Dance surfaces must provide adequate shock absorption yet be firm enough to provide sufficient energy return to the dancer to enhance performance and reduce fatigue. Surfaces that are too firm with little or no give (such as concrete and asphalt) may lead to early muscular fatigue because the musculoskeletal system of the lower extremities must act to absorb most of the shock. Once this system fails to absorb shock adequately, afflictions of the feet (e.g., stress fractures) may follow. On the other hand, if a dance surface is too soft, this too can lead to early fatigue. In this situation, there is adequate absorption but inadequate energy return to the dancer, thus requiring considerably more effort to perform the desired movements. Early fatigue often leads to injury. Inside Tips On Evaluating Common Foot Injuries One should evaluate the ballet dancer’s foot problem in a sport-specific fashion. Instruct dancers to bring their slippers and pointe shoes to the evaluation so you can examine them for signs of abnormal stress or use and worn when appropriate. A general foot assessment is best supplemented by asking the dancer to perform the maneuvers or assume the positions that aggravate or induce the symptoms. If the movement permits, you can carefully palpate the affected region during that athletic stress. You should keep an eye out for some of the following conditions: Epiphysitis. The necessity for 90 to 100 degrees of dorsiflexion in the first metatarsalphalangeal joint has been noted. People are rarely born with this much motion in this joint, so it must be obtained by some molding of the growing epiphysis. This motion can result in an epiphysitis of the proximal phalangeal epiphysis during adolescence, which presents with tenderness, inflammation and pain with activity that is relieved by rest. The condition tends to recur, but disappears when the epiphysis fuses at maturity. This condition, in many ways, resembles Osgood-Schlatter disease that is commonly seen in the adolescent’s knee and is known as Osgood-Schlatter disease of the foot. As far as treatment goes, you should emphasize modified activities for four to five weeks until the symptoms subside and then allow gradual resumption of normal routines as tolerated by the patient. Treatment Advice For Bunions Bunions. Bunions are common in dancers. They begin to develop at the end of the teens and occur in both male and female dancers. They are often symptomatic at the end of class, since the foot is forced into a tight shoe. Padding with lamb’s wool around the tender area is a simple and effective means of relieving pain. Placing spacers between the first and second toes will usually make the foot more functional, as this alignment maintains maximum motion in the MPJ. The young female dancers with this problem should be encouraged to wear wide shoes (e.g., boy’s sneakers) and to resize their toe shoes often. It should be done at least yearly and every six to eight months if they are in a growth spurt. If you’re treating a serious dancer, you should never operate on bunions because the operation, no matter how carefully it is performed, will usually limit the motion in the first MPJ. Addressing Sesamoid Pain In Dancers Sesamoiditis and sesamoid fractures. Sesamoiditis and sesamoid fractures can be annoying problems because they heal so slowly. Sesamoiditis has many causes. Here are some causes to keep in mind. • Contusion. Contusions will respond to conservative therapy but often heal slowly. • Sprain of a bipartite sesamoid. The injury X-ray film compared to an old film will sometimes show widening of the distance between the two fragments. • Stress fracture. The bone scan will be positive. • Fracture. A fracture will usually heal either by bone or fibrous union. • Avulsion fracture of the proximal pole. • Osteonecrosis. This condition occurs often in the lateral sesamoid, occasionally in the medial and in both on rare occasions. The cause is unknown and the prognosis is often poor because the bone may fragment as it heals and pain may persist. In some patients, healing will occur but the process is slow and uncertain. • Osteoarthritis with loss of the cartilage space and spur formation. You’ll usually see this on the X-ray sesamoid view and it usually affects adults. • Entrapment neuropathies, especially adjacent to the medial sesamoid, can mimic sesamoiditis or be part of the problem.