Common Foot and Ankle Injuries in Ballet

Dance is a unique art form that requires athleticism intertwined with grace and musicality. The unique bodily positions and maneuvers that dancers execute are physically demanding, and many dancers have undergone years of training to be able to move their joints in extreme ranges. As a result, foot and ankle injuries (FAI) are notoriously common in the dance community as much of the locomotion that dancers perform stem from the grounding of the feet (Vosseller et al., 2019). There are a variety of dance styles that all demand different types of foot and ankle positioning and flexibility. Ballet dancers who are en pointe, or wearing pointe shoes to dance on their toes, are especially affected by FAI compared to dancers of other styles (Wanke et al., 2013). Thus, much of the medical literature regarding FAI has been written about the injuries acquired through ballet movements. In this article, we will discuss the types of FAI that are widespread in ballet, describe their nuances as well as the treatments and therapies used to heal these injuries.

FAI injuries acquired from delicate ballet movements can occur through a plethora of ways. In general, the two main culprits are the constant shifts between forced maximum weight bearing dorsiflexion (fig. 1)  and forced maximum weight bearing plantar flexion (fig. 2) in addition to incorrect jump kinematics (Vosseller et al., 2019; Hansberger, 2018). There are two different categories of FAI: acute traumatic injuries and chronic injuries. Acute traumatic injuries are severe and are characterized by sudden onset due to falls, incorrect lands, twists, etc. Chronic injuries, on the other hand, result from the constant and repetitive pressure placed on the ankles and feet, or the microtrauma due to persistently poor dance technique (Hillier, 2004; Kadel, 2014).

Common acute traumatic injuries include ankle sprains and metatarsal bone fractures. Ankle sprains are frequent and are usually less serious than other FAIs. Sprains happen when the ankle is twisted, rolled or turned in a way that causes one or more ligaments to be torn or stretched (Vosseller et al., 2019). In many cases, sprains in ballet result from landing incorrectly from a jump or finishing a turn sequence with an unusual foot stance. Fractures, on the other hand, are more serious and detrimental. Dancers experience FAI fractures primarily in the ankles and metatarsal (foot) bones, the latter of which is typically caused by constant pressure on the second metatarsal bone during the plie position (fig. 1) (fig. 3) (Hillier 2004).

Common chronic injuries consist of impingement syndromes, osseous pathologies (irregular bone alignment), and tendon and ligament abnormalities. Impingement syndromes of the ankle are a group of disorders that immobilize the ankle by limiting its range of motion. In ballet dancers, posterior impingement syndrome (PIS) and anterolateral impingement syndrome (AIS) occur most frequently. PIS refers to limited movement in the plantar flexion position while AIS  consists of constrained motion in the dorsiflexion position (Hillier, 2004). Paratenonitis is another impingement syndrome that occurs when the paratenon, a thin sheath of tissue that surrounds certain tendons like the Achilles tendon, becomes inflamed (Steinberg et al., 2011). While impingement syndromes target the muscles and tendons, osseous pathologies are caused by inconsistencies in bone anatomy. Os trigonum syndrome, for example, is a type of osseous pathology in which the os trigonum, an accessory (extra) bone, becomes wedged between three other leg bones, leading to inflammation of the involved structures (fig 5). Another group of FAIs is tendon and ligament abnormalities, which includes disorders such as sesamoiditis and flexor hallucis longus tenosynovitis. Sesamoiditis causes pain on the ball of the foot at the bottom of the big toe. It is named for the sesamoid bones attached to the metatarsals of the hallux (fig. 4), which become inflamed from the combined pressure of fitting into pointe shoes, as well as balancing the body’s entire weight on the box of the pointe shoes (Sims, 2014).

Treatments for both acute and chronic FAIs include non-invasive and surgical interventions. Nonoperative techniques include utilizing a fracture brace for ankle and metatarsal fractures. For treating os trigonum syndrome, surgeons can remove the os trigonum bone (Kadel, 2014).

Ballet dancing is as much of a sport as it is an art form. In the pursuit of excellence, it is not uncommon to find many dancers with foot and ankle injuries of varying degrees. The different FAIs all have their own nuances in onset, diagnosis, prognosis, and treatment but they all have a lasting impact on the dancers who are affected. Sports injuries on dancers are career threatening and may lead to health difficulties later on in their lives. Many treatment plans for FAIs require dancers to suspend all physical activity, including dancing, which can take a toll mentally. The best way for dancers to mitigate chances of these happenings are to practice proper ballet technique, avoid dancing when fatigued, dance on softer floors, and practice appropriate warmup and cooldown routines.

Edited by Andy Chen

References

Hansberger, B. L., Acocello, S., Slater, L. V., Hart, J. M., & Ambegaonkar, J. P. (2018). Peak Lower Extremity Landing Kinematics in Dancers and Nondancers. Journal of Athletic Training, 53(4), 379–385. https://doi.org/10.4085/1062-6050-465-16

Hillier, J. C., Peace, K., Hulme, A., & Healy, J. C. (2004). MRI features of foot and ankle injuries in ballet dancers. The British Journal of Radiology, 77(918), 532–537. https://doi.org/10.1259/bjr/60447506

Kadel, N. (2014). Foot and Ankle Problems in Dancers. Physical Medicine and Rehabilitation Clinics of North America, 25(4), 829–844. https://doi.org/10.1016/j.pmr.2014.06.003

Ojofeitimi, S., Bronner, S., & Woo, H. (2012). Injury incidence in hip hop dance. Scandinavian Journal of Medicine & Science in Sports, 22(3), 347–355. https://doi.org/10.1111/j.1600-0838.2010.01173.x

Sims, A. L., & Kurup, H. V. (2014). Painful sesamoid of the great toe. World Journal of Orthopedics, 5(2), 146–150. https://doi.org/10.5312/wjo.v5.i2.146

Steinberg, N., Hershkovitz, I., Peleg, S., Dar, G., Masharawi, Y., & Siev-Ner, I. (2011). Paratenonitis of the Foot and Ankle in Young Female Dancers. Foot & Ankle International, 32(12), 1115–1121. https://doi.org/10.3113/FAI.2011.1115

Vosseller, J. T., Dennis, E. R., & Bronner, S. (2019). Ankle Injuries in Dancers. JAAOS – Journal of the American Academy of Orthopaedic Surgeons, 27(16), 582–589. https://doi.org/10.5435/JAAOS-D-18-00596

Walls, R. J., Brennan, S. A., Hodnett, P., O’Byrne, J. M., Eustace, S. J., & Stephens, M. M. (2010). Overuse ankle injuries in professional Irish dancers. Foot and Ankle Surgery, 16(1), 45–49. https://doi.org/10.1016/j.fas.2009.05.003

Wanke, E. M., Arendt, M., Mill, H., & Groneberg, D. A. (2013). Occupational accidents in professional dance with focus on gender differences. Journal of Occupational Medicine and Toxicology, 8(35), https://doi.org/10.1186/1745-6673-8-35Werber, B. (2011). Dance Medicine of the Foot and Ankle: A Review. Clinics in Podiatric Medicine and Surgery, 28(1), 137–154. https://doi.org/10.1016/j.cpm.2010.10.005

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