuse.[10] Although irritation may happen at the knot of Henry and within the sesamoids of the great toe, the most commonly irritated location is deep to the flexor retinaculum, where the tendon lies within the fibro-osseous tunnel.[10]

Recurrent irritation of the tendon’s sheath can lead to hypertrophy of the tendon within this tunnel.[11] Thickening or fibrosis may impede the normal gliding of the tendon, thus creating pain and movement restrictions.[11] Increased pain and decreased use can cause weakness of the tendon and muscle. Adhesions and the development of calcific nodules can follow.[12]

Dancer’s tendonitis is more common in female ballet dancers who spend plenty of time en pointe or demi-pointe.[13] FHL tendonitis can occur as a primary condition, or as a secondary condition of os trigonum impingement syndrome.[13] Failure to accurately treat inflammation may result in a nodule (obstruction of the fibrous tunnel the tendon runs through) or partial or complete tear of the tendon.[14]

Dancers are exposed to a wide range of risk factors that could lead to overuse injuries. The most common factors include:

  • Training load parameters
  • Environmental conditions like hard floors and cold studios
  • Equipment used, especially shoes
  • Prior history of injury
  • Nutritional deficiencies[15][16]

Clinical Signs and Symptoms

Subjective Assessment

Injury to the FHL tendon is typically characterised by pain situated posterior and inferior to the medial malleolus, which gets worse by jumping and landing or going from demi-pointe to full pointe.[17] Demi-pointe position in ballet is when the dancer is on the balls of their feet, referred to as half-point and Full Pointe ("en pointe" position) is when the dancer has a completely extended vertical foot). In dancers, the FHL tendon is typically compressed while performing a relevé position and is overstretched while performing a plié position.[17] In such cases, the dancer will feel pain around the posteromedial ankle when performing the plié.[9] This can also be incorporated with a sensation of crepitus in the tendon and triggering of the great toe depending on the severity of the tendon injury. Triggering can also involve an inability to relax the toe after full plantar flexion when pointing the foot, resulting in a locking sensation of the great toe. This condition is often painful because, as the tendon begins to fray, it becomes swollen, irritated, and inflamed. Fluid accumulates around the affected area, leading to swelling and discomfort for the patient. [18]

Injury to the FHL (flexor hallucis longus) tendon is typically characterised by pain located posterior and inferior to the medial malleolus. This pain often worsens with activities such as jumping, landing, or transitioning from demi-pointe to full pointe.[17] In ballet, the demi-pointe position refers to being on the balls of the feet (half-point), while the full pointe position involves a fully extended vertical foot ("en pointe"). During a relevé position, the FHL tendon is compressed, whereas it is overstretched during a plié. Consequently, dancers may experience pain around the posteromedial ankle during a plié. This condition can also be accompanied by sensations of crepitus and triggering of the great toe, depending on the severity of the injury. Triggering may manifest as an inability to relax the toe after full plantar flexion, leading to a locking sensation. As the tendon frays, it becomes swollen, irritated, and inflamed, with fluid accumulation around the area, resulting in significant swelling and discomfort.

Objective Assessment

Clinical examination of the foot and ankle in a dancer with a suspected FHL injury involves specific attention to four regions of the foot and ankle:

  • Posterior ankle
  • Sustentaculum tali
  • Plantar midfoot
  • The level of the sesamoids

The ankle and great toe are held in either a neutral or dorsiflexed position to put the FHL under tension. Proximally, the muscle and the musculotendinous junction are palpated just posterior and lateral to the posterior tibial tendon. Medially and inferior to the sustentaculum tali, the FHL is often palpated as it passes through the fibro-osseous tunnel. At the plantar surface, the FHL can be found just plantar to the navicular and medial cuneiform bone, and it can often be palpated as it traverses the knot of Henry. Distally, the FHL is palpated while it travels between the sesamoids.[6]

There will also be pain with resisted flexion of the hallux IP joint.[4] Great toe triggering can be felt with active or passive motion with no tenderness at the level of the first metatarsal head. Resistance to the FHL could also be painful. Often, one can best elicit pain by placing the ankle in the plantar flexion and pressing on the FHL tendon area while moving the great toe into a forced dorsiflexion position. This will result in pain and tenderness at the point of manual compression in the posterior ankle region.[2] Pseudo-hallux rigidus may be present, as illustrated by a limitation of great toe dorsiflexion with the knee fully extended and the ankle in full dorsiflexion. Symptoms can be further provoked with ankle inversion. It can decrease the dimension of the tarsal tunnel causing more compression or irritation to the FHL tendon.[12]

