Author: Maggie Lorraine on behalf of the IADMS Education Committee 

Perfecting the art of dance requires long hours of intensive training over many years with constant repetitions of exercises to refine and perfect the execution of sequences and movements. Dance places high demands on the body and for this reason professional dance training institutions often include physique testing, conducted by the resident physiotherapist as part of the audition process. Subsequently even the physiques that are deemed “ideal” for training at a pre professional level are at risk of injury as a result of faulty alignment and technique. In recent years the quest for greater virtuosity in performance has added an extra layer of risk to the aspiring young dancer who is hoping to achieve a career in dance. Issues such as more intrusive stretching techniques to achieve higher extensions of the leg, bigger and higher jumps with added complexity, more virtuosic turns and particularly greater engagement of the spine in movement. These trends have all added to the necessity for dance teachers to have a comprehensive knowledge of human anatomy, physiology and kinesiology. This knowledge will give teachers the information to guide their students to reach their full potential and to avoid sustaining injuries. 

No dancer is immune to the possibility of injury, however the young dancer who is experiencing a growth spurt is at the greatest risk. Whilst growing, a child’s bones are more susceptible to issues, since as the bones lengthen the growth places stress on the muscle tendon unit and consequently the young dancer at a higher risk for stress fractures and fractures. 

Building from our previous posts on the foot’s skeletal and muscular structure, this article focuses on the foot and issues that arise from faulty biomechanics, technique and resulting from over pronation of the feet. 

Incorrect turn out of the legs and feet often results in over pronation or “rolling “of the foot and ankle. To make up for inadequate mobility at the hip, dancers often rely on the rotation of the knee, and ankle to achieve the desired 180-degree turn out of the feet. This problematic mode of movement compromises the control of the rotation of the leg in the hip socket and the efficient recruitment of the deep rotator (turn out) muscles which assist in the stabilizing muscles of the legs and pelvis. Maintaining alignment, stability, strength and control is difficult to achieve whilst dancing with torsion of the knee, and pronated foot. When the foot is pronated the weight of the body falls through the unaligned joints of the knee and ankle creating an increased torque of the medial (inner) arch and ankle and poor intrinsic foot muscle control (see photograph above). 

When there is poor intrinsic muscle strength in the arch of the foot, foot pain may occur. The intrinsic foot muscles are the tiny muscles, which contribute to control a ballet dancer's arch. If the muscles are not working effectively, larger muscles known as the extrinsic foot muscles, which originate on the leg and cross over the ankle joint, become overused. 

Over-pronation of the feet can lead to a number of problematic conditions, which contribute to foot pain and may cause conditions such as bunions, hallux rigidus, plantar fasciitis, and sesamoiditis. 

Unfortunately bunions can be common in dancers. They begin to develop in young dancers who do not have the muscle recruitment in place to support the growing bones. Both male and female dancers are at risk from the increased stress on the medial column of the foot as a dancer attempts to achieve greater turnout from the knee and ankle. Some bunions (or hallux valgus) are hereditary, however dancers may develop them as a result of forcing turn out with little to no intrinsic muscle control. Tight fitting shoes and pointe shoes may also contribute to bunions as the shoes narrow to the pointe and the foot is broadest across the metatarsals. Squeezing the toes into narrow pointe shoes put pressure onto the big toe joint which is exacerbated by carrying the weight of the body on the tiny surface of the shoe en pointe. 

Repeated strain on the big toe joint may result in hallux rigidus or stiffness of the big toe. Dancers 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.  

Metatarsalgia is an overuse injury and the term describes pain in the ball of the foot, which usually develops over months. High impact activities such as jumping without sound foot control and abnormal weight distribution on the foot can result in this injury. Although this injury is not solely a result of hyperpronation, the reduced foot control resulting from poor intrinsic strength will be a contributing factor. 

Sesamoiditis is another condition where pain is often felt in the ball of the foot and is a result of excessive pressure on the forefoot. The sesamiod bones are two tiny bones within the flexor hallucis longus (FHL) that run to the big toe and when a person has sesamoiditis the tendon become inflamed. Dancers, who alternate between extreme plantar flexion and dorsiflexion rely on the flexor hallucis longus (FHL) for dynamic stability of the foot during these movements and they may be particularly susceptible to this condition. Other causes can be an increase in activity, having a foot with a high arch or a bony foot (with insufficient fat to protect the tiny bones) and also stress fractures. Most frequently dancers with sesamoiditis have an imbalance of FHL vs. gastrocnemius/soleus {calf muscles} and FHL vs. intrinsics. 

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 each time the foot is used, and is prone to overloading 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 and it is known as plantar fascilitis. 

This article has focused on foot injuries, which may result from faulty biomechanics of the foot in dancers. 

Forcing turn out from the foot and ankle instead of at the top of the leg at the hip joint results in faulty alignment and poor muscle recruitment. Dancers require strong intrinsic muscles of the feet, which are imperative for aligned foot control against the ground in repetitive movements of the foot, pointe work and jumping. Without this control of the foot the dancer is at risk of injury. 

The next article in this series will examine issues resulting from incorrect stretching of the foot and faulty biomechanics of rising to demi pointe and pointe.

Maggie Lorraine

Resources

The following IADMS link provides an excellent training program for dancers:

• Turnout for Dancers: Supplemental Training
• Feet: Skeletal and Muscular Structure
• Resource Paper: The challenge of the Adolescent Dancer

Follow these links for more information:

YouTube - 1

YouTube - 2 

Further reading:

Grossman G, Krasnow D and Welsh TM. Effective use of turnout: biomechanical, neuromuscular, and behavioral considerations. Journal of Dance Education 2005; 5(1): 15-27.

Jeffrey A. Russell, PhD, ATC. Breaking pointe: Foot and ankle injuries in dance.

Maggie Lorraine is the Leading Teacher in Ballet at the Victorian College of the Arts Secondary School and is a member of the IADMS Education Committee.