A Dancer’s Distress: The Achilles Heel

Ballet is a beautiful art form that requires the utmost grace and athleticism. Although the performance often appears effortless, this is far from the reality. The process of achieving a dancer’s grace is quite strenuous on the body and requires precise attention to technique and form in order to avoid injury.

The prevalence of injury in ballet is high. According to Milan and colleagues, 65-80% of ballet injuries occur in the lower extremity, and often times, the pain is felt at the foot and ankle.1 Additionally, Achilles tendinitis and flexor hallicis longus tendinitis tend to be very common in dancers.

What is tendinitis?medial ankle anatomy

Tendinitis is an inflammation or irritation of a tendon.  A tendon is a strong cord that attaches a muscle to a bone.   We have many tendons in our body. The Achilles tendon attaches the calf muscle to the heel.  The flexor hallicus longus tendon attaches flexor hallicus longus muscle to the big toe.

Why does this happen?

The Achilles and flexor hallucis longus tendons are particularly vulnerable to injury among ballet dancers because muscle tissues are stressed every time the dancer jumps, lifts into demipointé, lifts en pointé, or lowers into plié.1 The muscles involved in performing these actions are lengthened and shortened to maximum levels. If the tendon is tight, over time, pain will ensue. Also, if the dancer is using improper form during the technique, the ankle structures will become overly stressed.  Repetitive turnout work,  pointé work, and leaps with an improper technique such as; impaired range of motion at the hips and “rolling in” at the arch, can contribute to excessive stress at the tendons of the foot and ankle, leading to pain.

Rolling in of the foot

Above left is an example of “rolling in” of the foot2

Improper footwear can also contribute to Achilles tendinitis. The shape of the toe box and proper fit is important, and often ignored.  Dancers with unsteady ankles should choose a square toe box in the en pointé slippers and make sure that the fit is not cutting in to any bony prominence.  Unlike athletic shoes, ballet footwear is not designed to provide foot stability or shock absorption. The main main focus of ballet footwear is appearance.  Therefore, the body, through all the ligaments, tendons, muscles, and bones must provide the shock absorption and stability. The calf muscles, in particular, act as springs to provide push off and shock absorption. Improper stretching, wobbly ankles and “rolling in” of the foot all affect the biomechanics leading to Achilles tendinitis or flexor hallucis longus tendinitis.

Other factors that contribute to Achilles tendinitis involve the flooring of the studio or performance surfaces. Three important properties of dance surfaces are resiliency, shock absorption, and surface friction.3 Resiliency is the ability for a dancer to achieve lift off from the floor. Shock absorption occurs when the dancer lands and the floor absorbs the shock, not just the dancers body. Friction involves having a good contact with the floor so slips and falls are avoided. Ideally, the flooring would have layer of springs underneath for improved shock absorbency. This isn’t always possible, and can put increased stress on the dancer’s body.

How can ankle tendinitis be prevented and what can I do to address the problem?

It is important to address signs of pain or irritation right away.  Don’t wait until it is so painful that you cannot perform. Often dancers are simply prescribed NSAIDs/anti-inflammatories and recommended to rest and ice the area.  However, tendons do not heal with merely anti-inflammatory medication and rest alone.  Tendons require specific eccentric loading exercises to heal (talk to your PT about eccentric ankle exercises).  Additionally, the injury will re-occur if the root cause of the problem is not addressed.  It is a good idea to master the fundamentals of ballet before moving on to more advanced levels of performance.  Noticing alignment irregularities such as “rolling in” of the foot, aka hyperpronation of the foot and “sickling” of the ankle (think of a farmer’s sickle) and correcting the alignment both in static positions as well as during leaps and jumps is the first step.  Performing foot/ankle stability and stretching exercises to strengthen and lengthen appropriate  muscles in the legs and foot is useful to help improve the structural support of the lower body.  Finally, working on re-educating the muscles on proper placement during all types of movement with the expert eye your physical therapist can address or prevent a multitude of injuries.

Take home tips:

  • Stretch the calf muscles before and after dancing activity.

  • Master the ability to hold an adequate arch position, first in parallel, then in turnout, and finally en pointé.

  • Avoid “rolling in” of the foot.

  • Avoid “caving in” of the arch when landing jumps.

  • Only perform turn out to the point allowed by hip rotation.

If you have any problems with these techniques, call Solana Beach Physical Therapy for a professional consultation and treatment. Your physical therapist will examine the dancer’s technique statically and during motion from the whole body standpoint to address areas of limitation in order to help heal the injury and prevent recurrence of injury.  The combination of in-office treatment and home exercise instructions will enable the dancer to return to painless dance with confidence and a smile.

Be well,

Jacqueline Cowan, PT, DPT

References:

1. Milan KR. Injury in ballet: A review of relevant topics for the physical therapist. JOSPT. 1994; 19(2):121-129.
2. Dance Magazine. The Seven Deadly Sins. http://dancemagazine.com/news/The_Seven_Deadly_Sins/. Accessed    December 3, 2015.
3. Seals JG. A study of dance surfaces. Clin Sports Med. 1983; 2(3):557-561.