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THE FOOT AND ANKLE

Structure
The ankle joint connects the lower leg to the foot and, in dance, allows for
pointing the toe (plantar flexion) and flexing the foot during plié (dorsiflexion).
The ankle also allows for inversion and eversion, producing turn-in and turn-
out, respectively. The 26 bones in the foot work in concert with ligamentous
support and muscular force to create three separate arches, critical for
shock absorption during jumps. Structurally, the ideal foot for ballet is
considered to be a flexible “square foot”, which has equal-length first and
second toes.

Common Injuries of the Foot

Dancer’s Fracture
“I landed badly from a jump and now it hurts to walk.”

Causes
This is the most common acute fracture seen in dancers. This fracture
occurs along the 5th metatarsal, the long bone on the outside of the foot.
The typical method of injury is landing from a jump on an inverted (turned-in)
foot. The dancer will usually experience immediate pain and swelling. He or
she may or may not be able to walk.

Treatment
Treatment typically consists of ice, elevation, and limiting weight bearing
activities. Consulting with a physician to confirm a fracture will be necessary.
A dancer’s fracture will require a period of immobilization while the injury
heals. Rehabilitation should follow to rebuild foot and ankle mobility and
strength.

Sesamoiditis
“I have pain underneath my big toe, particularly while walking without shoes.”
Sesamoid bones are unique in that they are not connected to any other
bones in the body. There are two very small bones (about the size of a kernel
of corn) on the underside of the forefoot near the big toe. These two
sesamoids provide a smooth surface over which tendons controlling the big
toe are located.

Causes
The sesamoids provide a support surface while the dancer is on demi-
pointe. The tendon that runs between the sesamoids can become inflamed,
causing sesamoiditis, a form of tendinitis. Pain is focused under the big toe
on the ball of the foot. With sesamoiditis, pain may develop gradually. There
may be pain while bending and straightening the big toe.

Treatment
The dancer may be required to rest and take time off from rehearsals while
the pain and inflammation from sesamoiditis decreases. A consult with a
physician is indicated to rule out a sesamoid fracture. A physical therapist or
athletic trainer consult is also helpful to identify and correct muscle
imbalances and assist with acute symptom relief. The use of a J-shaped
pad around the area of the sesamoid to relieve pressure may be helpful, as
is taping the toe so that it remains slightly downward (plantarflexed). It may
take several months for the pain associated with sesamoiditis to be
completely relieved. Surgical intervention to remove the sesamoid bones
should only be considered after all conservative measures have been
exhausted.

Hallux Valgus and Bunion
“My big toe points inward and is painful.”
Hallux valgus and bunion can be seen in the public at large; however,
dancers generally develop this condition at a younger than typical age. This
injury usually has a gradual onset and is often associated with other
postural and or biomechanical faults involving other joints (most often a
tendency to pronate, or roll-in, during turned-out positions). It is characterized
by medial movement of the first metatarsal head (big toe), where a bunion
bump will gradually form. Consequently the phalanges of the great toe will
shift towards the other toes.

Signs and Symptoms
The dancer will notice a gradual onset of foot pain at the area of the big toe
or ball of the foot. Pain will be greatest with weight bearing and particularly
jumping activities. Typically, dancers will notice pain with excessive pressure
to the affected area, sometimes to the point where the slightest contact
causes exquisite pain.

Treatment
The best course of action is to identify a hallux valgus condition as early as
possible and clarify its structural and/or biomechanical causes. Conditions
that are caught early on can be treated with either strengthening exercises,
stretching and/or orthotic prescription. Often, a toe spacer between the first
and second toes can help with alignment and prevent further progression of
the injury. Conditions that develop into significant structural changes can be
very difficult to manage and may require surgical intervention. It is imperative
that the clinician treating the dancer looks at the ankle, knee, and hip joints
to identify any proximal impairments. Finally, attention to a dancer’s
technique with plié, relevé, and jumping is essential to limiting the
progression of hallux valgus identified.

Hallux Rigidus (or Limitus)
“I have pain with full relevé.”

Causes
This condition is characterized by pain and/or restriction of movement at the
joints of the big toe. To achieve full demi-pointe the metatarsal phalangeal
joint must be able to make a 90 degree angle. Dancers who start later in life
may lack this much mobility. A dancer without mobility who forces a high
demi-pointe will cause the bones in the joint to impinge on each other. If this
is done repeatedly, bone spurs will develop leading to even further
decreased motion in the joint, inflammation and eventual degeneration of
the joint.

