April 8, 2021

Foot and ankle injuries in dancers

Practising ballet and classical dance, either as sport or for fun, are a fantastic way to keep your body fit and strong. But, have you ever stopped to think about the extreme physical demands dancing places on the body? In today’s blog we take a look at how our bodies are affected by dance, identify common injuries and explain how physio can help support you in your practice.

Dancing and injury

Dancers of all disciplines place a variety of demands on their bodies. They need to recruit and balance extreme mobility, strength and control whilst ensuring their movements are aesthetically pleasing (Smith et al. 2015). A dancer’s foot and ankle are crucial in performing most ballet techniques, including en pointe, demi-pointe and pliѐ. They also contribute significantly to achieving ideal aesthetics and lines (McCormack et al. 2018).

Intensive dance training involves strenuous, repetitive movements and the resulting impact and stress pushes the foot and ankle complex to its limits. With the number of hours dancers dedicate to their practice, it is not surprising that 75% of dancers’ injuries are due to overuse (Smith et al. 2015). More specifically, a ten-year study by Prem et al. (2016) at a professional ballet company found that foot and ankle injuries are accountable for 38% of all injuries. Spine injuries account for just 20%, which further highlights the significant risks of both foot and ankle injuries in dancers.

Why foot and ankle injuries?

Ballet dancers are required to train intensively to achieve the desired aesthetics in their performance. This quest for perfection requires exhaustive repetition of the same movements, leading to increased risk of injury. An expert panel has suggested that flexibility and range, especially at the hip, femur, foot and ankle in the ‘turn-out’ position, are key components for a healthy ballet dancer (McCormack et al. 2018). More specifically, the pointe positions require good mobility in the ankle; this fully plantar-flexed position (on tiptoes) is an important aesthetic manoeuvre to continue the length of the line in the lower limb (McCormack et al. 2018).

The mid-foot plays an important role in the biomechanics of other movements. In demi-pointe it allows sufficient weight-bearing through the metatarsal phalangeal joints (where the foot meets the toes). This permits the dancer to perform explosive jumps as well as complete sustained manoeuvres (McCormack et al. 2018). The combination of these extreme ranges of movements and the repetition of an isolated part of choreography (especially when fatigued) is responsible for numerous foot and ankle injuries in dancers (Costa et al. 2016).

Movements en pointe also reduce a dancer’s base of support. This requires great muscle and neurophysiological effort, causing joint overload and ligament and muscle micro-trauma – again leading to injury (Costa et al. 2016).

Therefore, the foot and ankle is a complex and critical area of focus in ballet. The art requires the contradicting requirements of mobility and stability in order to perform not only aesthetically pleasing but explosive movements.

What injuries are most commonly seen?

There are many injuries that can occur at the foot and ankle complex. However, the most common injuries are lateral ankle sprains, achilles tendonitis, metatarsal stress fractures and tibialis posterior strain/tears (Prem et al. 2016).

Lateral ankle sprains and metatarsal stress fractures (also known as ‘Dancer’s Fracture’ which affects the distal shaft of the fifth metatarsal) are closely related. The mechanism involves an inward rotation whilst the foot is axially loaded in a plantar-flexed position (McCormack et al. 2018). Prem et al. (2016) found 23% of dancers suffered with chronic ankle instability, which subsequently predisposes them to ‘dancers fracture’. Inversion injuries such as these can cause secondary pathologies including osteochondral lesions to the talus and posterior impingement (Smith et al. 2015). Therefore, physiotherapists need to be vigilant when assessing foot and ankle injuries in dancers to ensure other injuries are not missed, causing problems later down the line.

Here are some of the most common injuries and their symptoms:

Achilles Tendinitis

“My calf feels tight and it is painful down into my heel. It hurts during jump routines.”

• The Achilles tendon joins your calf muscles to your heel bone
• This is the most common tendon injury in dancers
• The Achilles tendon helps with all foot movements; therefore it is constantly irritated during dance
• This condition causes pain swelling, stiffness and weakness of the Achilles tendon (Brukner & Khan, 2009).

Dancers heel (Posterior impingement syndrome)

“I have pain in the back of my ankle when I pointe my toe and perform a relevé.”

• Most common in dancers who are dancing on demi-pointe or pointe (Kadel et al., 2000).
• The tissues and bony structures become compressed in the ankle’s posterior aspect
• This condition causes pain and stiffness in the plantar/posterior heel area
• Pain may be achy and sore in nature and is aggravated by both long periods of sitting and increased activity

Trigger toe/FHL tenosynovitis

• FHL tendonitis is commonly associated or coexistent with posterior impingement, especially in ballet dancers (Maquirriain, 2005)
• Symptoms can occur anywhere along the FHL tendon from the hallux, through the plantar foot and up the posterior aspect of the leg (Michelson & Dunn, 2005)
• Symptoms include pain, stiffness, weakness, sickling (to avoid pain) and locking of the joint

Anterior impingement syndrome

“It hurts at the top of my foot where the crease is when I perform pliés. Sometimes I can’t perform a full plié because of the pain.”

