Dancers place high demands on the foot and ankle. Given these challenges and rigorous expectations for performance, treatment of injuries in this population can be intricate and challenging. Accordingly, this author discusses the differentiation of common dance injuries, relevant psychological issues and pertinent keys to treatment.
Practitioners who treat dancers need to have a knowledge and understanding of the dynamics of dance. Dancers are a different breed of athlete because of the artistry needed in addition to the pure physicality, psychological makeup and high expectations from everyone. Nutrition issues and a high incidence of injury raise the stakes.
Dancers train daily for many years, investing time, focus and energy. They do this with the understanding that employment in the business is questionable and that even successful employment guarantees nothing in the future and the possibility of living at the poverty level.
The doctor and therapist need to understand the language of dance. The official dictionary for proper ballet terms is in French. Schools around the world consistently use these terms. Most dancers start with ballet at an early age and generally continue with it as it is the foundation of most other dance styles.
The vocabulary is different for other types of dance so the dancer and doctor need to be well versed. With this understanding, the doctor can properly evaluate the positions and movements that dancers need to execute the skills. It is not uncommon for children and teenagers to be involved with four to five styles of dance at the same studio and perform all styles within one dance show. The various styles use different neurological and motor patterning, which dancers learn with consistent repetition and regularity, effectively increasing strength in a cross-training type of fashion.
As dancers age, many will choose a style (sometimes subconsciously) that suits their body type and aptitude. The classic ballet student typically has a slender body, which most traditional dance companies still desire. This in itself can be very defeating to the young dancer who has the wrong body type but desires the classic ballet program. The broader, more muscular female may gravitate toward jazz and modern styles, which utilize and accept a more athletic body type.
Shoes are different for each dance style. There are ballet slippers, pointe shoes, jazz shoes, tap shoes and ballroom shoes. Ensuring a good fit is critical with all of these shoes. Although simple early youth fitting is straightforward, when the dancer advances into the pointe shoe, it is very important for a experienced fitter to do the job. The foot can be a “square foot” with all toes even, a “Greek foot” with the second toe being the longest or an “Egyptian foot” with the first toe being the longest. The different shaped feet need the proper fit inside the toe box.
Poorly fitting shoes will affect dance technique and can cause issues with blisters, skin lesions and the possible development of hammertoes or bunions. As the pointe dancer improves, the shoe make, fit and structure change. Since pointe shoes are made of paper, glue and satin fabrics, they are subject to sweat and material breakdown. The lifespan for the pointe shoe is 10 to 20 hours of dancing.
The materials that dancers place in pointe shoes can range from bubble wrap and gel pouches to paper towels and the more favorable lamb’s wool. Dancers may tape their toes and wrap them as if they are going into the boxing ring. Unfortunately, if injured, the pointe dancer does not have the luxury of wearing looser shoes. However, jazz or modern dancers may have more flexibility in this regard as their shoes are slightly forgiving and some dance barefoot so jazz and modern dancers may use flesh-colored bandaging and taping.
If dancers need some supportive measures inside the shoe, they can modify some shoe styles with simple padding or small dress orthotics. If injured, the dancer may be able to take a class in another more supportive shoe like a jazz gym shoe that can accommodate padding. Understanding dance shoe gear and being creative with modifications can augment the podiatric physician’s treatment plan.
It is still commonplace that studios expect their dancers to be at class and perform in dance shows on a regular basis. Quite often the dancer feels the need to be perfect and to have a beautifully aligned, slim body that is pleasing to the teacher. Like professional companies, the pre-professional company has high expectations and will also have a rigorous schedule, testing individuals to their limits to prepare them for a new career.
It is imperative that dancers can handle the rigors of dance classes and show schedules, and be able to cope with the mental and competitive stresses as well as any possible injury potential. Management of their bodies is a reality at this point of their career and they need to take that management very seriously.
Dancers are usually high achievers with type A personalities. They may be insecure perfectionists who always strive to take themselves to the limit. The nature of dance pushes dancers to improve their technique and achieve milestones of strength and technique abilities. All of this can promote some unhealthy eating patterns, habits and possible anorexia issues. Dancers may have a poor diet due to insufficient calories or a lack of nutrient rich food. They may also smoke to appease food cravings.
All of these bad habits can ultimately be disastrous due to the predisposition toward injury and downtime. It is known that psychological distress has a significant association with injury duration so it is important to address these psychological stresses and intervene when necessary.1 In the professional world, dancers are expected to dance or be available for choreographic training, even if they are on workman’s compensation. The doctor should feel comfortable communicating to the dancer, parents of minors, artistic staff and therapists.
When treating dancers, there are factors we must understand that may be more problematic than in some other typical athletes. The level of difficulty and the movement of this sport ride on extreme precision so any of the intrinsic and extrinsic factors I will discuss below can and will cause injury, big or small.
Intrinsic factors include anatomical variations in height and weight, biomechanical lower extremity alignment issues, strength and flexibility deficits, age and sex, fatigue, diet, cardiovascular endurance, sleep allotment and personality/stress coping strategies.