Compensations for lack of full mobility include sickling. This position will
decrease impingement but it is not an esthetically acceptable line and puts
the dancer at risk for ankle sprains. An acceptable and safe compensation
for this condition is a half demi-pointe position. The dancer must learn to
rise onto the ball of the foot without forcing the foot into full demi-pointe.

Treatment
During the acute stages, rest and ice are helpful to reduce pain and
inflammation. A good way to ice this injury is with an ice massage for 5
minutes. Stretching of the foot can be done to help improve flexibility. The
stretch into a demi-pointe position can be done in a non-weight bearing
position, in a pain free range and should be held for 30 seconds. The
dancer should assess the available pain free range of the joint and learn to
work within that range. Taping the great toe to restrict full demi-pointe can be
effective in relieving symptoms. The tape should be applied so that the toe
remains slightly downward (plantarflexed). Mobilization of the metatarsal
phalangeal joint by an experienced clinician is also quite effective.

Plantar Fasciitis
“My foot hurts when I walk barefoot, especially first thing in the morning.”

Causes
Plantar Fasciitis is an overuse injury affecting the sole of the foot. The tough,
fibrous band of tissue (fascia) connecting the heel bone to the base of the
toes becomes inflamed and painful. Most often people will experience pain
first thing in the morning when they step out of bed. Dancers will often
experience an increase in pain after class, or following lengthy weight
bearing activities. Plantar fascia pain can also be influenced by tightness in
the calf or the Achilles tendon, or dancing on a hard surface or a non-sprung
floor.

Treatment
The earlier plantar fasciitis is treated, the quicker it can be resolved. Rest
and ice are the first treatments for plantar fasciitis. Anti-inflammatory
medication can also be helpful. For persistent conditions, physical therapy
or athletic training treatments to assist with tight tissues and identify
weakness is indicated. Chronic conditions respond well to the use of an
overnight splint (issued by your physician or clinician) to provide a long
duration stretch to the affected tissues.

Metatarsalgia
“I have pain over the balls of my feet.”

Causes
Metatarsalgia is characterized by pain and tenderness along the ball of the
foot. For dancers, this is commonly caused by instability in the joints of the
smaller toes. Repeated sprains and overstretched ligaments can lead to
laxity, or increased flexibility in these joints. For a dancer, years of overwork
and forcing of extreme motion in the foot can increase laxity and may cause
subluxation of these joints.

Treatment
As with all acute inflammatory conditions, ice and rest are appropriate.
Strengthening the muscles that control toe flexion can be helpful. This can
be done with towel scrunches (using your toes to grab a towel placed on the
ground and drawing it towards you). A metatarsal pad just behind the balls
of the feet can help prevent subluxations and may relieve pain.

Common Injuries of the Ankle

Achilles Tendinitis
“My heel and lower calf hurt, particularly while running or jumping.”
Tendinitis can occur in any of the tendons about the ankle, including the
flexor hallucis longus tendon (the dancer’s tendon), the peroneus brevis
tendon, and the peroneus longus tendon. It most commonly occurs,
however, in the body’s longest tendon—the Achilles tendon. Able to
withstand forces equal to and greater than 1000 pounds, this tendon
connects the calf muscles to the heel bone (calcaneus) and is responsible
for plantar flexion of the foot to achieve releve and performing jumps. Due to
its’ heavy workload in the dancing population, it is prone to inflammation
(tendinitis). It unfortunately is also the most frequently ruptured tendon in
dancers and non-dancers alike.

Causes
Most cases of Achilles tendonitis are due to overtraining of the dancer,
particularly heavy training during a short period of time. Other contributing
factors for Achilles inflammation would be:
• Returning to dance after a long period of rest
• A natural lack of flexibility in the calf muscles
• Dancing on a hard surface or a non-sprung floor
Aside from pain over the area of the Achilles, dancers with Achilles
tendonitis can also notice:
• Mild pain after dancing that worsens
• Tenderness in the morning located ½” above tendon attachment to heel
bone
• Stiffness that fades once tendon is sufficiently warm
• Swelling and inflammation

Treatment
As with all overuse injuries, the sooner the injury is addressed, the more
positive the outcome. Rest and ice are immediate treatments for conditions
that do not allow for any pain free activity. Active stretching of the Achilles is
helpful. However, dancers need to exercise caution with stretching the
Achilles beyond the point of comfort. Strengthening exercises should be
introduced gradually. For chronic conditions, the use of an overnight splint to
assist with dorsiflexion range of motion can be helpful. Orthotic prescription
can be helpful to correct any structural imbalances in the foot. However, if a
dancer has no correctable faults, orthotics may not assist with symptom
relief.

