The Foot and Ankle
The following information is intended as a resource and should not be used to self-diagnose or treat. Use of non-steroidal anti-inflammatory drugs (NSAID’s) may be used to reduce inflammation and pain associated with that inflammation. Dancers should be aware that dancing while taking NSAID’s can mask pain, which can lead to further tissue injury.
The ankle joint connects the lower leg to the foot and, in dance, allows for pointing the toe (plantar flexion) and flexing the foot during plié (dorsiflexion). The ankle also allows for inversion and eversion, producing turn-in and turn-out, respectively. The 26 bones in the foot work in concert with ligamentous support and muscular force to create three separate arches, critical for shock absorption during jumps. Structurally, the ideal foot for ballet is considered to be a flexible “square foot”, which has equal-length first and second toes.
Common Injuries of the Foot
Common Injuries of the Ankle
"I landed badly from a jump and now it hurts to walk."
This is the most common acute fracture seen in dancers. This fracture occurs along the 5th metatarsal, the long bone on the outside of the foot. The typical method of injury is landing from a jump on an inverted (turned-in) foot. The dancer will usually experience immediate pain and swelling. He or she may or may not be able to walk.
Treatment typically consists of ice, elevation, and limiting weight bearing activities. Consulting with a physician to confirm a fracture will be necessary. A dancer’s fracture will require a period of immobilization while the injury heals. Rehabilitation should follow to rebuild foot and ankle mobility and strength.
"I have pain underneath my big toe, particularly while walking without shoes."
Sesamoid bones are unique in that they are not connected to any other bones in the body. There are two very small bones (about the size of a kernel of corn) on the underside of the forefoot near the big toe. These two sesamoids provide a smooth surface over which tendons controlling the big toe are located.
The sesamoids provide a support surface while the dancer is on demi-pointe. The tendon that runs between the sesamoids can become inflamed, causing sesamoiditis, a form of tendinitis. Pain is focused under the big toe on the ball of the foot. With sesamoiditis, pain may develop gradually. There may be pain while bending and straightening the big toe.
The dancer may be required to rest and take time off from rehearsals while the pain and inflammation from sesamoiditis decreases. A consult with a physician is indicated to rule out a sesamoid fracture. A physical therapist or athletic trainer consult is also helpful to identify and correct muscle imbalances and assist with acute symptom relief. The use of a J-shaped pad around the area of the sesamoid to relieve pressure may be helpful, as is taping the toe so that it remains slightly downward (plantarflexed). It may take several months for the pain associated with sesamoiditis to be completely relieved. Surgical intervention to remove the sesamoid bones should only be considered after all conservative measures have been exhausted.
"My big toe points inward and is painful."
Hallux valgus and bunion can be seen in the public at large; however, dancers generally develop this condition at a younger than typical age. This injury usually has a gradual onset and is often associated with other postural and or biomechanical faults involving other joints (most often a tendency to pronate, or roll-in, during turned-out positions). It is characterized by medial movement of the first metatarsal head (big toe), where a bunion bump will gradually form. Consequently the phalanges of the great toe will shift towards the other toes.
Signs and Symptoms
The dancer will notice a gradual onset of foot pain at the area of the big toe or ball of the foot. Pain will be greatest with weight bearing and particularly jumping activities. Typically, dancers will notice pain with excessive pressure to the affected area, sometimes to the point where the slightest contact causes exquisite pain.
The best course of action is to identify a hallux valgus condition as early as possible and clarify its structural and/or biomechanical causes. Conditions that are caught early on can be treated with either strengthening exercises, stretching and/or orthotic prescription. Often, a toe spacer between the first and second toes can help with alignment and prevent further progression of the injury. Conditions that develop into significant structural changes can be very difficult to manage and may require surgical intervention. It is imperative that the clinician treating the dancer looks at the ankle, knee, and hip joints to identify any proximal impairments. Finally, attention to a dancer’s technique with plié, relevé, and jumping is essential to limiting the progression of hallux valgus identified.
"I have pain with full relevé."
