Most common injuries in ballet

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A real cause of concern not only in dancers, Bunions can affect anyone. Learn about what is happening in your toe joint, why a Bunion forms and what to do if this happens.

The posterior part of the ankle is very susceptible to injury in ballet dancers due to the high amount of load that is put through this section of the foot. Find out which common injuries affect this area.

Stress fractures are a common injury in dancers and can be frustratingly recurrent. This is due to the fact that dancers tend to go back to their full dance load before addressing all of the contributing factors.

Let’s start with a little discussion on what bunions actually are. A bunion (Hallux Valgus) is an abnormal lump of bone that forms on the joint at the base of the big toe, which can become quite red and inflamed. Often the range of motion in the big toe becomes restricted and even working on demi pointe is difficult.

A bunion is a mal-alignment of the big toe joint, with an inwards drift of the toe and a large bony 1st toe joint so the toes no longer looks straight. While most people think that the problem is the big toe drifting in, often the problem starts when the first metatarsal (the major foot bone that attaches to the big toe) starts to angle away from the foot.

Hereditary (especially via the female line)
Weakness of intrinsic muscles of the feet
Rolling in (pronation) of the feet
Leaning on the big toe in a tendu, especially to second or derrière
Walking with turned out feet
Reduced mobility of the big toe when on demi-pointe
Weakness of muscles controlling the big toe
Restricted pointe range

Alteration in alignment of the first toe
Inflammation of the 1st toe joint
Pain in the 1st toe joint with movement
Rotation of the big toe so that the nail no longer faces upwards
Restriction in range of demi pointe
Occasionally bruising of the toe nail occurs

Depending on how many of the causative factors are true for the dancer with bunions, a series of exercises to ensure correct alignment and stability of the lower limb should be implemented. Many exercises to target these areas are described in detail in The Perfect Pointe Book and the Advanced Foot Control for Dancers course. Other treatments that can help manage bunions include:

Supportive foot wear with correct width and arch support can provide relief –shoes such as ballet flats, thongs (flip flops) and Ugg boots (or slippers) should be avoided
Mobilisation of the mid foot to help re-align the toe correctly, and then taping and padding in the shoe to keep the toe in alignment.
Taping to help draw the 1st metatarsal back in towards the second and correct any rotation and drop of the 1st metatarsal.
Foam padding shaped like a donut to off load the pressure on the outside of the big toe.

However, correcting the placement of the toe is actually a tiny part of the rehabilitation of a bunion. One of the most important factors is being able to identify and correct all of the contributing factors to ensure that your bunion does not get any worse. In some cases you can dramatically alter the appearance of the big toe and significantly decrease pain levels.

It is important to establish exactly why your bunion is occurring. This can not only help you treat the condition more effectively, but can also help you prevent the bunion from becoming worse. A bunion (Hallux Valgus) is an abnormal lump of bone that forms on the joint at the base of the big toe, which can become quite red and inflamed. Often the range of motion in the big toe becomes restricted and even working on demi pointé becomes difficult.

While most people think that the problem is the big toe drifting inwards, often the problem starts when the first metatarsal (the major foot bone that attaches to the big toe) starts to angle away from the foot. Overtime, under the continuing stress of this altered position of the joint and the irritation that this causes, the joint can become inflamed. As a result of this there is often an extra bony growth around the toe joint.

While no amount of conservative treatment can remove any bony growth, Some simple massage and taping techniques can help realign the foot and toe. This is very important before commencing any exercises aimed at strengthening the foot to ensure that the foot is being trained in optimal alignment.

There are many different reasons for pain at the back of the ankle, however this can be really hard to determine yourself. Getting a correct diagnosis will really guide your treatment because the treatment is quite different for each diagnosis. Make sure to find a qualified health professional who knows a lot about dancer’s feet for the best result! However, learning about each of the different injuries that can give you pain at the back of the ankle can empower you to ensure you are getting the most appropriate treatment.