Trigger Toe
“My big toe ‘clicks’ and gets ‘caught’ sometimes. I have to use my hands to
release it.”
Trigger toe occurs most commonly in female classical ballet dancers. It
results when the flexor hallucis longus (FHL) tendon on the inside of the
ankle moves irregularly through its anatomical pulley mechanism around
the ankle. Sometimes, the tendon actually locks distal to the tendon canal
(near the big toe) and prohibits a dancer from using the strength in her big
toe when en pointe.

Causes
Trigger toe can be the result of inflammation or a partial rupture of the FHL
tendon, accompanied by swelling along the sheath in which it’s contained.
The tendon may become frayed and scarred down, adhering to the sheath
and creating friction, inhibiting its smooth gliding motion. The condition may
present as non-painful and annoying for a period of time before becoming
painful. Pain is typically noticed as a dancer lowers from demi-pointe to flat.

Treatment
Early identification of trigger point can assist in its recovery. Dancers should
use ice, particularly ice massage as a way to decrease local inflammation.
An athletic trainer or physical therapist consult is helpful to assist with soft
tissue management of scarring or adhesions along the tendon. The dancer
should take the time to perform slow, gentle stretching of the great toe prior
to dancing. More significant cases may require surgery to release the
ligamentous portion of the FHL sheath and repair the tendon.
Impingement Syndromes

Posterior impingement syndrome (dancer’s heel)
“I have pain with pointing my foot and relevé.”

Causes
Posterior impingement syndrome, commonly known as dancer’s heel,
involves compression of soft tissues at the back of the ankle. A bony-
formation or bump behind the ankle causes this compression. The dancer
generally feels discomfort at the back of the ankle when the toe is pointed or
in relevé.

Treatment
Dancers should use ice and anti-inflammatory medications to help reduce
soft tissue swelling. Stretching of the tissues in the back of the heel (calf and
Achilles) is important to reduce the stress placed on those structures. A
physician and physical therapy/athletic training consults are indicated to
identify joint mobility restrictions or other imbalances that might be
contributing to the condition. Some health-care professionals may
recommend steroid injections to assist with local inflammation. Finally, if
non-surgical treatment does not help alleviate the discomfort, surgical
intervention will be required to remove the bump that is compressing the soft
tissue.

Anterior Impingement Syndrome
“I can’t achieve full plié on one side. And when I do, it’s painful.”

Causes
Anterior impingement syndrome involves the top of the ankle where the shin
bone (tibia) meets the ankle (talus). There can be direct contact between
these bony structures. With hundreds or thousands of pliés, this direct
contact can eventually result in a bony formation at the front of the ankle. This
bony formation compresses the soft tissue and creates pain. A dancer will
typically notice pain with deep pliés, as well as significant swelling at the
front of the ankle joint.

Treatment
Early recognition of symptoms is extremely important because anterior
impingement syndrome is not reversible. Ice and/or anti-inflammatory
medications can be helpful to reduce local swelling. A clinician can assist
with re-establishing normal joint mobility or identifying areas of inadequate
strength or flexibility. A dancer may want to try some simple ideas to help
relieve stress to the tissues during class or performances, including:

- perform in street shoes
- use one-quarter to half-inch heel lifts
- discontinue forced pliés

With advanced cases, surgery is sometimes pursued. It should be
understood by the dancer that surgery very often leads to a recurrence of the
bone formation within three to four years.

Lateral Ankle Sprain
“I rolled my ankle during class and heard a ‘pop’ sound.”
Ankle sprains are the most common type of ankle injury for dancers. Ankle
sprains involve the lateral (outside) structures of the ankle and occur when
the ankle is inverted (turned or rolled outwards). A lateral ankle sprain is the
result of tears to any of the lateral stabilizing ligaments. Sprains are graded
1st, 2nd, or 3rd degree (3rd degree being the most severe) depending on
the involvement and integrity of these ligaments.

Causes
Ankle sprains are usually sustained upon landing jumps, either improperly
or landing on an object or another dancers foot. It is common for significant
sprains to also produce an audible ‘pop’ sound. Other related factors that
can contribute to ankle sprains include:
1. working close to the limits of strength
2. a slight loss of balance
3. a lapse in concentration
Upon sustaining an ankle sprain, a dancer will usually notice swelling and
pain over the lateral ankle. The severity of these symptoms will vary
depending on the severity of the sprain. Some dancers are able to walk,
some are unable to bear weight at all. Bruising over the lateral ankle can
emerge within 1-3 days following an ankle sprain.

