Dance Injuries of the Foot and Ankle: Difference between revisions

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* Psycho-physical condition of dancer
* Psycho-physical condition of dancer
* Environmental factors
* Environmental factors
** Floor type
** Floor type<ref name=":0" /><ref>Campbell RS, Lehr ME, Livingston A, McCurdy M, Ware JK. [https://www.sciencedirect.com/science/article/abs/pii/S1466853X18305169 Intrinsic modifiable risk factors in ballet dancers: Applying evidence based practice principles to enhance clinical applications.] Physical Therapy in Sport. 2019 Jul 1;38:106-14.</ref>
** 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<ref name=":0">Cardoso AA, Reis NM, Marinho AP, Vieira MD, Boing L, Guimarães AC. [https://www.scielo.br/j/rbme/a/ZMwvSfMh6WSbBxZPhWGnf3k/?format=html&lang=en&stop=next Injuries in professional dancers: a systematic review.] Revista Brasileira de Medicina do Esporte. 2017 Nov;23:504-9.</ref>
** 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<ref name=":0">Cardoso AA, Reis NM, Marinho AP, Vieira MD, Boing L, Guimarães AC. [https://www.scielo.br/j/rbme/a/ZMwvSfMh6WSbBxZPhWGnf3k/?format=html&lang=en&stop=next Injuries in professional dancers: a systematic review.] Revista Brasileira de Medicina do Esporte. 2017 Nov;23:504-9.</ref>
** “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”<ref name=":0" />
** “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”<ref name=":0" />


== Acute vs overuse injuries ==
== Acute vs Overuse Injuries ==


* Acute
* Acute
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** Repeated microtrauma
** Repeated microtrauma


== Additional contributing factors ==
== Additional Contributing Factors ==


* Transitioning from Part time to Full - -time or professional ballet<ref>Fuller M, Moyle GM, Hunt AP, Minett GM. [https://www.ingentaconnect.com/content/jmrp/jdms/2019/00000023/00000003/art00004 Ballet and contemporary dance injuries when transitioning to full-time training or professional level dance: a systematic review]. Journal of Dance Medicine & Science. 2019 Sep 1;23(3):112-25.</ref>
* Transitioning from Part time to Full - -time or professional ballet<ref>Fuller M, Moyle GM, Hunt AP, Minett GM. [https://www.ingentaconnect.com/content/jmrp/jdms/2019/00000023/00000003/art00004 Ballet and contemporary dance injuries when transitioning to full-time training or professional level dance: a systematic review]. Journal of Dance Medicine & Science. 2019 Sep 1;23(3):112-25.</ref>
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* and/or decreased plantar flexion rom to allow ideal positioning of body over toes.  
* and/or decreased plantar flexion rom to allow ideal positioning of body over toes.  


*
== Anterior Ankle Injuries ==


== Anterior ankle issues ==
* Anterior bone spurs
 
** Often found in mature or retired dancers
* Anterior impingement
* Anterior bone spurs (mature/retired dancer)
* Tibial stress syndrome<ref name=":3" />
* Tibial stress syndrome<ref name=":3" />
* Tibial stress fracture (less common)
* Tibial stress fracture  
* Anterior lig and tendon pathology esp EHL (trying to improve point, injure surrounding lig, long-term instability)
* Anterior ligament and tendon pathology esp  
** Commonly in the Extensor Hallucus Longus from trying to improve point, injuries surrounding ligaments and long-term instability
* Anterior capsule synovitis
* Anterior capsule synovitis
* Anterior impingement