Positive Tomasen test: This test assesses the influence of the FHL on the first MTP motion. This test is performed by assessing first MTP motion in both positions that is, in maximal plantarflexion and moderate dorsiflexion of the ankle. To perform the test accurately, the first metatarsal head should be stabilised to avoid compensatory first metatarsal head plantar flexion. A positive test consists of discomfort or reduced first MTP joint extension by 20 degrees with ankle dorsiflexion.[11] When you allow the patient to release the foot and to now plantarflex and point the foot, then they will have a better range of motion of the big toe. So this occurs because when putting the foot into dorsiflexion, it makes that tendon taut.[19]

[20]

Diagnostic Procedures

FHL-Ultrasonography.Probe position {transverse (a) and longitudinal views (b)} F: Fibula S: Soleus muscle.

X-Rays will not provide an accurate diagnosis of FHL injuries. Nevertheless, X-Rays is good for ruling out fractures that can cause an impingement of the FHL tendon (calcaneus, distal medial malleolus, or os trigonum). A comprehensive patient history, followed by a full physical examination is usually critical for accurately diagnosing this condition. On the other hand, in some cases, MRI is required to evaluate tears in the FHL tendon and any sources of impingement of the FHL. One of the best diagnostic examinations for FHL tendonitis condition is dynamic ultrasound.[21] This allows real-time testing of the FHL tendon while it goes through a range of motion.[17] Ultrasound often can be the option for the diagnosis of stenosis or impingement of a low-lying muscle. Often, one can combine ultrasound with MRI to check for os trigonum problems or posterior ankle impingement.[9]

Differential Diagnosis

Treatment

If FHL tendonitis is diagnosed, avoid pointe work until the inflammation subsides. Also, take an inventory of the dancer’s technique- specifically the alignment of the feet. Forcing turnout to the extreme results in the inner ridge of the foot to roll in, which may either lead to or exacerbate the symptoms. Conservative management includes anti-inflammatory drugs, ice, and physiotherapy. A recent systematic review[22] shows that physiotherapeutic interventions have positive effects in several domains, including pain, ROM, and functional status, thus have a potential role in the treatment of ballet dancers after injuries. However, the small evidence base and methodological limitation of the review calls for a cautious approach while considering the physiotherapy options for managing injuries in a ballet dancer. Surgery should be considered when all other approaches fail. Recovery from FHL surgery may take over three months.

One of the essential components of treatment is that the patient should take relative rest from any activity that elicits their pain until its symptom-free (crutches may be required in some cases). This permits the body to initiate the healing process in the absence of further tissue damage. Once the patient can achieve these activities pain-free, a gradual return to these activities is indicated provided there is no aggregation of symptoms. Neglecting symptoms or adopting a ‘no pain, no gain’ attitude is likely to lead to the injury becoming chronic. Once chronic, healing slows down significantly resulting in markedly increased recovery time and an increased likelihood of future episodes of recurrence. Immediate appropriate therapy in all patients with FHL tendonitis is important to ensure an optimal outcome. Manual therapy combined with a functional exercise program is particularly powerful and effective for achieving a full resolution. It might take at least four to six weeks of conservative treatment for a complete recovery. Often, all activities cannot be resumed until the pain symptoms have fully subsided. Even after the pain intensity has subsided, a slow return to activities is recommended. In the case of dancers, this could indicate initially avoiding point work, jumps, or grand plies (a grand plié requires a full knee bend).

Conservative Care for Dancer’s Tendonitis

Peace and Love Protocol

Following Peace and Love protocol particularly with regular icing and anti-inflammatory medication can help to significantly reduce inflammation in the initial phase of this condition.[23] Following appropriate nutritional, dietary, and possible pharmaceutical recommendations are also necessary.

Activity Modifications

Reduction in activities that precipitate pain is necessary to promote healing. for instance, avoid cessation of pointe work, jumps or grand plies etc.[24]

Pain Management

  • Supports (crutches or walker boot) can seldom be beneficial (in the short term).
  • Motion specific release techniques.
  • Taping of the foot and ankle.

Below you will see a short video of a taping strategy for the FHL muscle and tendon to help relieve pain and discomfort.

[25]

Target Specific Exercises

Introduce target specific exercises that support the improvement in strength, flexibility, and balance. As symptoms subside, stretching and range of motion exercises are added in a pain-free range to aid restore normal range of motion. Special attention should be given to the stretching of triceps surae since female ballet dancers tend to have limited ankle-foot dorsiflexion range.[26] Adequate dorsiflexion ROM may help with the absorption of high landing forces, avoidance of compensatory pronation, and prevention of double heel strikes during landing from jumps.