Extrinsic factors include hours spent dancing (or what we call “exposures”), shoe fitting issues, flooring issues, set design, lighting and music tempo, temperature, travel and performance schedules, and rehearsal schedules.
When these intrinsic and extrinsic factors intersect, they will be the recipe for injury. Although there are some factors in the extrinsic category that dancers may not have complete control of, they can modify many of the intrinsic factors. It is the job of the physician and physical therapist to educate all dancers, especially the youngest ones, so they can learn to manage their bodies more effectively.
Dermatological issues may appear minor in comparison to musculoskeletal issues but calluses and corns can be painful and debilitating to the dancer. Pressure can create a blister, corn or even a small ulcer on toes and joints. Wearing the pointe shoe or other tight dance shoes can be excruciating but the dancer is obliged to remain on stage, smiling and dancing. Floor burns, blisters or splinters can occur if dancing or walking around the studio barefoot.
Proper foot hygiene is important for the dancer. Regularly trimming nails and calluses will keep them from causing more pressures. Nail injuries are the norm due to the various techniques and shoe gear. Many dancers have dystrophic nail plates or develop infected nail grooves. Trimming and filing down nail thickness can help with excessive pressures in the dance shoes. Dancers can quickly and easily treat nail issues with great relief and minimal effort and downtime.
Eighty-five percent of all dancers will have a musculoskeletal injury during their career with over 50 percent of these injuries occurring in the foot or ankle.2 Typically, the majority of all lower extremity injuries will be overuse in nature although the ankle sprain is one of the most common traumatic dance injuries.
Posterior ankle issues may include os trigonum impingement syndrome; an irregular posterior process of the talus causing impingement; posterior synovitis of the ankle and/or subtalar joint capsule; Achilles tendonitis and/or retrocalcaneal bursitis.
Although the Achilles and bursa issues are less common, they can still occur in the dancer. They may be precipitated by a change in shoe gear, choreography with more jumping or varied footwork, or deeper plié type movements, which will really challenge the tendon and bursa. Similar to treatment for our typical patients, the use of a higher heel can help alleviate pain and adding a small lift for dance shoes may be beneficial as well.
Other conditions on the posterior side will induce pain when the dancer is in the en pointe position (plantarflexed). The tissues can get impinged and cause trouble with any of the posterior structures. True synovitis and thickening of the posterior capsules of the ankle and/or subtalar joints are very common. From the constant and extreme deep stretching of the posterior tissues, an unusual thickening of the posterior capsular tissues may occur. The joint fluid becomes inflamed and the excessive tissues can protrude slightly. This causes the joints to not articulate properly, leading the dancer to report having a “jammed” and/or “full” feeling in the posterior ankle. She may also say that it feels like the ankle needs to be “popped” or adjusted.
Os trigonum impingement has similar symptoms. If one decides that os trigonum impingement is the only issue occurring and conservative therapy fails, excision may be the best option but the clinician should time this appropriately in such a way as to minimize downtime for class schedules, rehearsals or performances.
Anterior ankle and foot issues may include anterior ankle joint impingement syndrome; anterior ankle bone spurs; tibial stress fracture; or anterior tendon and ligament pathology.
These injuries are painful when the dancer is in plié positions (dorsiflexed). The anterior ankle capsule can show signs of synovitis similar to the posterior conditions and this may occur concurrently. The dancer may develop a small lipping or spurring in the anterior ankle. This more typically occurs in a mature or retired dancer.
A less common injury is the tibial stress fracture, which may be ongoing and undertreated for too long. This injury can lead to the dreaded “black line” so an involved fracture and a lengthy treatment course may ensue.
The anterior tibial tendon or extensor hallucis longus tendons can become inflamed, which may result from the dancer trying to improve the pointed foot’s appearance with overzealous stretching methods or devices. This practice may also injure ligaments surrounding the tarsal or tarsometatarsal joints. Long-term instability can occur due to the continued pointed position already stressing those tissues. One should educate the dancer on how to stretch properly and strengthen the foot’s intrinsic and extrinsic musculature.
Medial ankle and foot injuries may include posterior tibial tendon injury, flexor hallucis longus tendon injury and medial ligament injury.
Out of all medial side injuries, the flexor hallucis longus injury is by far the most common. Its etiology starts with poor foot alignment and strength of the foot and hip musculature. Due to the fact that this tendon is so long, it has a delicate lever system that is prone to injury. If there is weak hip musculature, such as in the gluteus medius, it will predispose the dancer to internal leg rotation and excessive pronation of the foot.
When this is combined with the tendency to overpronate either due to faulty technique or genetics, there will be a major eccentric strain on the medial ankle tendons, especially the flexor hallucis longus. This injury can be lengthy and requires good radiographic testing, preferably diagnostic ultrasound. Treating any of the medial tendons should always include foot and hip strengthening, balance and biomechanical control with shoegear and possible orthoses.
Lateral ankle and foot issues may include cuboid subluxation issues, lateral ankle sprains, sinus tarsi issues, and peroneal tendon and retinaculum issues.
