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Bunions in Ballerinas: it’s not really the shoes!

Posted By Megan Maddocks, Monday, February 27, 2017

I have bunions, two in fact. They were never a problem while I danced, but they got worse when I stopped. As a podiatrist, this made me curious about the relationship between pointe shoes and bunions (more accurately called hallux valgus). Below is a brief summary of a literature review I presented at the 2016 annual IADMS conference in Hong Kong, outlining some extrinsic risk factors unique to female ballet dancers.

 

Hallux valgus (HV) is a common1 and complex deformity2. Being particularly common to dancers 3–9, it is believed that dancing plays a role in the cause and development of HV 10–12, however much research suggests that dancing is not a likely cause of HV 11–13.

 

COMMON MISCONCEPTIONS

It has been shown that the average number of dancing hours per week 3,14, hours of pointe work per week 3,14, total years of doing pointe work3 and the age of starting pointe3 are not significantly associated with HV in the dancer 3. Also, the intensity of practice (professional vs recreational) is not predicting variable for HV 3 and an increased Beighton (hypermobility) score, which most dancers have, has not been associated with HV10.

 

HV is mostly related to anatomical hereditary factors and to incorrect technical execution, rather than to the amount of dancing hours, with or without pointe shoes. 3,14

 

TRAUMA

Apart from rupture of the medial ligament of the big toe joint (first metatarsophalangeal joint – 1st MTPJ)3,14 from an incorrect landing or unexpected accident, there is substantial microtrauma to the joint from the hard pointe shoe box15.

 

FOOTWEAR

Constrictive Footwear

There is currently not enough evidence to implicate footwear in the development of HV 1,16. HV has been reported in populations that don’t wear shoes 1,17.         

 

Dance Footwear:

Ballet Flats

Ballet pumps are chosen to fit tighter and tighter as girls get older, eventually fitting more like a glove than a shoe18. They are fitted, like pointe shoes, when the foot is non-weight bearing and pointed 18, ignoring the fact that the foot expands on weight bearing, resulting in the toes being squished together and increasing the tension on the inside of the big toe joint (1st MTPJ).

 

The Pointe Shoe

The bottom end of the box (block), on which the dancers bear weight, is flat, whereas the pointed toes do not form a straight line, resulting in the longest toe, usually the big toe (hallux), supporting the majority of the body’s weight when en pointe19.

                                                                                                              

Inappropriate pointe shoe fit could exacerbate HV formation1,19: an overly narrow, short or soft toe box, results in the toes being squashed, increased tension on the big toe joint (1st MTPJ) and a general lack of support of the foot, (Fig.1). Proper pointe shoe fit is recommended to prevent or delay HV deformity, especially in the predisposed dancer1.

Fig. 1 – Foot structure change in a pointe shoe that is too narrow, created by M Maddocks

 

DANCE TECHNIQUE

All turnout must be from the hip 6,18, however, it may be augmented at the knee, ankle, and foot 1,6,15,20. These forced turn out positions may result in pronation of the foot, with abduction of the big toe (points toward 2nd toe) and an increase valgus force on the joint 1,3,6,7,13–15,20, (Fig. 2). When the foot is frequently forced into exaggerated “turnout”, the supporting ligaments and tendons on the bottom and medial side of the foot and ankle may be lengthened and cause them to lose their ability to support the ankle joint and the arch of the foot 3,14,15,21

Fig.2 – Hyperpronation / Rolling in : foot compensation for poor turnout at the hip, From Davenport1

 

It has been show that ankle plantarflexion is associated with HV3, and the average ankle plantarflexion (pointed foot) in professional female ballet dancers is 113°, which is more than twice the normal value of 50° 22. The combination of maximal ankle plantar flexion and an “over-pointed” foot may accelerate the progression of hallux valgus and exacerbate the symptoms 3.

 

 A small degree of ‘‘winging’’ (Fig. 3) can add to the aesthetic alignment of the line of the leg, however, an excess of pressure is applied through the first toe, particularly in a pronated foot 1,13. Hyperpronation or excessive “winging” of the foot while en pointe or demi-pointe may also result in microtrauma of the big toe joint (1st MTPJ)1.

 

 Proper technique may prevent excessive loads on the big toe joint (1st MTPJ), which in turn may reduce the incidence of bunions.13

 

Fig. 3 – Winging: a technique fault in which the feet are forced outward or abducted at the ankles (Photographer: Darian Volkova)

 

Teacher Influence

Teachers should constantly strive to see that the leg and foot turn out as a unit from the hip18,21. Every effort should be made to control or avoid compensatory foot hyperpronation, as well as excessive winging, as it may increase the risk of hallux valgus development 1,6,18,21.

