How To Identify And Treat Common Ballet Injuries
With ballet dancers, foot and ankle injuries often occur due to increased jarring of the foot and ankle and poor intrinsic muscle strength.
Unlike the athlete, who often wears a shoe specially designed to stabilize the foot and absorb shock, the ballet dancer wears only a thin slipper or toe shoe. Therefore, the majority of the forces of impact in this setting must be absorbed by the lower extremities. It is the failure to effectively and efficiently absorb these forces that can lead to injury to structures about the foot. Factors that can contribute to this ineffective absorption of energy include anatomic variation, improper technique and, in some cases, fatigue.
With poor intrinsic muscle strength of the arch, foot pain may occur. The "intrinsic" foot muscles are tiny little muscles which help control the position of a ballet dancer's arch, and are responsible for the control of the toes within the shoe en pointe. If these small muscles are not working effectively, larger muscles known as the extrinsic foot muscles (which originate further up the leg), become overused as they attempt to perform two roles. This often leads to conditions such as:
• Anterior Compartment Syndrome
• Stress fractures of the shin bone (tibia)
• Medial Tibial Stress Syndrome (also known as shin splints)
Weakness in the intrinsic foot muscles and overuse of the extrinsic foot muscles will also result in the toes 'clawing' both when rising, and en pointe.This is the biggest cause behind the nasty blisters that are often seen in photos of professional ballet dancers. Proper control of the intrinsic muscles will enable the middle joint of the toes to remain straight while fully pointing the rest of the foot.
Aside from trauma to the skin (blistering, callusing, broken nails), there are several other common foot complaints among ballet dancers. These include metatarsalgia, stress fractures, sesamoid pain, plantar fasciitis, bunions and bunion pain, and Achilles tendonitis….issues also commonly seen in women who have worn high heels most of their lives.
Causes of Injuries
1. Technique-Related Causal Factors
The single most important anatomic factor in classical ballet is proper turnout of the hip. Each of the five basic positions has a single common denominator: maximum external rotation of the hip. All ballet movements begin or end with one of these positions. The aspiring dancer who has the good fortune to have ligamentous laxity may have greater potential for superior turnout than “tighter” dancers.
Dance students with poor “natural” turnout at the hip may compensate by forcing external rotation (turning outwards) at the knee or the foot and ankle joints.
Rolling in, the equivalent of excessive pronation, is a technique employed by some dancers to compensate for inadequate external rotation ( turn out) at the hip. The consequence of such a manoeuvre is excessive strain on the medial (inside) structures of the foot and ankle, and can lead to chronic injuries.
Treatment: The treatment consists of the following:
1. Increase flexibility of hip muscles ( groin and gluteal muscles)
2. If the turnout at the hip is compensated with increased pronation which can cause excessive strain on foot, ankle and knee, orthotic therapy is required. Orthotics will realign the feet, knees and hips and prevent excessive pronation (feet roll in) resulting in decreased stress and strain on these areas.
2.High Arched Feet:
High Arched Foot Of a Ballet Dancer
A high arched foot, with it's inherent rigid midfoot, can also present problems to the aspiring ballet dancer. The high arched foot absorbs energy poorly and often diverts forces to structures unaccustomed or poorly suited to absorb stress. High arched feet are especially vulnerable to ligamentous strain, fasciitis and stress fracture.
3. Hyperextension of the big Toe
The injury generally occurs when the toe is hyperextended back or forward. This happens most commonly when an athlete stubs his/her toe. It presents with localised pain and swelling at the first big toe joint. Hyperextension of the big toe joint is a painful injury that is slow to heal. It is caused by the toe of the ballet shoe catching on the floor and forcing the toe to be bent downwards and back.
Bunion of the 1st hallux (big toe)
This is an enlargement of bone or tissue, either at the base of the big toe, or on the outside of the foot. The enlargement is often due to excess Pronation (rolling in) of the foot.
Bunions are common in dancers. They begin to develop at the end of the teens and occur in both male and female dancers. Some bunions (or hallux valgus) are hereditary, however dancers often develop them due to the constant pressure of the tight fitting toe shoe against their feet, and the increased stress on the medial column as a dancer attempts to achieve more ‘turn-out’. The constant friction of a tight shoe can exacerbate bunion pain.
Treatment: Padding with lamb’s wool around the tender area is a simple and effective means of relieving pain. Placing spacers between the first and second toes will usually make the foot more functional, as this alignment maintains maximum motion in the big toe joint. The young female dancers with this problem should be encouraged to wear wide shoes (e.g., boy’s sneakers) and to resize their toe shoes often. It should be done at least yearly and every six to eight months if they are in a growth spurt.
Orthotic Therapy for Bunions: It is essential in treating bunions to address the underlying cause which is excess pronation. Bunions are caused by poor biomechanics. To correct this you need orthotics which will realign the feet and help prevent the progression of the bunion.
