FOOT AND ANKLE INJURIES IN BALLET

By Adam Bitterman DO and Simon Lee, MD,  Rush University Medical Center, Foot and Ankle Section, Department of Orthopaedic Surgery (This article first published in SidelineSportsDoc)

Foot and ankle injuries are extremely common amongst those participating in dance activities. Those impacting the lower extremity account for roughly 65-80% of all dancer injuries.. Currently, it is estimated that organized ballet dancing begins when children are as young as 6 to 8 in age and its popularity is increasing. As the demands of the dancing community increase so too does the evolution of the field of dance medicine. ballet

Ballet dancers are prone to a wide spectrum of injuries to the lower extremity including soft tissue irritation and inflammation, stress fractures, osteoarthritis, sprains, impingement syndrome and acute fractures. At the professional level, injuries are noted to vary based on rank, gender, role, and experience level. This is in contrast to the amateur class where inexperience and inappropriate training may play a greater role in injury prevalence.

One must keep in mind that male dancers and female dancers perform different maneuvers and act in different roles during a performance. Therefore, each has an elevated risk of certain injuries. Additionally, in the published medical literature, conflict still persists regarding age and injury; no general consensus exists regarding those injury characteristics of the older participant versus the younger dancer.

Whether participating in a purely recreational or competitive environment, these injuries are generally a result of overuse impact on the hard floors as well as sudden changes and bursts of activity. Participants in dancing activities usually begin preparing for such competitions and recitals at an early age and over time their training may increase in frequency and amplitude leaving them prone to both acute and chronic injuries.

Other contributing factors include the extreme positioning that these dancers must endure. A classic example is the “en pointe” position, which leads to additional stress of the dancer’s body weight on the tips of the toes as well as the ankle. Also playing a role in a dancer’s injury pattern is their shoewear, or lack thereof. The usual ballet en pointe slipper may be broken in easily and lose its supportive nature rather quickly, which can contribute to injury.

Acute injuries most commonly affecting the ballet dancer’s lower extremity are ankle sprains. These ligamentous injuries are a result of the ankle being positioned in such a way that there is less inherent stability of the boney articulation; thus leading to more stress being incurred by these structures. Whether a partial tear or complete rupture, ankle sprains may cause the athlete to have immediate pain and difficulty bearing weight on the affected leg.

Supportive treatment for these injuries includes resting the leg but also a focused exercise program to increase the strength of the supporting musculature. Compressive adjuvants may assist in providing additional support. Other acute injuries include fractures of the ankle or metatarsal bones, particularly the fifth metatarsal. These injuries may require surgical intervention and a period of rest to allow for more predictable healing and earlier return to dance.

Chronic injuries in the ballet dancer generally involve boney changes over time and pathology within the tendons traversing the ankle and feet. These injuries will obviously become more prevalent in dancers who have histories of more intense and longer periods of participation during their careers. In these athletes, impingement between the bones of the ankle joint can occur in the front as well as in the back. In order for dancers to achieve the en pointe position, they must maintain a hyperplantarflexed position of their foot lending to the boney pathology and pain in the back of the ankle.

The great toe is also an area for concern amongst dancing injuries. Participants may develop bunions over time or degenerative arthritis and a stiff first toe. Additionally, they may complain of pinpoint tenderness underneath the great toe where the sesamoid bones articulate with the longer foot bones. Metatarsalgia may result from altered mechanics of the joints of the ball of the foot or an abnormal landing, or simply chronic repetitive overuse, which results in additional stresses in the area, which manifests as pain along the ball of the foot.

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Other complaints to the undersurface (plantar aspect) of the foot may include plantar fasciitis, which is an inflammation of the supporting tissue traversing the bottom of the foot to the heel bone. Tendinitis, also known as inflammation of the tendon, may affect the many tendinous structures that exist within the lower extremity. In particular, the Achilles tendon, the largest tendon in the body, may become irritated over time and lead to calf pain or weakness while attempting to perform certain maneuvers. Another commonly affected tendon is the flexor tendon to the big toe. This may result from a slight tearing or a diseased tendon, which manifests clinically as pain, weakness, and possibly locking of the toe.

Treatment of these injuries is generally conservative as surgical treatment may lead to changes in overall performance, prolonged recovery time and even risk early retirement from dancing. When determining a return to performance protocol, it is imperative that the dancing athlete has a good understanding of the risk of recurrence. After all, these injuries place dancers at risk for altering their performance or even shortening one’s career.

When evaluating for injury prevention it is often helpful to differentiate risk factors as intrinsic versus extrinsic factors. Intrinsic factors would be those that are inherent to each individual such as their anatomy, any prior injuries, or contributing medical issues. Extrinsic factors would be those such as the dance surface, training regimen and schedule for example.

Being able to compartmentalize injury causality into intrinsic and extrinsic factors allows for better risk identification, stratification and ultimately treatment. Unfortunately, it is less feasible to change the floor material as opposed to ensuring appropriate stretching, strengthening and transitioning from low amplitude work to high intensity training. Having a good understanding of the modifiable risk factors will ultimately lead to safer participation in ballet.

Overall, it is important to treat dancing injuries aggressively in order to maintain essential foot and ankle motion and limit future disability. Understanding the mechanics of dance will lead to better identification, treatment and outcomes of many ballet related injuries.

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SideLineSportsDocMidwest Orthopaedics at Rush