• Anterior impingement occurs through compression of the bony structures and soft tissue at the anterior aspect of the ankle
• The compression occurs when the foot is in full dorsi-flexion (Talusan et al., 2014)
• Pain may be achy in nature or sharp when impinging

Plantar fasciitis

“The bottom of my foot hurts when I get up in the morning and the pain increases after dance class.”

• Having flat arches, standing on your feet for long hours daily and having tight Achilles tendons can predispose you to this injury (Duff, 2004)
• The facia underneath the foot thickens
• The bottom of the foot is often very tender to touch

Shin splints

“It is painful on the front of my shins, especially after class when I have been repetitively jumping and running.”

• Symptoms include tenderness and aching along the front of your shin
• Symptoms increase during exercise
• Dancers are susceptible due to the repetitive forces that occur in dance (Thacker et al., 2002) e.g. excessive jumping on hard surfaces or dancing on a raked stage

Lateral ankle sprain

“I landed funny and rolled over on my ankle. It hurts on the outside of my foot and my ankle feels unstable.”

• This is when the lateral ligaments are overstretched or torn
• Symptoms include swelling, tenderness and an unstable ankle (Kennedy et al., 2007).
• This injury occurs from rolling over on your ankle or landing on your ankle in the rolled-out position

Hallux rigidus

“My big toe is really painful. I find it really hard to move and it hurts when I go onto full relevé.”

• Hallux rigidus is characterised by pain and stiffness at the big toe (ACFAS, 2004).
• Over time it becomes increasingly harder to bend the toe
• The most common cause for this is faulty biomechanics and structural abnormalities
• Individuals whose feet roll in are susceptible to this. Some dancers forcefully roll their foot in to increase their turn out. Over time this has detrimental effects

Dancers fracture

“I landed awkwardly in class and now it hurts on the outside of my foot near my little toe when I walk.”

• The pain presented is very localised on the fifth metatarsal
• It can cause swelling and difficulty walking
• It is usually caused by a twisting action of the ankle much like the mechanisms for a lateral ankle sprain (Kennedy et al., 2007)

Metatarsalgia

“The balls of my feet are painful.”

• The pain can be described as a burning or aching sensation
• Pain often occurs in the area where the second, third and fourth toes meet the ball of the foot (Espinosa et al., 2010)
• Pain gets worse when you are weight-bearing

Therapy for foot and ankle injuries

Sport and dance therapy is effective for treating current injuries as well as preventing those injuries from re-occurring. Therapy can involve a range of treatment methods including deep tissue massage, manual therapy, ultrasound, electrotherapy, exercise therapy, stretching and strengthening. Khan et al., (1995) suggests that for a speedy recovery in dance, the main focus of therapy should be on technique correction, manual therapy, strengthening and nutritional advice.

The use of floor barre

In ballet, “turn out” is used for many movements. Some dancers have a forced turn out where they use the floor and alter their biomechanics to increase their range. This can predispose dancers to injury.

• Ellam (2000) says that floor barre is a very effective way to develop true turn out and to help diminish forced turn out.
• It also helps to maintain alignment without having to weight bear on the injury and allows the dancers to gently isolate specific muscle groups, therefore it is a good tool for injury prevention.

Physiotherapy for dancers

There are numerous factors to consider when treating dancers due to the biomechanical demands of ballet throughout the whole kinetic chain. The degree of ‘turn-out’ is a very important aspect of ballet. 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. These all may put the dancer at greater risk of injury (Bowerman et al. 2015).

Furthermore, lack of hip strength can also be responsible for many injuries occurring at or below the knee. Weak hips can lead to faulty biomechanics and lower limb alignment (Bowerman et al. 2015). Therefore, it is extremely important that physiotherapists look proximally as well as locally foot and ankle injuries in dancers.

When treating females, it is also important that physiotherapists consider their menstrual cycle and/or onset of menarche. If there are any irregularities, the risk of injury increases, especially bony stress injuries in the foot. This is especially important for adolescent dancers.

Your physiotherapist should also go the ‘extra mile’. If possible they should speak to the dance teacher and/or choreographer or watch any rehearsal videos to gain a deeper understanding of what could be causing the foot and ankle injuries in dancers. This will result in less time-out from dancing and rehearsal-time!

As a dancer you should also consider visiting a physiotherapist for a screening protocol or ‘readiness’ assessment. You’ll get a preventative programme to make sure you remain a healthy ballet dancer.

“RESPECT YOUR BODY. EAT WELL. DANCE FOREVER” – Eliza Gaynor Minden