Frequently subjecting the lower extremity to constant stress, dancers can be prone to dermatological issues, injuries due to biomechanical etiologies and bone injuries. Accordingly, this author discusses key intrinsic factors with this patient population, keys to the diagnostic workup and how to facilitate a timely return to the stage.
Due to the young starting age of dancers, varying body types and frequent physical challenges, we may see a range of dancers and dance-related injuries in our offices. Dancers may compete at elite dance competitions where professionals screen and grade them on posture, flexibility, strength, technique and the ability to twist their feet. The rigors and demands of dancers may consist of 15 to 18-plus hours of dance classes per week. All of this makes it crucial to have a comprehensive knowledge of common injury causes, diagnostic techniques and treatment strategies to get dancers back to the stage quickly and safely.
Dancers are a bit unique in comparison to other athletes. They are perfectionists, are driven to perform and want to please their teachers and coaches. With an increased number of dance styles, there has been an opportunity to accommodate different body types for the non-classical forms of dance. However, classic ballet still prefers the lean, lithe body type with beautiful arms, neck, slightly hyperextended knees and beautifully pointed feet.
The dance world, even with its variations in types of dance, still promotes continuous scrutiny of the dancers’ physiques, which may have consequences on emotional stability, eating and nutrition. There is always a threat of eating disorders so parents, teachers and healthcare providers must be intuitive and work together so the dancer gets the proper guidance and help. When lecturing at dance companies and studios, I always discuss and include information on proper nutrition and its positive and negative consequences.
What Factors Predispose Dancers To Injury?
There are predisposing factors and prevention strategies to offset injuries. Like athletes in many sports, dancers are more commonly prone to overuse injuries than traumatic injuries. It is important to determine the specific etiology so one can direct treatment.
There are intrinsic and extrinsic factors that may predispose a dancer to injury and these factors are important to note. The intrinsic factors are: age, height, weight, nutrition, cardiovascular endurance, sleep, foot mechanics, strength, flexibility, posture and personality traits that help deal with stress. The extrinsic factors that may lead to injury are: flooring, choreography, tempo, music, room temperature, shoe gear and rehearsal, travel or class schedules. These factors, either alone or intersecting, can definitely be a recipe for an injury. Although many of the extrinsic factors are not always modifiable, one can modify many of the intrinsic factors to a large extent.
It is my intent to identify those factors that can lead to injury and arrive at the solution. Understanding these etiologic factors will help to create a prevention strategy. This can have big consequences for a dance company as one can help offer solutions for chronically injured dancers or when trends occur with multiple dancers having similar injuries at the same time. With this due diligence, we can then educate the dancer, parent, studio or dance company.
Keys To An Effective Patient History And Physical
During the first visit, ascertaining an extensive history is very important. In order to become a dance medicine specialist, all practitioners must be willing to allot the time to assess the dancer thoroughly with the history and the physical exam. One cannot complete the history effectively in a short timeframe. The history has to include many items, including information on hours danced per week, types of dance, dance studio specifics, meal habits, sleep, menses, history of previous injuries and shoe gear, just to name a few.
Parents may be the main historians for the younger dancers but one should try to ask the dancer for details as well. Really listening and asking pertinent questions is especially invaluable and as with any good extensive history, the differential diagnosis will probably emerge prior to the exam.
I prefer to complete a full lower extremity dance evaluation. This includes a complete biomechanical foot exam and a full flexibility and strength exam along with a barefoot gait analysis. This full exam is necessary to understand the alignment and biomechanics that may have led to the overuse injury.
Traumatic injury may be a bit easier to assess although even traumatic injuries can be related to those intrinsic and extrinsic factors. In dance medicine, we often say the last pass across the floor at the end of the class, the end of the week, the end of a rehearsal or the end of an intensive rehearsal can lead to various injuries. This injury can be related to pure exhaustion, low blood sugar or dehydration, causing changes in technique and posture.