The cuboid bone can be a source of lateral foot pain. These cases commonly involve a rotational strain to the bone, either following a lateral ankle sprain or peroneus longus weakness, strain or injury. If the bone becomes subluxed slightly from its resting position, it will cause sharp, exquisite pain that may feel like a fracture. Without concurrent soft tissue injury, simple manipulations and cuboid padding are the treatments of choice.
Lateral ankle sprains are common and one should treat these swiftly and aggressively. Weightbearing “walking boots” are preferred as they provide continuous acute care and some offloading while keeping the foot at a 90 degree closed pack position, which is best for the ligamentous structures to heal. The dancer relies on the feedback and stability from the lateral ankle ligaments so when one of these ligaments is compromised, it may cause instability and further injury. Overuse peroneal tendon or retinaculum stresses can occur as well, and not uncommonly as sequelae of the ankle sprain. Aggressive strengthening and proprioception work is advised for lateral ankle injuries in order to prevent future compensatory patterns and new injuries.
As a podiatric physician, it is crucial to understand that the foot can affect the knee, hip, core musculature and spine. Unless a dermatology condition is the chief complaint, it is important to evaluate the whole lower extremity.
The dancer should be in tights or shorts for the best visualization while testing. Evaluate flexibility and strength for symmetry, and do a complete biomechanical exam to detect any intrinsic biomechanical factors. Address and correct any deviations visible in the exams. Dancers can benefit from foot orthotics in their street shoes if they have abnormal pronation. Some dancers may walk externally rotated due to habits they develop in class. Encourage dancers to walk with a normal angle of gait in order to offload the hip rotators.
Since dancers have to be experts in stabilizing the whole lower extremity while utilizing the upper extremity in unison, it is important to test dancers in the movements they have to perform. It is known that a typical ballet class will include over 200 jumps in upward of 10 to 12 times body weight.
Testing balance is also very important. It appears that balance and skill level may suddenly change during adolescent years. These changes can be due to growth spurts, which create changes in sensorimotor adaptations, but these issues will reverse in time. Dance-related tests will help the practitioner see weaknesses that will be more relatable to the actual activity.
Standing X-rays are essential to evaluate for both injury and the alignment of the foot. X-rays that capture the dancer inside the ballet slipper or pointe shoe can also aid in the evaluation of injuries. With the aid of extra radiology testing, one can confirm the diagnosis. Subsequent decisions to pull a dancer out of rehearsals or a performance can allow the artistic staff to make other arrangements for a replacement.
I prefer obtaining a diagnostic ultrasound at an outside facility. Real time functional evaluation can reveal the strain or shear of the tissues. With an experienced physician technician, this modality picks up extreme detail and can show the very fine collagen alignment of the soft tissues. If bony structures are involved, magnetic resonance imaging (MRI) or computed tomography (CT) are the best choices. It is important to have a radiology facility on hand that offers cash pricing for exams so the dancer without health insurance benefits can afford the test.
Utilizing a variety of modalities all at once is the best choice. One should favor conservative treatment over surgical. Treating the acute nature of the problem along with the biomechanical aspects has to happen simultaneously.
In addition to traditional heat or cold therapies as well as functional and postural strengthening methods for the hip and foot, various physical therapy modalities can help treat acute issues and more chronic disorders quickly and inexpensively. Massage therapy is an excellent modality for muscle injury as it helps improve blood flow, increases range of motion, releases deep congestion and aids in chronic scar tissue repair.
I limit nonsteroidal anti-inflammatory drug (NSAID) prescription but utilize holistic homeopathic medications via injection, topicals and oral methods to reduce acute pathology when corticosteroid injections or NSAIDs are contraindicated. Holistic treatments may include acupuncture and nutrition counseling. Other treatments such as strapping, padding and taping can augment the treatment plan.
Staying positive and on track with treatments will help patients reduce the despair that may settle in. Encourage cross-training activities that will help with injury rehabilitation, cardiovascular and mental health. Discussion with artistic staff or dance teachers is helpful, and will aid in adherence. Discuss and modify shoegear as needed.
Surgical intervention should be very limited and take place only when considerable conservative treatments have failed to resolve the problem. In my experience with dancer patients, surgeries with the quickest positive outcomes are those that excise or remove problematic structures as opposed to primary repairs. When it comes to surgeries for conditions like bunions, one should postpone these procedures until the patient’s dancing career is complete as a mere loss of 5 to 10 degrees of dorsiflexion at the metatarsophalangeal joint in the dancer could be career ending. More in-depth surgeries may predispose the dancer to extended layoff periods so this should be clear to all involved parties.
The postoperative course will always take more time in the dancer than for our typical surgical patients. Returning to the rigors of the extreme foot positions necessary for dance will take many more weeks for recovery. A very clear-cut discussion regarding the postoperative course will help with the psychological health of the dancers as well as for the dance company or studio in order to plan for their absence.
Dr. Schoene has been a sports and dance medicine specialist for over 25 years. She is a Fellow of the American Academy of Podiatric Sports Medicine, the American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Schoene is also a licensed certified athletic trainer. She works with many professional and pre-professional dance companies in the Chicago area.
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