This condition is characterized by pain and/or restriction of movement at the joints of the big toe. To achieve full demi-pointe the metatarsal phalangeal joint must be able to make a 90 degree angle. Dancers who start later in life may lack this much mobility. A dancer without mobility who forces a high demi-pointe will cause the bones in the joint to impinge on each other. If this is done repeatedly, bone spurs will develop leading to even further decreased motion in the joint, inflammation and eventual degeneration of the joint.
Compensations for lack of full mobility include sickling. This position will decrease impingement but it is not an esthetically acceptable line and puts the dancer at risk for ankle sprains. An acceptable and safe compensation for this condition is a half demi-pointe position. The dancer must learn to rise onto the ball of the foot without forcing the foot into full demi-pointe.
|Full Demipointe||Half Demipointe||Sickling|
During the acute stages, rest and ice are helpful to reduce pain and inflammation. A good way to ice this injury is with an ice massage for 5 minutes. Stretching of the foot can be done to help improve flexibility. The stretch into a demi-pointe position can be done in a non-weight bearing position, in a pain free range and should be held for 30 seconds. The dancer should assess the available pain free range of the joint and learn to work within that range. Taping the great toe to restrict full demi-pointe can be effective in relieving symptoms. The tape should be applied so that the toe remains slightly downward (plantarflexed). Mobilization of the metatarsal phalangeal joint by an experienced clinician is also quite effective.
Stretching of big toe
and sole of the foot
"My foot hurts when I walk barefoot, especially first thing in the morning."
Plantar Fasciitis is an overuse injury affecting the sole of the foot. The tough, fibrous band of tissue (fascia) connecting the heel bone to the base of the toes becomes inflamed and painful. Most often people will experience pain first thing in the morning when they step out of bed. Dancers will often experience an increase in pain after class, or following lengthy weight bearing activities. Plantar fascia pain can also be influenced by tightness in the calf or the Achilles tendon, or dancing on a hard surface or a non-sprung floor.
The earlier plantar fasciitis is treated, the quicker it can be resolved. Rest and ice are the first treatments for plantar fasciitis. Anti-inflammatory medication can also be helpful. For persistent conditions, physical therapy or athletic training treatments to assist with tight tissues and identify weakness is indicated. Chronic conditions respond well to the use of an overnight splint (issued by your physician or clinician) to provide a long duration stretch to the affected tissues.
"I have pain over the balls of my feet.”
Metatarsalgia is characterized by pain and tenderness along the ball of the foot. For dancers, this is commonly caused by instability in the joints of the smaller toes. Repeated sprains and overstretched ligaments can lead to laxity, or increased flexibility in these joints. For a dancer, years of overwork and forcing of extreme motion in the foot can increase laxity and may cause subluxation of these joints.
As with all acute inflammatory conditions, ice and rest are appropriate. Strengthening the muscles that control toe flexion can be helpful. This can be done with towel scrunches (using your toes to grab a towel placed on the ground and drawing it towards you). A metatarsal pad just behind the balls of the feet can help prevent subluxations and may relieve pain.
Common Injuries of the Ankle
"My heel and lower calf hurt, particularly while running or jumping."
Tendinitis can occur in any of the tendons about the ankle, including the flexor hallucis longus tendon (the dancer’s tendon), the peroneus brevis tendon, and the peroneus longus tendon. It most commonly occurs, however, in the body’s longest tendon—the Achilles tendon. Able to withstand forces equal to and greater than 1000 pounds, this tendon connects the calf muscles to the heel bone (calcaneus) and is responsible for plantar flexion of the foot to achieve releve and performing jumps. Due to its’ heavy workload in the dancing population, it is prone to inflammation (tendinitis). It unfortunately is also the most frequently ruptured tendon in dancers and non-dancers alike.
Most cases of Achilles tendonitis are due to overtraining of the dancer, particularly heavy training during a short period of time. Other contributing factors for Achilles inflammation would be:
- Returning to dance after a long period of rest
- A natural lack of flexibility in the calf muscles
- Dancing on a hard surface or a non-sprung floor
Aside from pain over the area of the Achilles, dancers with Achilles tendonitis can also notice:
- Mild pain after dancing that worsens
- Tenderness in the morning located ½” above tendon attachment to heel bone
- Stiffness that fades once tendon is sufficiently warm
- Swelling and inflammation
As with all overuse injuries, the sooner the injury is addressed, the more positive the outcome. Rest and ice are immediate treatments for conditions that do not allow for any pain free activity. Active stretching of the Achilles is helpful. However, dancers need to exercise caution with stretching the Achilles beyond the point of comfort. Strengthening exercises should be introduced gradually. For chronic conditions, the use of an overnight splint to assist with dorsiflexion range of motion can be helpful. Orthotic prescription can be helpful to correct any structural imbalances in the foot. However, if a dancer has no correctable faults, orthotics may not assist with symptom relief.
