by Caroline von Fluegge-Chen
“I landed badly from a jump and now it hurts to walk.”
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.
“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.
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.
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.
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.
Hallux Rigidus (or Limitus)
“I have pain with full relevé.”
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.
“My foot hurts when I walk barefoot, especially first thing in the morning.”
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.
“I have pain over the balls of my feet.”
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.
“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.
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
Trigger Toe/FHL Tenosynovitis
“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.
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.
Posterior Impingement Syndrome
“I have pain with pointing my foot and relevé.”
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.
Anterior Impingement Syndrome
“I can’t achieve full plié on one side. And when I do, it’s painful.”
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.
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.
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.
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 splint.
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.