Some examples may include:

Posterior impingement,
Os Trigonum
FHL Tendinopathy (Flexor Hallucis Longus)
Tibialis Posterior Tendinopathy
Achilles Tendinopathy
Sever's Disease

This is especially relevant if you have a Posterior Impingement. If you have pain in the back of the ankle, and continually test it to check if it is still sore, it will persist for a very long time. If you've got swollen tissues, and by testing it you compress them some more, they'll get a little bit more inflamed. Inflamed tissues take up more space, causing more compression. I highly recommend taping the foot so that you actually can’t test it, as its often this is done subconsciously. Check out our Posterior Impingement Management Guide to get all the details on my three day strategy for settling pain very quickly.

When dancers have pain in the the back of the ankle they often repeatedly try to stretch it out. Especially if you have a tendinopathy, repeated stretching can actually exacerbate it and make it worse. Part of the tendon rehab will include loading the tendon, but this needs to be done in a very specific, active and graded way, rather than passively stretching the tissues. Please clarify any mobilisation or stretching exercises that you are with the therapist who you're working with, to make sure that they are okay with your specific diagnosis. Otherwise, you may be undoing the good work that you're doing with the rest of your rehab.

A “fracture” is a disruption, or break in a bone.

Some fractures, called stress fractures, are microscopic, and develop more over a period of time, rather than with one big incident. Our bodies are amazing, and adapt remarkably well to the things we demand of them. However, if too much load is placed through a bone, in a particular direction, and it does not have the strength to endure such forces, a stress fracture may develop. Over time tiny faults will appear within the bone, and unless the forces imposed in that bone are changed, they will accumulate and develop into a more major fault in the bone.

Stress fractures often follow a progression of three stages;

A) Bone Strain – Re-modelling of bone, or increased activity of the cells that build bone is the first sign of an issue with loading in the bone. This stage is very rarely picked up as the dancer does not feel much pain at all. The remodeling may sometimes be picked up by a bone scan looking for other issues.

B) Stress Reaction – Once there is a tender portion of bone, but before the bone shows signs of a fracture, it is called a stress reaction. This stage is often seen in dancers who are increasing hours or changing styles of dance. If problems with technique or foot wear are picked up at this stage, it is possible to avoid the development of a stress fracture. Many dancers avoid reporting pain at this stage as they are scared of "Having an injury" however, if it is caught early, and dealt with appropriately, then more severe injury and disability can often be avoided.

C) Stress Fracture – Once there is development of an actual fault in the bone, it is classed as a stress fracture, and usually a period of non-weight-bearing is needed to resolve the symptoms. Depending on the risk factors of that particular dancer, treatment may vary considerably, so it is important to be guided by your therapist on any time off, use of a boot, and a gradual build back into class.

Errors in Technique (in Dancers) such as incorrect posture, poor weight dispersion across the foot e.t.c.
"Fishing" the foot en pointe, or the foot twisting in the shoe.
Impact of an unfamiliar surface, such as dancing on an unfamiliar stage, or jumping on concrete for a photo shoot.
Training errors such as too rapid an increase in the number of hours training, such as when a dancer starts full time training.
Stress caused by another foot problem. I.e. Walking on the outer border of the foot to avoid pain under the big toe joint.
Wearing poorly cushioned shoes while dancing or walking on hard surfaces. This includes the frequent use of "UGG Boots" in winter and Thongs/flip flops/Sandals in summer. This is a huge problem for dancers as ballet shoes tend to lack essential support.
Poorly fitted pointe shoes can also add tremendous amount of unnecessary stress to particular parts of the foot.
Abnormal foot structure, such as flat feet or extremely high arches can cause load to be focused in certain parts of the foot.
Restricted range in one part of the foot, often due to a previous injury, can cause more load in the more mobile areas.
Repetitive pounding on the ground, without appropriate control of the landing phase, or striking the foot too hard during Battements Frappé e.t.c.
Rapidly increased levels of activity without correct conditioning, often during rehearsals for shows and exams.
Obesity, or a sudden increase in body weight in a short period of time.
Eating Disorders - Malnutrition causes bone density to decrease.
Rapid decrease in bone density e.g. Osteoporosis or Osteopenia.

In analysing your injury, your therapist or doctor may be able to diagnose your injury strictly on the basis of a physical exam. The therapist will assess the injured area, comparing it to the uninjured leg or knee. He or she will evaluate visible signs of injury such as tender skin, swelling, and differences in joint mobility or appearance.