==== Anterior impingement syndrome ====
==== Anterior Impingement Syndrome ====


* Agg – repetitive forced dorsiflexion (Plie)  
* Aggravated by repetitive forced dorsiflexion (Plie)
* Educate – stretch properly and strengthen intrinsic and extrinsic musculature
* Symptoms are generally progressive in nature
* Occurring primarily secondary to the repetitive forced ankle dorsiflexion (forcing plie)
* Treatment
* Symptoms generally progressive
** Educate the dancer on correct stretching, focus on strengthening intrinsic and extrinsic musculature
* Responds to conservative treatment but as progresses surgery is effective
** Address biomechanical faults and look higher up for compensations or weakness
* Address biomechanical faults = look higher up  
** Mulligan Mobilisation with movement, Passive Accessory Movement, chair ankle rocker
* Dance movements contributing =plie, rolling ankles, forcing turnout
** Often responsive to conservative treatment.
* Compensation=lifting up heel earlier
** Surgery is effective if condition has progressed far enough<ref name=":4">Khurana A, Singh I, Singh MS. [https://jassm.org/is-anterior-and-posterior-ankle-impingement-under-diagnosed-a-review/ Is anterior and posterior ankle impingement under-diagnosed? A review]. Journal of Arthroscopic Surgery and Sports Medicine. 2021 Jan 10;2(1):58-65.</ref>
* Rehab = Mulligan Mobilisation with movement, Passive Accessory Movement, chair ankle rocker
* Ballet specific considerations
* Surgery is effective if condition has progressed far enough<ref name=":4">Khurana A, Singh I, Singh MS. [https://jassm.org/is-anterior-and-posterior-ankle-impingement-under-diagnosed-a-review/ Is anterior and posterior ankle impingement under-diagnosed? A review]. Journal of Arthroscopic Surgery and Sports Medicine. 2021 Jan 10;2(1):58-65.</ref>
** Dance movements contributing =plie, rolling ankles, forcing turnout
** Compensation=lifting up heel earlierh


== Posterior ankle issues ==
== Posterior Ankle Injuries ==


* Posterior Ankle Impingement Syndrome
* Achilles tendinopathy<ref name=":5">Batenhorst EZ. [https://digitalcommons.wou.edu/cgi/viewcontent.cgi?article=1225&context=honors_theses A Dancer’s View: Analysis and Prevention of Common Dance Injuries]. 2020</ref>
* Achilles tendinopathy<ref name=":5">Batenhorst EZ. [https://digitalcommons.wou.edu/cgi/viewcontent.cgi?article=1225&context=honors_theses A Dancer’s View: Analysis and Prevention of Common Dance Injuries]. 2020</ref>
** The prevalence of this injury in dancers is due to releves, jumps, turns, and pointe work
** 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
** Can be caused by tying ribbons incorrectly across achilles tendon or from hard floors.
 
** Choreograper from few jumps to lots of jumps
Choreograper from few jumps to lots of jumps


==== Posterior ankle impingement syndrome ====
==== Posterior Ankle Impingement Syndrome ====


* Dancers heel
* Often referred to as Dancers heel
* Forced plantarflexion
* Aggravated by forced plantarflexion and often coincides with FHL tendinopathy
* Often coincides with FHL tendinopathy
* Symptoms are
* Bony or soft tissue
** 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
* Can be operated on<ref name=":4" /><ref>Grigoryev K. ''[https://www.proquest.com/openview/13aa37c86679bb28ab06a1a1d8ee37f0/1?pq-origsite=gscholar&cbl=18750&diss=y Comparison of Open and Endoscopic Surgical Procedures as a Treatment of Posterior Ankle Impingement Syndrome in Ballet Dancers: A Meta-Analysis]'' (Doctoral dissertation, California State University, Fresno).</ref>
* Treatment
* 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
** Educate the dancer on
* biomechanics check - plie, grand plie, releve
** Bony or soft tissue
* stretch - hams, adductors, tib A, calves
** Can be operated on<ref name=":4" /><ref>Grigoryev K. ''[https://www.proquest.com/openview/13aa37c86679bb28ab06a1a1d8ee37f0/1?pq-origsite=gscholar&cbl=18750&diss=y Comparison of Open and Endoscopic Surgical Procedures as a Treatment of Posterior Ankle Impingement Syndrome in Ballet Dancers: A Meta-Analysis]'' (Doctoral dissertation, California State University, Fresno).</ref>
* strengthen - glutes, hamstrings, adductors, abductors
* Ballet specific considerations
* rehab- mobility crawls, isometric Single leg heel raise, eccentric single leg heel lowering
** 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<ref name=":3">Rietveld AB. [https://scholarlypublications.universiteitleiden.nl/access/item%3A2947375/view Performing arts medicine with a focus on Relevé in Dancers]. Leiden University; 2017 Nov 28.</ref>
PAIS in Ballet<ref name=":3">Rietveld AB. [https://scholarlypublications.universiteitleiden.nl/access/item%3A2947375/view Performing arts medicine with a focus on Relevé in Dancers]. Leiden University; 2017 Nov 28.</ref>
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* 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
* 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 Injuries ==