 

CONCLUSIONS

The unique positions and postures used in classical ballet are all potentially dangerous for the foot and leg6,18, with unique and increased forces through the big toe joint (1st MTPJ) and the foot while in extreme positions 1,3,5.

If that isn’t bad enough, the pointe shoe is the antithesis of everything that we, as podiatrists, know about footwear 18. Shoes for ballet dancers are not made for health 18, yet “dancer’s feet are the instruments on which their art depends”13.

Pointe shoes are definitely not protective of HV development 1, and it is almost impossible to prevent HV formation in an individual who is genetically predisposed18, but the evidence is not sufficient to conclude that pointe work causes HV1.

Dancers, like the rest of the population, are either prone to developing bunions or not 10,13,20. However, dancers are at high risk of developing hallux valgus as they have increased exposure to risk factors. Dancer’s at risk of developing HV need to be identified as early as possible and need to be managed conservatively with focus on good technique to reduce dance and non-dance biomechanical risk factors 3,6,13,23.

 

Megan Maddocks – Promotions Committee

Podiatrist – South Africa

 

 

REFERENCES

1.        Davenport KL, Simmel L, Kadel N. Hallux Valgus in Dancers: a closer look at dance technique and its impact on dancers’ feet. J Danc Med Sci. 2014;18(2):86-93.

2.        Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013;52(3):348-54. doi:10.1053/j.jfas.2013.01.006.

3.        Steinberg N, Zeev A, Dar G, et al. The Association between Hallux Valgus and Proximal Joint Alignment in Young Female Dancers. Int J Sports Med. 2015;36:67-74.

4.        Clippinger K. Dance Anatomy and Kinesiology.; 2007.

5.        Miller H, Schneider HJ, Bronson JL, McLain D. A New Consideration in Athletic Injuries: THe Classical Ballet Dancer. Clin Orthop Relat Res. 1975;(111):181-191.

6.        Kravitz SR, Huber S, Murgia C, Fink KL, Shaffer M, Varela L. Biomechanical Study of Bunion Development and Stress Produced in Classical Ballet. 1Journal Am Podiatr Med Assoc. 1985;75(7):338-345.

7.        Howse J. Disorders of the Great Toe in Dancers. Clin Sports Med. 1983;2(3):499-505.

8.        Baxter DE. Treatment of Bunion Deformity in the Athlete. Orthop Clin North Am. 1994;25(1):33-39.

9.        Schneider HJ, King AY, Bronson JL, Miller EH. Stress Injuries and Developmental Change of Lower Extremities in Ballet Dancers. Radiology. 1974;(113):627-632.

10.      Prisk VR, Loughlin PF, Kennedy JG. Forefoot Injuries in Dancers. Clin Sports Med. 2008;27:305-320. doi:10.1016/j.csm.2007.12.005.

11.      Einarsdottir H, Treoll S, Wykman A. Hallux Valgus in Ballet Dancers: A Myth? Foot Ankle Int. 1995;16(2):92-94.

12.      Kennedy JG, Hodgkins CW, Colombier J, Guyette S, Hamilton WG. Foot and ankle injuries in dancers. Int Sport J. 2007;8(3):141-165.

13.      Kennedy JG, Collumbier JA. Bunions in Dancers. Clin Sports Med. 2008;27:321-328. doi:10.1016/j.csm.2007.12.004.

14.      Biz C, Favero L, Stecco C, Aldegheri R. Hypermobility of the first ray in ballet dancer. Muscles Ligaments Tendons J. 2012;2(4):282-288.

15.      van Dijk C, Lim L, Poortman A, Al. E. Degenerative joint disease in female ballet dancers. Am J Sport Med. 1995;23(3):295-300.

16.      Nix SE, Vicenzino BT, Collins NJ, Smith MD. Characteristics of foot structure and footwear associated with hallux valgus: A systematic review. Osteoarthr Cartil. 2012;20(10):1059-1074. doi:10.1016/j.joca.2012.06.007.

17.      Zipfel B, Berger LR. Shod versus unshod: The emergence of forefoot pathology in modern humans? Foot. 2007;17:205-213. doi:10.1016/j.foot.2007.06.002.