Stretching

Calf and FHL stretch can be started in a pain-free range. For FHL stretch, place the big toe on a block into a dorsiflexed position and bring the knee towards the wall. Hold it for 20-30 seconds.

[27]

Improve Joint ROM

Ankle & Foot Mobilisation: Improving joint mobility is critical if addressing the body's full kinetic chain. The objective of joint mobilisation is to reverse adverse physiological changes by promoting movement between capsular fibres.[28]

Ankle and Foot Strengthening

Isolated muscle strengthening for an injured FHL muscle and tendon can involve the following type of exercises. These are listed as progressions with the first exercises being non-weight-bearing exercises, and the later examples being suitable alternatives when the athlete can fully weight-bear. All these exercises are designed to be performed in subtalar joint neutral positions so the athlete will require to be cued and coached on how to maintain a neutral position.

  • Resisted big toe plantar-flexion: Using resistance bands or tubing, wrap around the big toe. With light to medium resistance pull to bands/ tubing, start actively plantar-flexing the big toe and foot. Hold for 8-10 seconds. Slowly resist the pull back into a neutral position.[29]
  • Eccentric FHL strengthening: In a seated position, Wrap the resistance band around the great toe. keep the foot in dorsiflexion and eversion and push the band all the way down in plantarflexion and inversion against the resistance.

[30]

  • Towel scrunch with a heel lift: Place towel onto a smooth surface, such as tile or wooden floors; place a foot onto the towel. Actively begin to scrunch the big toe balling towel under toes. At the same time lift the heel off the towel (heel and big toe should be the plantar-flexed position if performed correctly). Place heel back onto the towel and dorsiflex big toe to begin the sequence again. Should perform until the towel is completely underfoot. This can be performed from seated or standing positions.[31]
  • Marble/ ball pickups: Using 1st and 2nd toes, dorsiflex to pick up marble/ball and drop into a cup/ container utilising plantar-flexion. Should be performed from a standing position.
  • Edge hovers: Standing on the edge of a step with the 1st and 2nd toes supported with the three outside toes hovering in space, actively press the 1st toe into the step and try to lift and hold the heel off the step. These can be held for 15-20 second holds.
  • Gastrocnemius and soleus complex strengthening: In standing position, perform relevé on a step by keeping a big toe outside a step and push up into a relevé position. This exercise helps in strengthening the gastrocnemius and soleus complex.

[32]

Proprioceptive exercises

Proprioceptive exercises play a key role in the rehabilitation process for the ankle-foot, as some injuries have been shown to impair reflex responses. These types of exercises are designed to challenge the ankle-foot complex using relatively unstable surfaces like wobble boards, ankle discs, etc. with increasing challenges incorporated to promote rapid neuromuscular responses such as adding relevés, closing the eyes, or catching weighted balls.[33]

Biomechanical corrective techniques

One of the most important aspects of treatment is retraining the biomechanics of the foot and ankle to prevent the injury from reoccurring. This involves not only the muscles in the feet but also your core and turnout muscles to make sure that the correct alignment of the leg can be maintained at all times. Often a Floor Barre is used to continue to maintain and improve techniques while retraining the muscle memory in the brain. If turn-out is insufficient it can result in the use of compensatory techniques including; increased lumbar lordosis, pronation of the feet, and abduction of the forefoot. Also, weak hips can lead to faulty biomechanics and lower limb alignment. These all can put the dancer at higher risk of injury.[34]

[35]

A gradual return to activities

Dance-specific movements that originally aggravated the condition are also gradually reintroduced, with particular care taken to correct any underlying specific technique related problems like overpronation, maintenance of turnout at the hip, or landing mechanics in jumps.[36]

Prevention

Considering the high incidence of injury involving the ankle and foot, prevention of injuries to this area should be a priority for dancers. Preventive conditioning measures should involve sound training principles to avoid extreme fatigue or sudden increases in dance training by maintaining condition during layoffs or breaks, as well as performing strength, flexibility, and proprioceptive exercises. Preventive technique considerations include using the suitable placement of the bodyweight over the axis of the foot through various techniques including the use of the stirrup muscles and maintaining sufficient turnout at the hip. With respect to equipment considerations, careful selection of well-fitting shoes, where appropriate,[37] well-designed transitions for the addition of pointe work in ballet dancers,[38] and use of floors with good resiliency and friction characteristics [39] whenever possible may also help prevent FHL injuries.