* Lateral ankle sprains (common)<ref name=":6">Bodini BD, Lucenteforte G, Serafin P, Barone L, Vitale JA, Serafin A, Sansone V, Negrini F. [https://www.mdpi.com/2076-3417/10/1/155 Do grade II ankle sprains have chronic effects on the functional ability of ballet dancers performing single-leg flat-foot stance? An observational cross-sectional study.] Applied Sciences. 2020 Jan;10(1):155.</ref>
* Lateral ankle sprains (common)<ref name=":6">Bodini BD, Lucenteforte G, Serafin P, Barone L, Vitale JA, Serafin A, Sansone V, Negrini F. [https://www.mdpi.com/2076-3417/10/1/155 Do grade II ankle sprains have chronic effects on the functional ability of ballet dancers performing single-leg flat-foot stance? An observational cross-sectional study.] Applied Sciences. 2020 Jan;10(1):155.</ref>
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* Peroneal tendon overuse and retinaculum stress
* Peroneal tendon overuse and retinaculum stress


==== Lateral ankle sprain ====
==== Lateral Ankle Sprain ====


* Dancer relies on feedback and stability from lateral lig<ref name=":6" />
* Aggravated by
* biomechanics check – first position pile, releve, passe. Alignment<ref name=":5" /> in demipointe or pointe
* Symptoms are
* stretch -  hams, quads, adductors, iliopsoas, calves
* Treatment
* Strengthen - glutes, dorsiflexors, everters  
** Educate the dancer on
* rehab- aggressive strengthening and proprioception, side plank tbd clamshell, SLB tap front around to back, resisted PF with eversion
* Ballet specific considerations
** Dancer relies on feedback and stability from lateral lig<ref name=":6" />
** biomechanics check – first position pile, releve, passe. Alignment<ref name=":5" /> 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 ==
== Toe Injuries ==


* Hallux Valgus
* Hallux Valgus
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* Ingrown toe nails
* Ingrown toe nails


==== Hallux rigidis ====
==== Hallux Rigidis ====
FHL<ref>Wentzell M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173219/ Conservative management of a chronic recurrent flexor hallucis longus stenosing tenosynovitis in a pre-professional ballet dancer: a case report.] The Journal of the Canadian Chiropractic Association. 2018 Aug;62(2):111.</ref> = primary dynamic stabiliser of medial ankle in pointe and demi pointe


* biomechanics check - parallel, first position, passe
* Associated with the FHL<ref>Wentzell M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173219/ Conservative management of a chronic recurrent flexor hallucis longus stenosing tenosynovitis in a pre-professional ballet dancer: a case report.] The Journal of the Canadian Chiropractic Association. 2018 Aug;62(2):111.</ref> = primary dynamic stabiliser of medial ankle in pointe and demi pointe
* stretch -iliopsoas, quads, adductors, calves
* Aggravated by
* Strengthen - glutes, hamstrings, adductors, abductors
* Symptoms are
* rehab-toe/ankle rocker w toe spacer, big toe flexion and extension, isometric theraband toe abduction, curl/flex with theraband, toe abduction, toe separation
* Treatment
** Educate the dancer on
* Ballet specific considerations
** 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 ====
==== Sesmoiditis ====