18.      Tax H. Ballet. In: Podopaediatrics. 2nd ed. Baltimore: Williams & Wilkins; 1985:401-419.

19.      Colucci LA, Klein DE. Development of an Innovative Pointe Shoe. Ergon Des. 2008.

20.      Shrader KE. Biomechanical evaluation of the Dancer. Orthop Phys Ther Clin North Am. 1996;5(4):455-475.

21.      Ahonen J. Biomechanics ofthe Foot in Dance: A Literature Review. 2Journal Danc Med Sci. 2008;12(3):99-108.

22.      Russell J a, Shave RM, Kruse DW, Koutedakis Y, Wyon M a. Ankle and foot contributions to extreme plantar- and dorsiflexion in female ballet dancers. Foot ankle Int / Am Orthop Foot Ankle Soc [and] Swiss Foot Ankle Soc. 2011;32(2):183-188. doi:10.3113/FAI.2011.0183.

23.      Weiss DS, Rist RA, Grossman G, Ed M. When Can I Start Pointe Work? Guidelines for Initiating Pointe Training. J Danc Med Sci. 2009;133:90-92.

Tags:  bunions  dancers  foot 

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Stretching the Point: Part 2

Posted By Gabrielle Davidson and Maggie Lorraine on behalf of the IADMS Education Committee, Wednesday, August 24, 2016

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 videowhich highlights the horror for a dancer of a career threatening injury:

Portrait of a Dancer: Lauren Cuthbertson

 

 

Tags:  dancers  foot  injury  teachers 

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Stretching the Point

Posted By Maggie Lorraine on behalf of the IADMS Education Committee, Monday, August 15, 2016

Learning how to bend the knees and point the feet may be the first movements that dance students learn. It is sobering to consider that both of these movements are potentially harmful if not executed correctly and practiced in perfect alignment.  Experienced teachers of children and young people often notice that by encouraging students to “stretch” their feet rather than “point”, they are less likely to crunch their toes. Crunching results in a “shortened” line of the foot. On the other hand, “stretching” encourages the students to lengthen the leg through to the ankle and arch of the foot.  Anatomically speaking we are talking here about plantarflexion of the ankle of course, although this actual term is seldom used in a teaching context.


 

The pointed or stretched foot is the image that we so closely identify with classical ballet and arguably the control of the stretched foot whilst dancing is one of the skills that may take the longest to master.  It requires repetition throughout the dancers’ training to ensure sound alignment.  When teaching young children to dance it is important to consider the bone development of the body, which is called ossification. The completion of growth in a tubular (long) bone is indicated by the fusion or closure of the epiphyses (growth plates), located at each end of the long bone.  The long bones of the feet are the metatarsals – full anatomical information about the foot is available in previous blog posts hereThe final epiphysis to close does so at an average age of 16 years in boys and 14 years in girls (1). Of course, dancing can place added stress on growing bones and negligent dance training may also affect the development of the bony structures - repetitive trauma in training and increased impact due to poor biomechanical alignment can cause the epiphyseal plate to widen, rather than close (2).

 

It is acknowledged that foot and ankle injuries are the most prevalent injuries in classical ballet in both the student and professional population (3). The extreme position of the foot and ankle when dancing on demi pointe, (see illustration b) where the ankle is in full plantarflexion, the body weight is distributed on the ball of the foot, or en pointe, where the dancer is on the tips of her toes (see illustration c), the weight of the body is carried through the ankle joint, and the longitudinal axis of the foot may put the dancer at risk of injury.  Poor training, alignment, and faulty technique are all contributing factors to injury. Dancers, like athletes, are prone to common overuse injuries but they are also vulnerable to unique injuries, due to the extreme demands of ballet.

 

 

Teaching students how to align their feet and ankles, avoiding the urge to sickle (invert) or fish or wing (evert) when stretching their feet, and also ensuring that they do not crunch their toes (in an attempt to achieve the illusion of a high arch) will hopefully assist the student in avoiding serious foot problems. These issues will be exacerbated when the dancer rises on demi or full pointe. The control of the ankle when rising in an aligned position is a strengthening action.  However, when the ankle and foot is not aligned the action of weight bearing is potentially injurious.

 

 

Frequently students crunch their toes in an attempt to point their feet harder and consequently this action contracts the muscles of the foot causing the joints of the foot and ankle to compress.  Unfortunately, due to the students wearing shoes, the teacher does not always notice this problem, and the repetitive action possibly results in weakness in the intrinsic foot muscles and overuse of the extrinsic foot muscles, though this reasoning needs to be investigated scientifically. The issue sets up a pattern in the use of the foot that results in the toes crunching both when rising on demi pointe.  Strengthening the intrinsic foot muscles could potentially enable the middle joint of the toes to remain lengthened while stretching the foot. Research groups around the world are currently investigating just such possibilities and continually present their progress at annual IADMS conferences.