Resources

Flexor Hallucis Longus (FHL) Tendinitis Video by Arthritis Health

References

  1. ↑ Rinonapoli G, Graziani M, Ceccarini P, Razzano C, Manfreda F, Caraffa A. Epidemiology of injuries connected with dance: a critical review on epidemiology. Med Glas (Zenica). 2020 Aug 1;17(2):256-64.
  2. ↑ 2.0 2.1 Kadel NJ. Foot and ankle injuries in dance. Physical Medicine and Rehabilitation Clinics. 2006 Nov 1;17(4):813-26.
  3. ↑ Vera AM, Barrera BD, Peterson LE, Yetter TR, Dong D, Delgado DA, McCulloch PC, Varner KE, Harris JD. An injury prevention program for professional ballet: A randomized controlled investigation. Orthopaedic journal of sports medicine. 2020 Jul 28;8(7):2325967120937643.
  4. ↑ 4.0 4.1 Rowley KM, Jarvis DN, Kurihara T, Chang YJ, Fietzer AL, Kulig K. Toe flexor strength, flexibility and function and flexor hallucis longus tendon morphology in dancers and non-dancers. Medical problems of performing artists. 2015 Sep 1;30(3):152-6.
  5. ↑ 5.0 5.1 Barchi EI, Swensen S, Dimant OE, Espiritu McKay T, Rose DJ. Flexor Hallucis Longus Tenolysis and Tenosynovectomy in Dancers. J Foot Ankle Surg 2022;61(1):84-87
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Murdock CJ, Munjal A, Agyeman K. Anatomy, Bony Pelvis and Lower Limb, Calf Flexor Hallucis Longus Muscle. StatPearls [Internet]. 2020 Aug 10.
  7. ↑ 7.0 7.1 7.2 Newman DP, Holkup KC, Jacobs AN, Gallo AC. Recalcitrant Flexor Hallucis Longus Dysfunction: A Case Study Demonstrating the Successful Application of an Adaptable Rehabilitation Program With a Two-Year Follow-Up. Cureus. 2021 Apr 6;13(4)
  8. ↑ 8.0 8.1 Maddox MB, Mashaw SA, MacDonald EM, et al. Four Tendinous Slips of Flexor Hallucis Longus Tendon: A Case Report. Cureus. 2024 May 3;16(5) . doi: 10.7759/cureus.59601
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 De-la-Cruz-Torres B, Barrera-García-Martín I, la Cueva-Reguera D, Bravo-Aguilar M, Blanco-Morales M, Navarro-Flores E, Romero-Morales C, Abuín-Porras V. Does Function Determine the Structure? Changes in Flexor Hallucis Longus Muscle and the Associated Performance Related to Dance Modality: A Cross-Sectional Study. Medicina. 2020 Apr;56(4):186.
  10. ↑ 10.0 10.1 10.2 Eberle CF, Moran B, Gleason T. The accessory flexor digitorum longus as a cause of flexor hallucis syndrome. Foot & ankle international. 2002 Jan;23(1):51-5.
  11. ↑ 11.0 11.1 11.2 Michelson J, O’Keefe J, Bougioukas L. Increased flexor hallucis longus tension decreases ankle dorsiflexion. Foot and Ankle Surgery. 2020 Jul 21.
  12. ↑ 12.0 12.1 Lughi M. Flexor Hallucis Longus Tendinopathy. InAnkle Joint Arthroscopy 2020 (pp. 201-205). Springer, Cham.
  13. ↑ 13.0 13.1 Hamilton WG. Stenosing tenosynovitis of the flexor hallucis longus tendon and posterior impingement upon the os trigonum in ballet dancers. Foot & ankle. 1982 Sep;3(2):74-80.
  14. ↑ Tokgöz MA, Ataoğlu MB, Ergişi Y, Bozkurt HH, Kanatlı U. Is there any effect of presence and size of os trigonum on flexor hallucis longus tendon lesions?. Foot and Ankle Surgery. 2020 Jun 1;26(4):469-72.
  15. ↑ Drews B. Dancing Sports. InInjury and Health Risk Management in Sports 2020 (pp. 721-724). Springer, Berlin, Heidelberg.
  16. ↑ Campbell RS, Lehr ME, Livingston AD, McCurdy M, Ware JK. Intrinsic modifiable risk factors in ballet dancers: Applying evidence-based practice principles to enhance clinical applications. Phys Ther Sport. 2019 Jul;38:106-14
  17. ↑ 17.0 17.1 17.2 17.3 de Cesar Netto C, Kennedy JG, Hamilton WG, O’Malley M. Foot and Ankle Injuries in Dancers. Baxter's The Foot and Ankle in Sport. 2020 Jan 25:436.