* Embedded within the FHB tendon and articulate with the plantar surface of the first metatarsal head
* Aggravated by
* Function – stabilise first MTPJ and improve power of the FHB tendon
** Embedded within the FHB tendon and articulate with the plantar surface of the first metatarsal head
* Technical errors – rolling in, pronation, forcing turnout
** Technical errors – rolling in, pronation, forcing turnout
* Collapsed arches = more pressure on sesmoids
** 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
* 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
* Symptoms are
* RX – padding to off-load area, use of stif soled shoes outside class (more support), assess and correct alignment, takes months to resolve
** Function – stabilise first MTPJ and improve power of the FHB tendon
* stretch - hams, glutes, adductors, roll calves
** SX – pain under first MT head on plantar forefoot, tenderness should move distally with DF of great toe
* Strengthen - glutes, hams, adductors, iliopsoas, intrinsic foot muscles
* Treatment
* rehab- tbd clamshells, foam roll ball squeeze leg lowering, prone hamstring curl to hip extension
** Educate the dancer on
** RX – padding to off-load area, use of stif soled shoes outside class (more support), assess and correct alignment, takes months to resolve
* Ballet specific considerations
** 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 ====
 
* Often referred to as a Dancers Fracture
* Aggravated by
* Symptoms are twisting injury, differentiate to jones fracture (occurs further down the base, repetitive stress = surgery
* Treatment
** non –operative
** Educate the dancer on
* Ballet specific considerations
** 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


==== 5th metatarsal fracture ====
== Plantar Fasciitis ==
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
* Aggravated by This injury is often associated with repetitive jumping which is why it has such a high prevalence in dancers<ref name=":5" />.
* Strengthen - glutes, hams, adductors, iliopsoas
* Symptoms
* rehab-side plank hip adduction, foam roll quadruped donkey kicks, quadruped car wheel
** Heel pain with first steps in the morning
** Heel pain after long periods of non-weight bearing
** Tenderness to the anterior medial heel
** Limited dorsiflexion and tight [[Achilles Tendon|achilles tendon]]
** A limp may be present or may have a preference to toe walking
** Pain is usually worse when barefoot on hard surfaces and with stair climbing
* Treatment: Conservative measures are the first choice
** Physiotherapy
** Rest from offending activity
** [[Cryotherapy|Ice]] after activity
** Deep [[Friction Massage|friction]] massage of the arch and insertion.
** Shoe inserts or [[orthotics]] and night splints
** [[Extracorporeal Shockwave Therapy (ESWT)|Extracorporeal shock-wave therapy]]<ref>Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. [https://www.mdpi.com/2075-1729/11/12/1287 A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis]. Life. 2021 Dec;11(12):1287.</ref> , botulinum toxin A, [[Lateral Epicondyle Tendinopathy Toolkit: Appendix G - Medical and Surgical Interventions|autologous platelet-rich plasma, dex prolotherapy, or steroid injections]].
** Advanced and invasive techniques should be combined with conservative therapy
** Surgery should be the last option if this process has become chronic and other less invasive therapies have failed<span class="reference" id="cite_ref-:0_2-3"></span>


== Plantar fasciitis ==
* Educate the dancer on proper stretching and rehab of the: Plantar fascia; [[Achilles Tendon|Achilles' tendon]]; [[Gastrocnemius]] and [[Soleus]].


* This injury is often associated with repetitive jumping which is why it has such a high prevalence in dancers<ref name=":5" />
* Ballet specific considerations
* biomechanics check - plie, developpe, gait
** biomechanics check - plie, developpe, gait
* stretch -iliopsoas, quads, adductors, calves
** stretch -iliopsoas, quads, adductors, calves
* Strengthen -glutes, abductors, deep rotators
** Strengthen -glutes, abductors, deep rotators
* rehab- chair SL bridges, SL heel raises on stairs, ankle/toe rockers, strapping
** rehab- chair SL bridges, SL heel raises on stairs, ankle/toe rockers, strapping
'''For more specific physio treatment options please see [[Plantar Fasciitis]] page'''


