Authors: Gabrielle Davidson and Maggie Lorraine on behalf of the IADMS Education Committee 

In Part 1 of “Stretching the Pointe” we discussed some issues that may arise as a result of incorrect use of the foot and faulty foot alignment in training.

Anatomical information about the foot is available in previous blog posts here.

In discussing the foot and the dancer, there are a few specific injuries and conditions that need to be taken into account to further strengthen the argument for ensuring correct alignment and muscle activation when teaching young dancers how to pointe their feet. 

One of the most common of these injuries is posterior impingement of the ankle. This is when tissues at the back of the ankle are inflamed and prevent full ankle range into plantarflexion (pointing, demi pointe or pointe). This can either be due to compression of the soft tissues between the posterior edge of the tibia, the talus bone and the superior calcaneus [1] or irritation of the tendon sheath of the FHL (flexor hallucis longus- the muscle that controls the big toe into plantar flexion- full pointe)[4]. Posterior impingement and FHL tenosynovitis can go hand in hand and are often caused by the repetitive nature of dancers rising to demi pointe and pointe, and also pointing their feet [5]. It is thought that poor coordination of the lower leg and intrinsic foot muscles can exacerbate this condition. The condition can also arise after a sprained ankle and forced plantar flexion injuries, and in some cases has also been attributed to the presence of an os trigonum, a small bone that sometimes develops behind the ankle bone (talus bone). The os trigonum is a normal part of the ankle anatomy but sometimes fails to fuse with the talus therefore creating a small ‘extra’ bone in the ankle, and this can sometimes increase the effect of posterior impingement [1,3]. 

FHL tenosynovitis is frequently seen in female ballet dancers. It has been called “dancer’s tendinitis” but research has found that the condition is rarely a pathology of the tendon itself but of the sheath surrounding the tendon [1,2,3]. As mentioned above it can be part of the posterior impingement syndrome. The flexor hallucis longus muscle originates from the back of the fibula (outer lower leg bone/ lateral lower leg bone), then travels down along the inside of the lower leg and ankle where it inserts into the base of the big toe via the tendon. Its primary role is to flex the big toe assisting to pointe the foot (into plantar flexion), stabilise the foot and ankle as the dancer rises to demi pointe, and assist the foot to rise to full pointe [4]. 

The repetitive change in foot position from full plantar flexion (on pointe position) to full dorsiflexion (plié position) can cause this FHL tendon sheath to become inflamed [5], especially if it is not being supported by the other ankle and intrinsic foot muscles. 

The repetitive loading of bones, especially in the feet, in activities such as fouettés (repetitive plantar flexion action of one foot on and off pointe) or landing from a series of repetitive jumps may cause bony stress. This is when loading of the bone outweighs its ability to recover and remodel, therefore leading to weakening of the bone structure itself and the resulting stress reactions or fractures [6,9]. 

Dancers are susceptible to a unique fracture at the base of the second metatarsal called the “dancer’s fracture” that is rare in other athletes and possibly as a result of the demi pointe and pointe work they carry out whilst dancing [5,7]. Controlling the amount of load a dancer is undertaking and controlling the rate at which this is increased, as well as making sure they have sufficient muscle support in both their feet and ankles will always help to reduce the risk of these overuse injuries. 

Injuries to the mid foot in dancers while rare, can be debilitating [5]. The mid foot comprises the navicular, cuboid and three cuneiform bones. It stabilises the arch and transfers the forces generated by the calf, to the front of the foot during the stance phase of gait, so in dance terms this is whenever the dancer moves through their feet either rising or jumping. Acute cuboid subluxation may occur with ankle sprains, overuse of the peroneal muscles during repetitive movements such as rising up and down from pointe and excessive pronation of the foot, although the precise mechanism has not been proven [8]. Stress fractures and fractures of the navicular bone can be a career ending injury for a dancer. 

Lisfranc injuries are injuries that occur to any part of the articulations of the 5 long metatarsal bones with the tarsal bones. These bones are connected by thick plantar ligaments (found on the underside of the bones) and strengthened by the tendons of tibialis posterior, peroneal tendons as they wrap under the foot and tibialis anterior tendon over the top of the arch. The Lisfranc ligament is the only ligament that binds the first and second metatarsal bones [8]. The mechanism of injury to this area in dancers may result from trauma to the foot of the female dancer when performing advanced pas de deux choreography where the edge of the pointe shoe sticks against an irregular floor surface when being slid along the foot by her partner. It can also occur from missed jump landings, during pirouettes/spins or during take-off for a jump [5]. 

Of course there are many more injuries that can occur in the course of a young dancer’s life but these are just a few of the main ones seen in the feet and ankles, some of which can be reduced with particular technique training and attention given to the development of specific muscle activity in the calves and intrinsic muscles of the feet, as mentioned in the previous blog post from the Education Committee. 

The biggest message for young dancers, is to not allow pain to continue for too long. Seek treatment earlier rather than later to prevent too much time out of the studio and take heed of exercises and advice given by health professionals as their aim will always be to get you back dancing as soon as possible and for as long as possible. 

Gabrielle Davidson and Maggie Lorraine
B.PHTY(HONS)             Leading teacher at the Victorian College of the Arts Secondary School 

References:

[1] Russell J.A., Kruse D.W., Koutedakis Y., McEwan I.M., Wyon M. Pathoanatomy of posterior ankle impingement in ballet dancers. Clin Anat. 2010;23:613–621. 

[2] Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers. J Bone Joint Surg Am 1996; 78 (10): 1491-1500. 

[3] Peace,KA., Hillier, JC., Hulme,A., Healy, JC. MRI features of Posterior Ankle Impingement Syndrome in Ballet Dancers: A Review of 25 Cases. Clinical Radiol 2004: 59:1024-1033 

[4] Kirane,YM., Michelson,JD., Sharkey, NA. Contribution of the Flexor Hallucis Longus to Loading of the First Metatarsal and First Metatarsaophalangeal joint. Foot Ankle Int 2008; 29(4):367-377 

[5] Kadel,N MD. Foot and Ankle Problems in Dancers.Phys Med Rehabil Clin N Am 2014; 25: 829-844 

[6] Davidson, G., Pizzari,T., & Mayes, S. The Influence of Second Toe and Metatarsal Length on Stress Fractures at the Base of the Second Metatarsal in Classical Dancers. Foot and Ankle International 2007;28: 1082-1086 

[7] Micheli, L. J., Sohn, R. S., & Solomon, R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am, 1985; 67(9), 1372-1375. 

[8] emdedicine.medscape.com. Lisfranc Fracture Dislocation Trevino, SG., Early, JS., Wade, AM., Vallurupalli, S., Flood, DL 

[9] Mayer, SW MD., Joyner, PW MD., Almekinders, LC MD., Parekh, SG MD MBA. Stress Fractures of the Foot and Ankle in Athletes. Sports Health 2015: 6(6), 481-557.  

Kadel, N. J. Foot and ankle injuries in dance. Physical medicine and rehabilitation clinics of North America 2006; 17(4), 813-826. 

O'Malley, M. J., Hamilton, W. G., Munyak, J., & DeFranco, M. J. Stress fractures at the base of the second metatarsal in ballet dancers. Foot & ankle international 1996; 17(2), 89-94. 

An interesting video, which highlights the horror for a dancer of a career threatening injury: Portrait of a Dancer: Lauren Cuthbertson