They should also look at the rest of the body, especially the trunk, spine and pelvis, looking for weaknesses or asymmetries that may have led to the injury occurring. Correctly identifying any contributing factors early will help in devising the most correct, and effective rehab program to help ensure that the injury does not reoccur.

Often people ask whether they should have an X-ray to check for stress fractures. Because they are rarely ‘displaced’ (when the bone has shifted its position), or appear all of the way though the bone (this can happen in very severe cases) Stress Fractures cannot initially be seen on regular x-rays. In addition, many people think that if their x-ray is ‘clear’ then they are fine, however this is not necessarily the case.

Sometimes the doctor or therapist may request a bone scan, an MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) scans to confirm the diagnosis, however these are often not needed.

Stress fractures are usually treated conservatively, without surgery. Treatment of the stress fracture will depend on the individual dancers risk factors and contributing factors, but may include the following:

Rest of the injured area is essential, and usually requires suspending the activity that caused the injury for six to eight weeks.
This should always be "Relative Rest" to avoid reconditioning in the rest of the body.
Possible use of an orthopaedic boot to offload the area - this should make the foot painfree
Some specialists do not advocate the use of an orthopaedic boot and believe that gentle weight bearing will encourage blood flow, so walking on the foot may be allowed, depending on your injury.
Avoidance of high-impact activities (Such as dance or gymnastics).
Use of contrast bathing, involving alternate hot and cold water baths, to encourage blood flow to the area.

NB - we now tend to avoid the traditional R.I.C.E treatment as this can actually reduce blood flow to the area and may delay healing.

A major component of the treatment for a stress fracture must always be in identifying and correcting any contributing factors that led to the injury developing in the first case. This may include, but is certainly not limited to:

Pelvic and core stability exercises
A modified class or Floor Barre to maintain condition in the rest of the body
Specific manual therapy techniques to mobilise stiff areas of the foot
Specific strengthening and re-patterning exercises for the foot and ankle
Fascial Mobility exercises to ensure balance and mobility in the body
Mirror therapy to maintain muscle patterning in the foot while not using it
Dietary and lifestyle changes including monitoring sleep habits and ceasing smoking if this is an issue

Floor barre is an extremely effective way of maintaining dance fitness and technique while enabling the dancer to retrain certain areas of their technique. The absence of gravity in some positions allows dancers to find and activate muscles that are easily overpowered by larger muscles. Often utilising these muscles over the more powerful muscles achieves better control of the movement and a nicer line. A good example is during développés; often the deep core muscles are not used while the quadriceps work strongly.

Once the stress fracture heals, normal activities should be gradually incorporated. A dancer should employ the 10% policy – workload should not be increased by more than 10% per week after the treatment period. With this type of injury it is extremely important that the dancer does not start working at full capacity immediately, as the injury could reoccur. It is important to slowly work yourself back to full time training.

It is essential that you are well conditioned and that equal time is given to work and rest to prevent fatigue. Make sure to start each day with warm up exercises and cool down at the end of the period of the exercise period. A balanced diet including vitamin D and calcium-rich foods is important in maintaining bone density and health.

Replace any old or ill-fitting ballet or athletic shoes, and ideally have a individual fitting with an experienced fitter, as the style and size of shoe that is most suitable for you may have changed following your rehab (often strengthen the foot can cause a change in shape)

If you experience pain or swelling in the injury site as you resume dancing, please stop all exercise immediately and seek the advice your health professional.

Due to the extended recovery time (6-10 weeks) for a stress fracture to fully heal, and the effect that this has on a dancers training, preventing stress fractures is of major importance. Gradually increasing workloads at a rate of no more than 10% a week and varying the training by using cross training techniques will help to off set the overload and repetition often associated with stress fractures.

Warming up properly and preparing the body for the workout will help to keep the muscles from fatiguing as quickly. This will also prevent injuries to the muscles and tendons, which could lead to further weakening of the bones. Injuries to the muscles, tendons or ligaments that support the skeletal system could lead to excess, and awkward, pressure on the bones.

Flexibility is essential for dancers and athletes as well. Muscles that are flexible will provide more support and, due to their elasticity, absorb more shock. They are also less susceptible to injury, which could lead to an imbalance or improper gait. Stiff muscles will also lead to incorrect running and landing patterns that could lead to extra stress.

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