My big toe 'clicks' and gets 'caught' sometimes. I have to use my hands to release it."
Trigger toe occurs most commonly in female classical ballet dancers. It results when the flexor hallucis longus (FHL) tendon on the inside of the ankle moves irregularly through its anatomical pulley mechanism around the ankle. Sometimes, the tendon actually locks distal to the tendon canal (near the big toe) and prohibits a dancer from using the strength in her big toe when en pointe.
Trigger toe can be the result of inflammation or a partial rupture of the FHL tendon, accompanied by swelling along the sheath in which it’s contained. The tendon may become frayed and scarred down, adhering to the sheath and creating friction, inhibiting its smooth gliding motion. The condition may present as non-painful and annoying for a period of time before becoming painful. Pain is typically noticed as a dancer lowers from demi-pointe to flat.
Early identification of trigger toe can assist in its recovery. Dancers should use ice, particularly ice massage as a way to decrease local inflammation. An athletic trainer or physical therapist consult is helpful to assist with soft tissue management of scarring or adhesions along the tendon. The dancer should take the time to perform slow, gentle stretching of the great toe prior to dancing. More significant cases may require surgery to release the ligamentous portion of the FHL sheath and repair the tendon.
Posterior impingement syndrome (dancer’s heel)
"I have pain with pointing my foot and relevé."
Posterior impingement syndrome, commonly known as dancer’s heel, involves compression of soft tissues at the back of the ankle. A bony-formation or bump behind the ankle causes this compression. The dancer generally feels discomfort at the back of the ankle when the toe is pointed or in relevé.
Dancers should use ice and anti-inflammatory medications to help reduce soft tissue swelling. Stretching of the tissues in the back of the heel (calf and Achilles) is important to reduce the stress placed on those structures. A physician and physical therapy/athletic training consults are indicated to identify joint mobility restrictions or other imbalances that might be contributing to the condition. Some health-care professionals may recommend steroid injections to assist with local inflammation. Finally, if non-surgical treatment does not help alleviate the discomfort, surgical intervention will be required to remove the bump that is compressing the soft tissue.
"I can’t achieve full plié on one side. And when I do, it’s painful."
Anterior impingement syndrome involves the top of the ankle where the shin bone (tibia) meets the ankle (talus). There can be direct contact between these bony structures. With hundreds or thousands of pliés, this direct contact can eventually result in a bony formation at the front of the ankle. This bony formation compresses the soft tissue and creates pain. A dancer will typically notice pain with deep pliés, as well as significant swelling at the front of the ankle joint.
Early recognition of symptoms is extremely important because anterior impingement syndrome is not reversible. Ice and/or anti-inflammatory medications can be helpful to reduce local swelling. A clinician can assist with re-establishing normal joint mobility or identifying areas of inadequate strength or flexibility. A dancer may want to try some simple ideas to help relieve stress to the tissues during class or performances, including:
- perform in street shoes
- use one-quarter to half-inch heel lifts
- discontinue forced pliés
With advanced cases, surgery is sometimes pursued. It should be understood by the dancer that surgery very often leads to a recurrence of the bone formation within three to four years.
"I rolled my ankle during class and heard a 'pop' sound."
Ankle sprains are the most common type of ankle injury for dancers. Ankle sprains involve the lateral (outside) structures of the ankle and occur when the ankle is inverted (turned or rolled outwards). A lateral ankle sprain is the result of tears to any of the lateral stabilizing ligaments. Sprains are graded 1st, 2nd, or 3rd degree (3rd degree being the most severe) depending on the involvement and integrity of these ligaments.