During the exam, it is very helpful for the dancer to be in shorts or tights. It is also important to evaluate the dance shoes including the pointe shoes on and off the foot. Taking X-rays with the pointe shoes on in relevé (half pointe) and up en pointe can help you ascertain if the shoe is the culprit, whether it is causing unusual pressures on the foot or knuckling within the shoe. Traditional X-rays, diagnostic ultrasound or magnetic resonance imaging (MRI) are also important as with any general patient exam. I believe if the injury involves soft tissue, the ultrasound exam is superior as it can help you assess the soft tissue issues along with functional and movement components as dancers move the foot into postures during the exam that may create pain. Doing so allows the clinician to assess for triggering, tears or tendon subluxations.
After confirming a diagnosis, it is time to address the injury swiftly with a multipronged treatment plan. I immediately suggest range of motion (ROM) exercises and tissue massage, but with careful restrictions for movement patterns that will cause harm. Reducing ecchymosis and edema via compression in order for tissue planes and fluids to move more efficiently is paramount. I utilize natural injection therapies in and around the area of injury immediately, and during subsequent visits.
It is so important to educate the dancer, parent and even the dance teacher as well. Have a clear, concise plan on what dancers can do, what cross-training techniques they can use or how long you suspect their dancing will be limited. This helps with studio or show planning as it establishes a general timeline for the dancer to strive for. There may be some tears but protecting the dancer and achieving complete resolution of symptoms are the goals. Encouraging adherence and keeping the dancer on track can be challenging, but nevertheless, this should be an ongoing discussion.
There may be times that an injury is not resolving as the clinician may expect. One should review imaging modalities, treatments and therapy techniques. If these reviews produce no discrepancies, discussion with parents or teachers may reveal alternative factors, such as demotivation, stress or malingering that could be having an adverse effect on the dancer’s recovery from injury.
Injuries and common conditions can fall into a few categories. There are injuries that involve the anterior, posterior, medial and lateral sides of the foot/ankle/legs that dance clinicians commonly see. I previously described these in an earlier dance article in Podiatry Today in April 2013.1 Although skin or toenails can get a bit irritated or blistered, dancers don’t generally come to discuss those issues. I discourage doing surgery on bunions and hammertoes before a dancer is retired. With these athletes (and with few exceptions), one should only discuss surgery on foot and ankle conditions after conservative care has failed.
Key Insights On Preventing And Treating Dermatological Issues
Dermatological issues are common and generally easy to address. Educating the dancers on these potential issues can increase their awareness and help them take suitable preventative measures.
We must help dancers understand how to handle the pain and pressures inside the shoe, or help the barefoot dancer accommodate with some ingenuity. Padding, taping and the addition of foams inside the shoes have to be very minimal so some creative finessing is important. Harder tap or Irish dance shoes can afford a bit more padding inside, but avoid restriction of foot and ankle movements. Using flexible tapes, very thin silicone or foam accommodations can be helpful.
Nail problems are common as most dancers will lose, bruise or have an infected nail at some point along the way. Educating patients on keeping nails short and treating them if they become infected will help to avoid issues or lessen the duration of pain.
Likewise, blisters and calluses can be common, especially if the shoes are too tight, ill fitting or if the dancer is not strong enough to allow the toes to stay straight while en half or full pointe. Soft corns between the toes due to moisture or improper fitting of dance shoes can open up into ulcers.
If partial or full nail temporary removal is inevitable, assure dancers that they will be back dancing fairly quickly with a small toe pad or tape wrap. Save permanent nail procedures for a time period when the dancer is not performing or can take a handful of days off if needed.
What You Should Know About Bone Injuries
Bone injuries can be fairly common in dancers. Overuse stress fractures, typically affecting the central metatarsals, can be common for athletes.
However, be aware that the experienced dancer will typically have an enlarged cylindrical cortical thickening of the second metatarsal shaft due to the constant foot and pointe work. One should not confuse this with a brewing or healing stress fracture. Dancers can avoid tibial stress fractures if one addresses the shin pain early on and focuses on mitigating the etiologic factors.
Another traumatic bone injury is the dancer’s fracture, which is a spiral oblique fracture of the fifth metatarsal. This can come from an inversion moment, especially when dancers are up en pointe or half pointe. Soft tissue traumatic injuries, such as lateral ankle sprains, can occur due to an improper landing or jump. A dancer’s fracture is typically soft tissue only in nature and is generally not associated with a fracture.