As teachers, we know that the habits that are developed in early training always affect the student in later years when greater complexity of training is introduced. Setting up the pattern amongst our students that they should strive to hold their feet evenly on the floor and keep their toes stretched out along the surface of the floor will help. While the feet are bearing the body’s weight they should be holding the ground at three points - one behind the back of the heel, and two in front of the heads of the first and fifth metatarsals. This triangle forms a base from which the muscles and soles of the feet can work to support the arch and align the feet. Potentially this will assist in the recruitment of the intrinsic foot muscles.

           

The intrinsic muscles are like the “core” muscles of the foot.  Because they are deep and don’t cross over too many joints, they can work well in stabilizing and protecting the arch and structures within the foot.  If the foot intrinsic muscles are weak, the foot structures are more prone to increased stress and injury.  Strengthening the intrinsic muscles of the foot is good for people with foot injuries and for those looking to prevent injury”(4).

 

Supporting the arches whilst standing all helps in ensuring strong, adaptable feet for dancing.

 

 

The extreme positions created when dancing on pointe are particularly hazardous if the body and foot are not physically ready to deal with the weight of the body on pointe. IADMS has produced a really useful guide to point readiness available here.

 

In conclusion movement habits practiced in early training can have a profound effect on the young dancer’s development and their potential for injury.  By laying the foundation of sound alignment the teacher will empower the student to achieve their goals with reduced potential for injury.  Celia Sparger describes it well: 

           

"It cannot be too strongly stressed that pointe work is the end result of slow and gradual training of the whole body, back, hips, thighs, legs, feet, co-ordination of movement and the 'placing' of the body, so that the weight is lifted upwards off the feet, with straight knees, perfect balance, with a perfect demi-pointe, and without any tendency on the part of the feet to sickle either in or out or the toes to curl or crunch. “

 

The IADMS Education Committee will post a follow up article describing possible foot and ankle conditions and injuries that may impact on the dancer written by Gabrielle Davidson who is the Physiotherapist of the Dance Department at the Victorian College of the Arts Secondary School.

 

Maggie Lorraine

Leading Teacher in Ballet at the Victorian College of the Arts Secondary School. Australia.

Member of the IADMS Education Committee

 

References

(1) Weiss, D., Rist, R. and Grossman, G. Guidelines for initiating pointe training.  IADMS Resource Paper, 2009.  Available here.

 

(2) Laor T, Wall EJ, Vu LP. Physeal widening in the knee due to stress injury in child athletes. AJR Am J Roentgenol. 2006; 186(5): 1260–1264.

 

(3) Foot and Ankle Injuries in Dance.  Physical Medicine and Rehabilitation Clinics of North America December 2006.  

 

(4) Amy McDowell, P.T From ARC Physical Therapy Blog

 

Further resources

Common Foot and Ankle Ballet Injuries

Dancing Child: Foot Development and Proper Technique

 

Micheli, L. J., Sohn, R. S., & Solomon, R. (1985). 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, 67(9), 1372-1375.

 

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

 

Wiesler, E. R., Hunter, D. M., Martin, D. F., Curl, W. W., & Hoen, H. (1996). Ankle flexibility and injury patterns in dancers. The American journal of sports medicine, 24(6), 754-757.

 

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

 

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

Tags:  dancers  foot  teachers  toes 

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Foot Injuries in Dancers. Are they preventable?

Posted By Maggie Lorraine on behalf of the IADMS Education Committee, Wednesday, July 6, 2016

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

 

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.

Tags:  dancers  feet  foot  injury  prevention  teachers 

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Feet: Skeletal and Muscular Structure

Posted By Elsa Urmston on behalf of the IADMS Education Committee, Tuesday, April 5, 2016

Over the next few months the Education Committee bloggers shine a light on the importance of the feet.  In June, Maggie Lorraine will write a two-part blog which focuses on potential foot injuries, structural issues, and working with them in dance.  We look forward to her insight.  By means of introduction to this topic, this short blog provides an introduction to the foot’s skeletal and muscular structure.



We all know that tired feeling in our feet at the end of a busy dancing day, don’t we?  They ache, they click, and let’s face it, dancers’ feet aren’t always the prettiest of things!  We look down at our bruised feet and hard skin, massage our insteps, and slather on moisturizer in an attempt to keep them as pliable as possible.  And no wonder, they work hard and we ask a lot of them!!