== Foot and Ankle Care ==
== Foot and Ankle Care ==

Revision as of 12:48, 13 March 2022

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[edit | edit source]

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[edit | edit source]

  • Previous injuries
  • Poor rehabilitation
  • Anatomical posture
  • Poor training incl. low levels of muscular strength and power[1]
  • Poor lumbopelvic control[2]
  • Technical mistakes[1]
  • Execution speed[1]
  • Choreographer
  • Dance style
  • Shoe fit and style
  • Psycho-physical condition of dancer
  • Environmental factors
    • Floor type[3][4]
    • 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[3]
    • “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”[3]

Acute vs Overuse Injuries[edit | edit source]

  • 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[edit | edit source]

  • Transitioning from Part time to Full - -time or professional ballet[5]
  • The foot can affect the knee, hip, core musculature and spine
  • TURNOUT
  • Biomechanical requirements[2] (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 [6]

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 Injuries[edit | edit source]

  • Anterior bone spurs
    • Often found in mature or retired dancers
  • Tibial stress syndrome[7]
  • Tibial stress fracture
  • Anterior ligament and tendon pathology esp
    • Commonly in the Extensor Hallucus Longus from trying to improve point, injuries surrounding ligaments and long-term instability
  • Anterior capsule synovitis
  • Anterior impingement

Anterior Impingement Syndrome[edit | edit source]

  • Aggravated by repetitive forced dorsiflexion (Plie)
  • Symptoms are generally progressive in nature
  • Treatment
    • Educate the dancer on correct stretching, focus on strengthening intrinsic and extrinsic musculature
    • Address biomechanical faults and look higher up for compensations or weakness
    • Mulligan Mobilisation with movement, Passive Accessory Movement, chair ankle rocker
    • Often responsive to conservative treatment.
    • Surgery is effective if condition has progressed far enough[8]
  • Ballet specific considerations
    • Dance movements contributing =plie, rolling ankles, forcing turnout
    • Compensation=lifting up heel earlierh

Posterior Ankle Injuries[edit | edit source]

  • Posterior Ankle Impingement Syndrome
  • Achilles tendinopathy[9]
    • 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[edit | edit source]

  • Often referred to as Dancers heel
  • Aggravated by forced plantarflexion and often coincides with FHL tendinopathy
  • Symptoms are
    • 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
  • Treatment
    • Educate the dancer on
    • Bony or soft tissue
    • Can be operated on[8][10]
  • Ballet specific considerations
    • 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[7]

  • 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 Injuries[edit | edit source]

  • Lateral ankle sprains (common)[11]
  • Cuboid subluxation issues (rotational strain to bone following other issues)
  • Sinus tarsi
  • Peroneal tendon overuse and retinaculum stress

Lateral Ankle Sprain[edit | edit source]

  • Aggravated by
  • Symptoms are
  • Treatment
    • Educate the dancer on
  • Ballet specific considerations
    • Dancer relies on feedback and stability from lateral lig[11]
    • biomechanics check – first position pile, releve, passe. Alignment[9] 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 Injuries[edit | edit source]

  • 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[edit | edit source]

  • Associated with the FHL[12] = primary dynamic stabiliser of medial ankle in pointe and demi pointe
  • Aggravated by
  • Symptoms are
  • Treatment
    • Educate the dancer on
  • Ballet specific considerations
    • 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[edit | edit source]

  • Aggravated by
    • Embedded within the FHB tendon and articulate with the plantar surface of the first metatarsal head
    • Technical errors – rolling in, pronation, forcing turnout
    • Collapsed arches = more pressure on sesmoids
    • 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
  • Symptoms are
    • Function – stabilise first MTPJ and improve power of the FHB tendon
    • SX – pain under first MT head on plantar forefoot, tenderness should move distally with DF of great toe
  • Treatment
    • Educate the dancer on
    • RX – padding to off-load area, use of stif soled shoes outside class (more support), assess and correct alignment, takes months to resolve
  • Ballet specific considerations
    • 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[edit | edit source]