  18. ↑ Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment. Foot & ankle international. 2005 Apr;26(4):291-303.
  19. ↑ Russell JA, McEwan IM, Koutedakis Y, Wyon MA. Clinical anatomy and biomechanics of the ankle in dance. Journal of dance medicine & science. 2008 Sep 1;12(3):75-82.
  20. ↑ FHL test.wmv Available from https://www.youtube.com/watch?v=6fKNLicaPp8
  21. ↑ Al-Qassab S, Davies A. Imaging of the foot and ankle. Surgery (Oxford). 2020 Feb 1;38(2):100-7.
  22. ↑ Skwiot M, Śliwiński Z, Żurawski A, Śliwiński G. Effectiveness of physiotherapy interventions for injury in ballet dancers: A systematic review. PLoS one. 2021 Jun 24;16(6):e0253437.
  23. ↑ Dubois B, Esculier J. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine 2020;54:72-73.
  24. ↑ Coplan JA. Ballet dancer's turnout and its relationship to self-reported injury. Journal of Orthopaedic & Sports Physical Therapy. 2002 Nov;32(11):579-84.
  25. ↑ KT TAPE Flexor Hallucis Longus (FHL) available from https://www.youtube.com/watch?v=wKGA858hYL8
  26. ↑ Hamilton WG, Hamilton LH, Marshall P, Molnar M. A profile of the musculoskeletal characteristics of elite professional ballet dancers. The American journal of sports medicine. 1992 May;20(3):267-73.
  27. ↑ FHL big toe stretch Available from https://www.youtube.com/watch?v=jIMGe0cZXpI
  28. ↑ Kadel NJ. Foot and ankle injuries in dance. Physical Medicine and Rehabilitation Clinics. 2006 Nov 1;17(4):813-26.
  29. ↑ Luk P, Thordarson D, Charlton T. Evaluation and management of posterior ankle pain in dancers. Journal of Dance Medicine & Science. 2013 Jun 15;17(2):79-83.
  30. ↑ Flexor Hallucis Longus. Emphasis Plantarflexion Inversion [video]. YouTube; 2017 [cited 2024 Sep 23]. Available from: https://www.youtube.com/watch?v=vM-gMzFw0qs
  31. ↑ Nachazel KM. Mechanism and Treatment of Tendinitis of the Flexor Hallucis Longus In Classical Ballet Dancers. International Journal of Athletic Therapy and Training. 2002 Mar 1;7(2):13-5.
  32. ↑ Pro Physio. Flexor Hallucis Tendinitis Relief for the Competitive Dancer [video]. YouTube; 2018 [cited 2024 Sep 23]. Available from: https://www.youtube.com/watch?v=i7O-REnNZAQ
  33. ↑ Hutt K, Redding E. The effect of an eyes-closed dance-specific training program on dynamic balance in elite pre-professional ballet dancers: a randomized controlled pilot study. Journal of Dance Medicine & Science. 2014 Mar 15;18(1):3-11.
  34. ↑ Bowerman EA, Whatman C, Harris N, Bradshaw E. A review of the risk factors for lower extremity overuse injuries in young elite female ballet dancers. Journal of Dance Medicine & Science. 2015 Jun 15;19(2):51-6.
  35. ↑ Shaw Bronner. Ballet Dancer Posture Evaluation Demonstration [video]. MedBridge; 2018 [cited 2024 Sep 23]. Available from: https://www.youtube.com/watch?v=jJqr5nOADWI
  36. ↑ Solomon R, Brown T, Gerbino PG, Micheli LJ. The young dancer. Clinics in sports medicine. 2000 Oct 1;19(4):717-39.
  37. ↑ Walter HL, Docherty CL, Schrader J. Ground reaction forces in ballet dancers landing in flat shoes versus pointe shoes. Journal of Dance Medicine & Science. 2011 Jun 15;15(2):61-4.
  38. ↑ Pearson SJ, Whitaker AF. Footwear in classical ballet: a study of pressure distribution and related foot injury in the adolescent dancer. Journal of Dance Medicine & Science. 2012 Jun 15;16(2):51-6.
  39. ↑ Hackney J, Brummel S, Becker D, Selbo A, Koons S, Stewart M. Effect of sprung (suspended) floor on lower extremity stiffness during a force-returning ballet jump. Medical problems of performing artists. 2011 Dec 1;26(4):195-9.
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