Ankle sprains are usually sustained upon landing jumps, either improperly or landing on an object or another dancers foot. It is common for significant sprains to also produce an audible 'pop' sound. Other related factors that can contribute to ankle sprains include:
- working close to the limits of strength
- a slight loss of balance
- a lapse in concentration
Upon sustaining an ankle sprain, a dancer will usually notice swelling and pain over the lateral ankle. The severity of these symptoms will vary depending on the severity of the sprain. Some dancers are able to walk, some are unable to bear weight at all. Bruising over the lateral ankle can emerge within 1-3 days following an ankle sprain.
As with any injury that involves inflammation, apply the RICE treatment protocol:
- Rest - avoid using the ankle to prevent further damage.
- Ice - apply ice or cold packs to the ankle for 15–20 minutes each hour to help reduce swelling.
- Compression - wrap a tensor bandage around the ankle to help reduce swelling.
- Elevation - elevate above the heart and support the ankle while resting to prevent blood from pooling and increasing swelling.
The severity of the ankle sprain will dictate the amount of protection and immobilization the ankle requires. A Grade 1 sprain may only need the support of an ace wrap bandage or an Aircast splint. A Grade 3 sprain may need to be immobilized with a splint and the dancer will likely need to use crutches or a walking boot for ambulation. Ankle sprains should be evaluated by a physician to rule out any fractures. Follow-up treatment with a physical therapist or athletic trainer is crucial to develop strength and balance prior to returning to dance activities and thus reduce the potential for recurring sprains.
"I have pain in the front of my shins. It hurts worse during class."
Shin splints, stress reactions, and stress fractures are all overuse injuries of the lower leg usually associated with forceful, repetitive activities such as running or jumping. Shin splints involve pain at the front of the lower leg in the shin region. The pain is caused by an irritation of either the periosteum (the lining of the tibia, or shin bone) or the muscles and tendons in the area. A stress reaction is defined by accelerated remodeling or re-absorption of bone. A stress fracture is a small crack or cracks that occur as a result of repeated loading of the bone when muscles are fatigued. Fatigued muscles transfer more of the load to the bone. Shin splints or stress reactions can progress to stress fractures if left untreated. Stress fractures can progress to complete bone fractures if left untreated. The feet are the most common site of stress fractures in dancers, and the tibia is the most common place for stress reactions or shin splints.
All three conditions result in an aching pain that may become more severe during activity. Intensive dance rehearsal and a high percentage of time dancing on pointe or demi-pointe will increase the stress and pressure on the foot and tibia. As muscles become fatigued the dancer may have difficulty maintaining position, and the muscles transfer stress to other soft tissues and bone. When the bone is repeatedly stressed and has low bone mineral density levels, it can eventually result in a stress fracture. Dancing on hard floors increases the risk of stress fractures and stress reactions.
Treatment of shin splints may involve various techniques, which include:
- resting the area
- applying ice to control inflammation
- physical therapy/athletic training treatments
- correcting any underlying postural distortions that may aggravate or contribute to the injury (knee hyperextension, weak abdominal muscles, anterior or posterior tilted pelvis, pronation/supination of the foot, etc.)
With stress fractures, rest for the injured area is the only treatment that will allow the bone to heal. It may be necessary to unload the stress for a period of time by using crutches or a walking boot. A lack of pain does not mean that the bone has healed (many people do not report symptoms). A dancer should consult with their physician or clinician prior to returning to dance. Upon return to dance, the dancer should not experience any pain. If the dancer resumes activity too quickly, the stress fracture is more likely to progress to a complete bone fracture.
- Proper training and teaching are essential to allow dancers of all ages to develop their skills without injury.
- Take adequate rest to allow the body to heal itself from daily wear and tear
- Maintain energy levels by eating and drinking adequately.
- Conditioning and strengthening of the leg muscles that support the arch are crucial.
- Try to avoid dancing on hard or uneven surfaces, which could cause injury.
- Take care of your shoes!
- Dancers should adopt new training schedules slowly.
- Although not always possible when dancing, but more so off stage or out of class, wear supportive footwear, and if you need to wear orthotics, wear them as often as possible.
- If dancers perform excessive pointe or demi-pointe work one day, they should focus on other types of work during the next workout.
- Early recognition of symptoms is important. Stop activity if pain or swelling occurs. If the pain persists after a few days rest, consult a sports-medicine physician.