Treating Foot And Ankle Injuries In Ballet Dancers

By Mark A. Caselli, DPM

The dancer’s feet are comparable to a concert pianist’s hands. Extensive training, often beginning before the age of 10, is common, especially among girls. Through the years, changing styles and great leaps have placed increased strain on the foot, resulting in the variety of dance injuries we must diagnose and treat today. In a follow-up to the last column (see “How To Identify And Treat Common Ballet Injuries,” pg. 70, April issue), let’s take a closer look at other common foot and ankle injuries that affect ballet dancers. The most common acute injury in theatrical dance is the ankle sprain. Most sprains usually involve the lateral ligamentous structures and result from forced inversion of the hind foot when landing from a jump. With the foot in plantarflexion, the talus is relatively unstable within the ankle mortise. In this position, the primary static restraint to inversion stress is the anterior talofibular ligament. Forced inversion results in stretch, partial or complete tear of this ligament with the immediate onset of pain and swelling within the sinus tarsi. Regardless of severity, ankle sprains are initially treated with rest, elevation, ice massage and a compressive dressing. However, there are different treatment protocols for different grades of sprains. How To Grade The Severity Of Ankle Sprains Grade I sprains are stable injuries that involve stretching or partial tearing of the anterior talofibular ligament. You can effectively treat these injuries with serial taping or the air cast. Patients should maintain icing, elevation and compression until all swelling has subsided. Emphasize to patients to continue with three-point crutch walking until they can walk with a normal gait. Grade II sprains usually involve a complete tear of the anterior talofibular ligament with varying degrees of injury to the calcanealfibular ligament. Patients with these injuries usually present with significant swelling. This often restricts initial treatment options to a compressive dressing and posterior splint. When swelling decreases, you may employ serial taping or the air cast. Grade III sprains involve complete or close to complete tears of both the anterior talofibular and calcanealfibular ligaments. Frequently, you can manage these injuries successfully via immobilization. However, the prognosis for a completely stable ankle following such treatment may be somewhat unpredictable. Dancers, like gymnasts, require absolute stability with the ankle in the plantarflexed position. If the torn lateral ligaments heal in a scarred, stretched position, this laxity can lead to chronic instability and may adversely affect performance. Operative management of grade III ankle sprains offers reliable restoration of ligament length and decreases the likelihood of long-term instability. Regardless of the method of treatment, adequate physical therapy and proper rehabilitation are necessary to restore normal use following injury. Key Pearls On Subluxing MPJs And Cuboids The collateral ligaments of the lesser metatarsophalangeal joints can be torn by a dorsiflexion sprain or, in an older dancer, can be stretched out, slowly leading to instability in the joint. When the dancer relevés onto the ball of the foot, the base of the phalanx subluxes onto the dorsum of the metatarsal head, forcing it downward (the dropped metatarsal), leading to metatarsalgia. When the dancer comes back down to the floor, the phalanx relocates and appears normal. The regular set of X-ray films will also be normal. To pick this condition up during the physical exam, you must do a Lachman test on the metatarsophalangeal joints. This test is similar to that which is done on the knee. When you test the joints in this manner, the affected toe will easily dislocate and then relocate, making the diagnosis apparent. Once the ligaments are loose, you cannot tighten them without surgical intervention. Sometimes flexion exercises and a toe retainer with padding under the metatarsal head will at least make the problem workable. The subluxing cuboid is a common but poorly recognized condition. It presents as lateral midfoot pain and an inability of the dancer to work through the foot, i.e., go smoothly from foot flat to relevé. This condition may present as an acute sprain or an insidious overuse injury.

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