  • Often referred to as a Dancers Fracture
  • Aggravated by
  • Symptoms are twisting injury, differentiate to jones fracture (occurs further down the base, repetitive stress = surgery
  • Treatment
    • non –operative
    • Educate the dancer on
  • Ballet specific considerations
    • 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[edit | edit source]

  • Aggravated by This injury is often associated with repetitive jumping which is why it has such a high prevalence in dancers[9].
  • Symptoms
    • Heel pain with first steps in the morning
    • Heel pain after long periods of non-weight bearing
    • Tenderness to the anterior medial heel
    • Limited dorsiflexion and tight achilles tendon
    • A limp may be present or may have a preference to toe walking
    • Pain is usually worse when barefoot on hard surfaces and with stair climbing
  • Treatment: Conservative measures are the first choice
  • Ballet specific considerations
    • 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

For more specific physio treatment options please see Plantar Fasciitis page

Foot and Ankle Care[edit | edit source]

  • 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

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 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.
  2. ↑ 2.0 2.1 Biernacki JL, Stracciolini A, Fraser J, Micheli LJ, Sugimoto D. Risk factors for lower-extremity injuries in female ballet dancers: a systematic review. Clinical journal of sport medicine. 2021 Mar 1;31(2):e64-79.
  3. ↑ 3.0 3.1 3.2 Cardoso AA, Reis NM, Marinho AP, Vieira MD, Boing L, Guimarães AC. Injuries in professional dancers: a systematic review. Revista Brasileira de Medicina do Esporte. 2017 Nov;23:504-9.
  4. ↑ Campbell RS, Lehr ME, Livingston A, McCurdy M, Ware JK. Intrinsic modifiable risk factors in ballet dancers: Applying evidence based practice principles to enhance clinical applications. Physical Therapy in Sport. 2019 Jul 1;38:106-14.
  5. ↑ Fuller M, Moyle GM, Hunt AP, Minett GM. Ballet and contemporary dance injuries when transitioning to full-time training or professional level dance: a systematic review. Journal of Dance Medicine & Science. 2019 Sep 1;23(3):112-25.
  6. ↑ En Pointe: What Ballet Dancers Should Know About Injury Prevention
  7. ↑ 7.0 7.1 Rietveld AB. Performing arts medicine with a focus on Relevé in Dancers. Leiden University; 2017 Nov 28.
  8. ↑ 8.0 8.1 Khurana A, Singh I, Singh MS. Is anterior and posterior ankle impingement under-diagnosed? A review. Journal of Arthroscopic Surgery and Sports Medicine. 2021 Jan 10;2(1):58-65.
  9. ↑ 9.0 9.1 9.2 Batenhorst EZ. A Dancer’s View: Analysis and Prevention of Common Dance Injuries. 2020
  10. ↑ Grigoryev K. Comparison of Open and Endoscopic Surgical Procedures as a Treatment of Posterior Ankle Impingement Syndrome in Ballet Dancers: A Meta-Analysis (Doctoral dissertation, California State University, Fresno).
  11. ↑ 11.0 11.1 Bodini BD, Lucenteforte G, Serafin P, Barone L, Vitale JA, Serafin A, Sansone V, Negrini F. Do grade II ankle sprains have chronic effects on the functional ability of ballet dancers performing single-leg flat-foot stance? An observational cross-sectional study. Applied Sciences. 2020 Jan;10(1):155.
  12. ↑ Wentzell M. Conservative management of a chronic recurrent flexor hallucis longus stenosing tenosynovitis in a pre-professional ballet dancer: a case report. The Journal of the Canadian Chiropractic Association. 2018 Aug;62(2):111.
  13. ↑ Rhim HC, Kwon J, Park J, Borg-Stein J, Tenforde AS. A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis. Life. 2021 Dec;11(12):1287.
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