The pointe shoe should be checked to make sure the toe box area matches the shape of the foot and is not too narrow.
Sesamoid bones are two tiny bones within the tendons in the foot that run to the big toe. When a person has sesamoiditis, the tendons around the sesamoid bones are often inflamed. This condition is a common problem among ballet dancers.
Symptoms: The most common symptom of sesamoiditis is pain in the ball-of-the-foot and swelling. The pain often occurs on the medial or inner side.
The pain may be constant, or it may occur with, or be aggravated by, movement of the big toe joint. The pain is often accompanied by swelling throughout the bottom of the forefoot.
What Causes Sesamoiditis? Sesamoiditis is usually caused by repetitive, excessive pressure on the forefoot. Other causes include increased activity, stress fractures, having a high arched foot, and having a bony foot. If you have a bony foot, you may not have enough fat on your foot to protect your sesamoid bones and tendons.
• Orthotic therapy
• A modified shoe
• Shoe pads
• Immobilization of the toe joint to speed the healing process
• Ibuprofen to decrease pain and swelling
Severe cases may require a below-the-knee walking cast for 2 to 4 weeks and the injection of steroids into the inflamed first metatarsophalangeal joint.
Performing a sesamoidectomy is usually not necessary for dancers because the pain will almost always subside eventually with conservative therapy alone. It is often difficult to get the dancer to be patient but the pain will usually go away if one can just wait long enough.
Conservative therapy of sesamoid problems may take six to 12 months. During this period, you may use pads to offload the sesamoids and dancers should minimize demi-pointe work. If the dancer still has disabling symptoms after one year of conservative treatment, you may consider a sesamoidectomy.
6. Hallux Limitus and Rigidus
Repeated strain on the big toe joint can result in stiffness of the big toe. Those who also present with bunions are more prone to hallux limitus. The shock and forces from dancing can lead to inflammation of the big toe joint, and over time cause stiffness and a lack of range of motion. Because of the pain and stiffness, dancers will shift their weight to the outside of the foot during demi-pointe. In extreme cases surgery may be necessary. Icing, rest, anti-inflammatory medication, and taping methods can assist in healing.
7. Morton’s Neuroma
Morton’s neuroma of the 3rd and 4th metatarsal
A neuroma feels like a burning or tingling that can shoot from the ball of the foot to the toes. Numbness and cramping may be present as well. It is caused by the impingement of nerve fibers between the metatarsals and toes, usually between the 2nd and 3rd toes but also between the 3rd and 4th toes. The nerves may become swollen and permanently scarred. Pain usually goes away when shoes are removed, suggesting the shoes are too narrow and excessively tight. Placing metatarsal pads in your street shoes is recommended. The toe box of the pointe shoes should be checked to make sure it matches the shape of the foot. A more square shaped toe box may be necessary, rather than a much more tapered one. A doctor may also inject cortisone into the inflamed area.
8. Plantar fasciitis
Plantar Fasciitis of the foot
Plantar Fasciitis: The plantar fascia is a dense band of fibrous tissue that originates at the heel and connects to the base of the toes. It stretches and contracts each time the foot is used, and is prone to overuse especially if the arch is not supported by proper footwear. Dancers experience pain and swelling at the inside base of the heel and arch area. Stretching the gastrocnemius complex, icing, anti-inflammatory medications, ultrasound, taping methods, massage, and supportive footwear and orthotics outside of the studio are all recommended.
9. Stress Fractures
Stress fracture of the metatarsal bone
Stress Fractures can occur in any bone, but in dancers a stress fracture occurs typically in the 2nd metatarsal. Tremendous stress is placed on the shaft of this bone while on pointe when the foot is maximally plantar-flexed. A stress fracture is evidence of ‘too much too soon’, and with dancers may also indicate inadequate vamp height of the toe shoe. The area around the fracture may appear tender and later on the involved area may become very swollen. Dancers are especially prone to stress fractures not only because of the physical demands of ballet but also the quest for thinness. Many young dancers with amenorrhea (also known as the Female Triad Syndrome) are not consuming enough calories, fat, and calcium to allow for estrogen production, which plays a crucial role in making strong bones.
10. Achilles Tendonitis:
The Achilles Tendon
The Achilles tendon, the largest tendon in the body, extends down the back of the leg to the heel and allows the dancer to rise onto pointe. Not lowering the heel completely down between relevés, ribbons that are wrapped too tightly around the ankle, and drawstrings or elastic which is too tight around the heel can all contribute to tendonitis.
Symptoms include tightness, soreness, and swelling of the tendon, pain during relevé, and sometimes a slight stretching noise. Icing, stretching, and anti-inflammatory medications are recommended. While wearing high heels outside the studio may help alleviate the pain of Achilles tendonitis, prolonged wearing of high heels will contribute to it.