Foot and Ankle Injuries in Dance

Types of dance

Today, dance encompasses various techniques and styles such as hip-hop, tap, musical theater, jazz, folk, ethnic, modern, and classical ballet. Although footwear is usually specific to the technique or choreography, most dance shoes rarely include a shock-absorbing sole, and some techniques, such as modern, are performed barefoot.

Causes of dance injuries

Anatomic alignment, poor training, technical errors, unfamiliar choreography or style, and environmental factors including flooring surfaces and theater temperature have been implicated as contributing factors to dance injuries. The female athlete triad, amenorrhea, disordered eating, and low bone density, has been implicated in an increased risk of stress fractures in dancers [10], [11], [12], [13]. Delayed menarche, common in ballet dancers, has been shown to have an association with

Dancing on pointe

The female ballet dancer often dances in the full pointe position, requiring marked ankle plantar flexion with the toes in a neutral position relative to the longitudinal axis of the foot (Fig. 1). Significant ankle plantar flexion and strength of the intrinsic muscles of the foot and the muscles surrounding the ankle are needed to successfully dance on pointe. The support of the body weight on pointe is borne in the ankle joint along with the tips of the first and second toes. Plantar

Turnout

The technique of classical ballet is based in turnout or outward rotation of the legs. Therefore, the movements of classical ballet must be executed in a turned-out position. The ideal turnout demonstrates 180° of external rotation starting at the hips and results in the feet being easily placed in a 180° position on the floor (Fig. 2A). Many students are unable to attain the perfect first or fifth position because of limitations of rotation in the hip, and to place their feet in the correct

Hallux rigidus

Hallux rigidus is an arthritic condition of the metatarsophalangeal joint. Dancers require 80° to 100° of dorsiflexion when performing relévé onto demi-pointe; therefore, this condition is quite disabling for a dancer. The stiffness in the joint causes the dancer to roll onto the lateral metatarsals in improper alignment or sickling when rising to demi-pointe.

Dancers with this condition report stiffness and pain of the first MTP joint. Dorsal fullness and a palpable osteophyte may be present,

Sesamoid injuries

Sesamoid injuries are difficult problems seen in the dancer. Sesamoiditis, bursitis, osteonecrosis, osteoarthritis, and stress fractures are included in the differential diagnosis of plantar MTP joint pain [22]. Prolonged disability can result from these injuries. The sesamoids are small bones imbedded in the flexor hallucis brevis (FHB) tendons, and they articulate with the plantar aspect of the first metatarsal head. They are exposed to significant force when rolling through the foot onto

Stress fractures of the metatarsals

Repetitive loading of bone causes bony stress reactions. Bone remodeling is impaired when loading is increased too rapidly, weakening the bone and leaving it at risk for stress fracture. The cause of stress fractures is multifactorial; amenorrhea, disordered eating, and osteopenia, the female athlete triad, are felt to contribute to higher rates of stress fracture for female dancers. More hours danced per day (greater than 5 h/d) and amenorrhea (greater than 90 days) have been demonstrated as

Midfoot injuries

Injuries to the midfoot in dancers, while rare, can be career-ending. The strong ligaments of the tarsometatarsal joints are required for support of the medial and longitudinal arches of the foot. These injuries can be missed, as radiographic findings are often subtle, and the sprain of the ligaments may not be identified without a weight-bearing anteroposterior film. Comparison films of the opposite foot are helpful in subtle injuries. Radiographs reveal a diastasis between the first and

Cuboid subluxation

Acute cuboid subluxation may occur with ankle sprains. The repetitive motions used rising up to and down from the on pointe position are associated with this injury when it is from overuse. The dancer will complain of lateral midfoot pain and an inability to roll through the foot correctly to achieve demi-pointe or the full pointe position. Some are unable to bear weight in acute injuries. Tenderness is usually on the plantar surface of the cuboid. Mobility of the transverse tarsal joints is

Ankle sprains

Ankle inversion injuries are the most common traumatic injuries in dancers. Improper jump landings and rolling over the lateral aspect of the foot while on demi-pointe are the usual mechanisms of injury. In both cases, the ankle is in plantar flexion. As with other athletes, the dancer's anterior talofibular ligament is the most frequently injured. Previous ankle sprain is the greatest risk factor for ankle sprain injury.

Dancers will complain of swelling and lateral ankle pain. If the dancer is

Posterior ankle impingement

Posterior ankle impingement is a painful condition of the posterior ankle, caused by compression of the tissues between the posterior edge of the tibia and the calcaneus when the foot is placed in extreme plantar flexion. Posterior impingement pain in the ankle may be the result of a posterior bony block of an accessory bone of the ankle, the os trigonum, or of a prominent posterior lateral process of the talus (Stieda's process). Fractures of the posterior lateral process of the talus also can

Flexor hallucis longus tendinitis

Often called dancer's tendinitis, FHL tendinitis is common in dancers. It has been described in other athletes, but it is seen most frequently in the female ballet dancer. A biomechanical study demonstrated that the muscles crossing the metatarsophalangeal joints work 2.5 to three times harder than those crossing just the ankle joint in dancers rising on to the full pointe position, placing these muscles and tendons (FHL, flexor digitorum longus [FDL]) at risk for overuse injuries [40]. The

Achilles tendon

Chronic Achilles tendinosis may be seen in male and female dancers. Dancers who force their turnout, leading to increased pronation in the midfoot and hindfoot, are at risk for Achilles tendon problems. Failure of the dancer to land with his or her heels on the ground from jumps also can contribute to shortening of the Achilles tendon and risk for injury. Ballet dancers may need adjustment of tight ribbons around the ankle, or the use of ribbons with elastic sewn in the area over the tendon.