Treatment
As with any injury that involves inflammation, apply the RICE treatment
protocol:
• Rest — avoid using the ankle to prevent further damage.
• Ice — apply ice or cold packs to the ankle for 15–20 minutes each hour to
help reduce swelling.
• Compression — wrap a tensor bandage around the ankle to help reduce
swelling.
• Elevation — elevate above the heart and support the ankle while resting to
prevent blood from pooling and increasing swelling.
The severity of the ankle sprain will dictate the amount of protection and
immobilization the ankle requires. A Grade 1 sprain may only need the
support of an ace wrap bandage or an Aircast splint. A Grade 3 sprain may
need to be immobilized with a splint and the dancer will likely need to use
crutches or a walking boot for ambulation. Ankle sprains should be
evaluated by a physician to rule out any fractures. Follow-up treatment with a
physical therapist or athletic trainer is crucial to develop strength and
balance prior to returning to dance activities and thus reduce the potential for
recurring sprains.

Shin splints, stress reactions, and stress fractures:
“I have pain in the front of my shins. It hurts worse during class.”
Shin splints, stress reactions, and stress fractures are all overuse injuries of
the lower leg usually associated with forceful, repetitive activities such as
running or jumping. Shin splints involve pain at the front of the lower leg in
the shin region. The pain is caused by an irritation of either the periosteum
(the lining of the tibia, or shin bone) or the muscles and tendons in the area.
A stress reaction is defined by accelerated remodeling or re-absorption of
bone. A stress fracture is a small crack or cracks that occur as a result of
repeated loading of the bone when muscles are fatigued. Fatigued muscles
transfer more of the load to the bone. Shin splints or stress reactions can
progress to stress fractures if left untreated. Stress fractures can progress to
complete bone fractures if left untreated. The feet are the most common site
of stress fractures in dancers, and the tibia is the most common place for
stress reactions or shin splints.

Causes
All three conditions result in an aching pain that may become more severe
during activity. Intensive dance rehearsal and a high percentage of time
dancing on pointe or demi-pointe will increase the stress and pressure on
the foot and tibia. As muscles become fatigued the dancer may have
difficulty maintaining position, and the muscles transfer stress to other soft
tissues and bone. When the bone is repeatedly stressed and has low bone
mineral density levels, it can eventually result in a stress fracture. Dancing
on hard floors increases the risk of stress fractures and stress reactions.

Treatment
Treatment of shin splints may involve various techniques, which include:
• resting the area
• applying ice to control inflammation
• physical therapy/athletic training treatments
• correcting any underlying postural distortions that may aggravate or
contribute to the injury (knee hyperextension, weak abdominal muscles,
anterior or posterior tilted pelvis, pronation/supination of the foot, etc.)

With stress fractures, rest for the injured area is the only treatment that will
allow the bone to heal. It may be necessary to unload the stress for a period
of time by using crutches or a walking boot. A lack of pain does not mean
that the bone has healed (many people do not report symptoms). A dancer
should consult with their physician or clinician prior to returning to dance.
Upon return to dance, the dancer should not experience any pain. If the
dancer resumes activity too quickly, the stress fracture is more likely to
progress to a complete bone fracture.
Foot and Ankle Injuries

Top Ten Prevention
tips for dancers

1. Proper training and
teaching are essential to
allow dancers of all ages
to develop their skills
without injury.

2. Take adequate rest to
allow the body to heal
itself from daily wear and
tear

3. Maintain energy levels
by eating and drinking
adequately.

4. Conditioning and
strengthening of the leg
muscles that support the
arch are crucial.
5. Try to avoid dancing on
hard or uneven surfaces,
which could cause injury.

6. Take care of your
shoes!

7. Dancers should adopt
new training schedules
slowly.

8. Although not always
possible when dancing,
but more so off stage or
out of class, wear
supportive footwear, and
if you need to wear
orthotics, wear them as
often as possible.

9. If dancers perform
excessive pointe or
demi-pointe work one
day, they should focus on
other types of work
during the next workout.

10. Early recognition of
symptoms is important.
Stop activity if pain or
swelling occurs. If the
pain persists after a few
days rest, consult a
sports-medicine
physician.