 

But what do you know about the structure of the foot?  It’s a hugely complex skeletal structure, comprising 26 bones, 34 joints and more than 100 muscles1, tendons and ligaments, all arranged to be weight-bearing in all sorts of different contexts from pointe to heeled shoes, from sliding across the floor in bare feet to taking off and landing on all surfaces of the foot.  And of course, the foot contributes to that sought-after, beautiful line from the toes and arch of the foot and into the rest of the lower leg in an arabesque.  Most importantly the foot is designed to create resilience and acts as a shock-absorber to the rest of the body. As Russell2 explains, “the foot’s structure, with its many bones intricately fitting together, provides a dynamic platform on which to support the body. The foot’s adaptability to the floor or ground, regardless of whether or not it is encased in a shoe, is what starts the process of pushing off the floor, absorbing shock when landing from a jump, changing direction in turns, and providing a surface on which to spin, to name a few of the foot’s functions important to dance.”

 

There are many super resources online which can help you learn the various bones and joints of the foot for example here and here, plus this interactive tutorial: Foot Anatomy Tutorial.

 

We provide a simple diagram here.



The foot can be divided into the posterior and anterior sections.  The ankle joint itself (a synovial hinge joint) is formed between the distal ends of the tibia and fibula and the talus where plantarflexion (pointing) and dorsiflexion (flexed foot) occurs.  The seven tarsal bones including the talus then make up the posterior portion of the foot, nearest to the heel, or calcaneus.  Each tarsal bone is roughly square in shape with flat articular surfaces and together the surfaces glide past each other to provide lateral stability just below the ankle joint itself; they contribute hugely to subtle changes in balance and it is here that inversion (sickling) and eversion (winging) can occur.  The five metatarsals and fourteen phalanges comprise the anterior section of the foot, extending away from the ankle joint itself down towards the toes.  These bones act as levers, alongside the muscular system of the lower legs and feet to allow the dancer to come up onto demi-pointe and ultimately to jump and locomote.

 

The skeletal structure of the foot also creates the longitudinal and transverse arches of the foot which are vital to spread the dancer’s weight across the whole foot.  The arches absorb shock from the ground in landing from a jump which is why it is so important for dancers to maintain strong, articulate feet.  The arches are reinforced by the ligament system and power is achieved by the muscles working on the joints to create motion through the foot’s resilient dome-like structure.

 

As you’d expect, the muscular system of the foot is also complex! They can be divided into two groups; extrinsic and intrinsic muscles.  The extrinsic muscles arise from the anterior, posterior and lateral areas of the lower leg and are mainly responsible for actions such as plantarflexion, dorsiflexion, inversion, and eversion.  The intrinsic muscles are responsible for more fine motor control actions such as the adaptation of the foot to the body’s weight and balance and the movement of individual toes.  These intrinsic muscles are layered through the foot to achieve the precision and intricate demands that dancers place on their feet – no wonder our feet and ankles fatigue!  These two great tutorials are a great interactive introduction to the musculature of the feet.

 

Intrinsic Muscles of the Foot: Dorsal Muscles

 

Intrinsic Muscles of Foot:  Plantar Muscles

 

 

So, the balance between strength and flexibility is of paramount importance in the dancer’s foot.  When it is achieved we are able to power through space, travelling with height, speed, and dexterity.  The simple directive of ‘using the floor’ is familiar to many of us.  Building strength and articulation can be achieved through emphasising the stroking of the sole of the foot on the floor in tendu and degagé, leaving the heel until last as the foot extends away from the body, and lowering it first as the foot closes back in.  This pressing of the foot into the ground strengthens the intrinsic muscles of the foot whilst also rehearsing the action of pushing into the ground to propel the body in a specific direction - fabulous conditioning exercise and a cornerstone of many dance techniques.  For more inspiration see The Royal Ballet’s class broadcast in 2014, a series of tendu exercises feature from about 6 minutes from the start of the video.

 

But what if strength and flexibility of the foot structure is compromised either through poor posture or dynamics in alignment of the body, or indeed due to an acute injury sustained whilst dancing? Our forthcoming posts will tackle these issues in June 2016.

 

 

References

 

1.  Clippinger, K.  The ankle and foot, Dance anatomy and kinesiology. Human Kinetics, 2007, 297-371.

 

2.  Russell, J.  Insights into the Position of the Ankle and Foot in Female Ballet Dancers En Pointe.  The IADMS Bulletin for Dancers and Teachers, 6(1), 2015, 10-12.  Available here.

 

 

Elsa Urmston, MSc, PGCAP, AFHEA, is the DanceEast Centre for Advanced Training Manager, Ipswich, UK and a member of the IADMS Education Committee.  She also sits on the One Dance UK Expert Panel for Children and Young People.
Email: elsa.urmston@danceeast.co.uk

 

Tags:  anatomy  feet  foot 

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