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.

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

“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
  • Often attributed to poor technique and incorrect execution of jumps and landing
  • Dancer usually has an incident to report
  • Many other contributing factors such as tiredness, fatigue or loss of balance
• Overuse
  • Excessive use
  • Repeated microtrauma

Risk Factors

• Previous injuries
• Poor rehabilitation
• Anatomical posture
• Poor training resulting in poor muscular strength
• Poor lumbopelvic control
• Technical mistakes
• Execution speed
• Choreographer
• Dance style
• Shoe fit and style
• Floor type

Additional Contributing Factors

• Transitioning from part time to professional dancer
• The foot can affect the knee, hip, core musculature and spine
• Lack of turnout
• Biomechanical requirements of pointe and demi pointe which require full plantarflexion with 90 degrees metatarsal phalangeal joint extension
• Floor type
• The dancers body and their management
• Psychology and expectations of dancers
• Decreased triceps surae (Gastrocs and Soleus) and Posterior Tibialis strength
• Decreased plantar flexion active range of motion

Muscle weakness often results in:

• Rolling in and out of the ankles (Increased ankle inversion/eversion)
• Decreased stability en pointe
• Decreased plantar flexion range of motion

Anterior Ankle Injuries

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

Anterior Impingement Syndrome

• Aggravated by repetitive forced dorsiflexion
• 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
• Ballet specific considerations
  • Dance movements contributing are the plie, forcing turnout and rolling ankles
  • Compensation is seen with a dancer lifting up heel earlier in a plie

Posterior Ankle Injuries

• Posterior Ankle Impingement Syndrome
• 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.
  • A contributing factor is often changing of a choreographer, especially when they advocate for an intense jumping routine

Posterior Ankle Impingement Syndrome

• Often referred to as Dancers heel, can be bony or soft tissue
• Aggravated by forced plantarflexion and often coincides with Flexus Hallucis Longus tendinopathy
• Symptoms are
  • Pain and tenderness over the posterolateral aspect of the ankle
  • Pain with:
    • Active plantar-flexion.
    • Axial loading
    • Great toe dorsiflexion
• Treatment
  • Educate the dancer on
  • Late stage degeneration can be operated on
• Ballet specific considerations
  • Biomechanics check: Plie, grand plie, releve
  • Stretch: Hamstrings, adductors, tibialis anterior, gastroc and soleus
  • Strengthen: Glutes, hamstrings, adductors, abductors
  • Specific rehabilitation: Mobility crawls, isometric single leg heel raise, eccentric single leg heel lowering

PAIS in Ballet

Ballet requires a controlled, persistent, extreme, active, and fully weightbearing state. As opposed to sports like soccer for example where the requirements of these demands are intermittent, like when kicking a ball.

Lateral Ankle Injuries

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

Lateral Ankle Sprain

• Aggravated by weak Triceps Surae (Gastrocs and Soleus) and Posterior Tibialis strength
• Symptoms are pain, swelling and instability
• Treatment
  • Ice, strapping, electrotherapy modalities, muscle strengthening
• Ballet specific considerations
  • Dancer regularly relies on feedback and stability from lateral ligament
  • Biomechanics check: First position pile, releve, passe, alignment in demipointe or pointe
  • Stretch: Hamstrings, quadriceps, adductors, iliopsoas, gastroc and soleus
  • Strengthen: Glutes, dorsiflexors, everters
  • Specific rehabilitation: aggressive strengthening and proprioception, side plank tbd clamshell, SLB tap front around to back, resisted PF with eversion

Toe Injuries

• Hallux Valgus
• Hallux Rigidus
• 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 Rigidus

• Associated with the Flexor Hallucis Longus which is the primary dynamic stabiliser of the medial ankle in pointe and demi pointe positions
• Aggravated by longer second toe with respect to first toe or excessive interphalangeal joint flexion compensation, also referred to as knuckling under
• Symptoms are a stiff and painful joint
• Treatment
  • Late stage treatment is a surgical debridement
• Ballet specific considerations
  • Biomechanics check: First position and passe
  • Stretch: Iliopsoas, quads, adductors, calves
  • Strengthen: Glutes, hamstrings, adductors, abductors
  • Specific rehabilitation: Toe/ankle rocker with a toe spacer, big toe flexion and extension, isometric theraband toe abduction, flexion with theraband, toe abduction, toe separation

Sesmoiditis

Sessemoid bones are embedded within the Flexor Hallucis Brevis tendon and articulate with the plantar surface of the first metatarsal head. It helps to stabilise first metatarsal phalangeal joint and improve power of the FHB tendon

• Aggravated by technical errors, such as rolling in, pronation and forcing turnout, and sollapsed arches which more pressure on sesmoids. Also aggravated by taking off and landing jumps especially without plie, rolling into Releve/demi pointe (more stressful than en pointe), walking with toe out gait/ in turn out
• Symptoms are pain under first metatarsal head on plantar forefoot, tenderness should move distally with dorsiflexion of great toe
• Treatment
  • Educate the dancer on the use of stiff soled shoes outside class, which offer more support. encourage padding to off-load area,
  • Always assess and correct alignment,
  • Unfortunately the condition takes months to resolve
• Ballet specific considerations
  • Stretch: Hamstrings, gluteal muscles, adductors, and to roll out calves
  • Strengthen: Gluteal muscles, hamstrings, adductors, iliopsoas, intrinsic foot muscles
  • Specific rehabilitation: Theraband 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 twisting injuries
• Remember to differentiate between Dancer's fracture and a Jones fracture, which occurs further down the base and is caused by repetitive stress. A Jones Fracture requires surgery.
• Treatment is conservative management and is non –operative
• Ballet specific considerations
  • Stretch: Hamstrings, gluteal muscles, adductors, and to roll out calves
  • Strengthen: Gluteal muscles, hamstrings, adductors, iliopsoas
  • Specific rehabilitation: Side plank hip adduction, foam roll, quadruped donkey kicks, quadruped car wheel

Plantar Fasciitis

• Aggravated by This injury is often associated with repetitive jumping which is why it has such a high prevalence in dancers.
• 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
  • Physiotherapy
  • Rest from offending activity
  • Ice after activity
  • Deep friction massage of the arch and insertion.
  • Shoe inserts or orthotics and night splints
  • Extracorporeal shock-wave therapy , botulinum toxin A, 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

• Educate the dancer on proper stretching and rehab of the: Plantar fascia; Achilles' tendon; Gastrocnemius and Soleus.

• Ballet specific considerations
  • biomechanics check - plie, developpe, gait
  • Stretch: Iliopsoas, quads, adductors, calves
  • Strengthen: Gluteal muscles, abductors, deep rotators
  • Specific rehabilitation: Chair straight leg bridges, straight leg heel raises on stairs, ankle/toe rockers, strapping

For more specific physio treatment options please see Plantar Fasciitis page

Foot and Ankle Care

• Pointework should always be progressed slowly and only progress once the individual has been assessed.
• Foot alignment should always be monitored
• Balance exercises, intrinsic foot exercises and calf stretching and strengthening should be included in training
• Dancers should be encouraged to walk with a normal of angle of gait. This allows offloading of the hip rotators. ie, not in a turnout position