Other inversion injuries could lead to peroneal tendon issues, inflammation, interstitial tears or chronic thickening if they go untreated for many weeks or months. Evaluation of the lateral retinaculum and assessing for midfoot sprains will rule out injury there. Complete a thorough evaluation, imaging and swift treatment as needed.
Pertinent Pearls On Treating Injuries With A Biomechanical Etiology
Foot alignment and the actual technical alignment needed for proper pointe work can be big factors in many injuries. Starting pointe work is not only an emotional step but a huge physical step for the young female dancer. Pointe work is arguably one of the hardest athletic endeavors and research suggests that the foot will take on approximately 12 times body weight when the dancer is jumping en pointe.2
Proper shoe fitting and foot position within the shoe evolve as the dancer improves her technique. It is very important to have the toes sitting within the toe box perfectly square to the ground when they rise up onto pointe position. I have found a mere divergence of 4 degrees from perpendicular on the toe box of the shoe will add an additional 40 pounds of pressure on the lateral ankle.
When the dancer is up and down hundreds of times during a class in an ill-fitting shoe, this creates potential problems. We want to see that the foot inverts nicely with relevé (half pointe) rather than rising with a pronated attitude. When the foot is pronated (called winging) the stress on the medial tendon group can be extreme. The flexor hallucis longus tendon is the most vulnerable as it is very long and can go into an excessive eccentric loaded moment. This tendon may start triggering or kinking within the fibro-osseous tunnel. If the dancer has less than perfect turnout, rolling the foot in will produce the desired aesthetic to get a perfect 180 degrees.
I see this tendon pathology more in younger dancers who are new or recently up en pointe, and less so in older, more experienced dancers. Careful monitoring and strengthening are helpful so the foot can withstand the rigors of those constant movements. Misalignment in feet, either intentional or congenital, may travel up the chain, putting strain on the medial knee joint, aggravating the medial knee soft tissues or the tibiofibular joint as lateral leg musculature may pull the fibula externally. Lateral upper leg musculature and the iliotibial band may be tight due to the constant excessive turnout.
Pushing the turnout may create cheating in the hip joint. If the external rotation is limited at the hips, the dancer may change the lumbar alignment, creating a hyperlordotic posture, which may produce the “cheating” turnout. Incorrect alignment or just the constant lifting of the leg into very extreme positions (battements) may produce a labral hip injury. Addressing and recognizing lower extremity weakness on the initial exam can help prevent these biomechanically driven overuse-type injuries.
After determining the source of the injury through the patient history and physical exam, one can suggest appropriate modalities and educate the dancer on effective strategies for prevention. Always treat underlying biomechanical issues with proper shoe gear and orthotics, and encourage dancers to utilize strengthening work to fix postural compensations or poor technique habits that may be due to weakness.
Limit immobilization as much as possible. Utilize alternative therapies such as massage, acupuncture, and creams and oils. Many dancers appreciate alternate therapies as they prefer not to use corticosteroids or medications.
Treating dancers can be very rewarding but it takes some practice, patience and time in the schedule. Opening up your armamentarium of treatment options can help facilitate a quicker recovery and the eventual return of the dancer to the stage.
Dr. Schoene is a sports medicine specialist and certified athletic trainer. She is a Fellow of the American College of Foot and Ankle Surgeons, the American Academy of Podiatric Sports Medicine, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Schoene has worked at the Atlanta Olympics, the World Cup games and the Olympic Training Center. She has also worked with many professional dance companies, including the Joffrey Ballet of Chicago, Hubbard Street Dance, Inaside Chicago Dance and Ballet Chicago. Dr. Schoene has been a podiatric consultant for the DePaul University Blue Demons since 1992.
1. Schoene L. A guide to diagnosing and treating common dance injuries. Podiatry Today. 2013; 26(4):48-54.
2. Laid JC, Kruse DW. Assessing readiness for en pointe in young ballet dancers. Pediatr Ann. 2016 45(1):e21-25.
For further reading, see “A Guide To Diagnosing And Treating Common Dance Injuries” in the April 2013 issue of Podiatry Today, “What You Should Know About Dance Injuries” in the January 2005 issue, “Treating A Dancer With Posterior ‘Impingement’ Pain” in the January 2013 issue, or “Key Biomechanical Insights For Treating Dance Injuries” in the June 2007 issue.
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