Review Article

Common Overuse Injuries of the and in Dancers

Itzhak Siev-Ner, M.D.

oot and ankle problems are the within the sheath resulting in increased soft tissues and this results in essentially most common injuries seen in pressure and stretching, both of which a shortening of the Achilles tendon rela- F dancers.1-3 Most of these cause pain. If untreated or inadequately tive to the now longer bone.7 injuries are the result of overuse and treated, it may also result in adhesions 3. Excessive shock absorbed by the not a result of acute injury. Thorough between the tendon and the sheath and/ tendon, especially while landing from screening to detect risk factors as well or scar tissue within the tendon, which jumps. Bad technique such as not as correct technique can prevent a further decreases elasticity and contrib- reaching full weight bearing includ- great deal of these injuries.4-6 utes to the chronicity of the condition. ing the heels at the end of each jump Tendinitis is the most common con- Sometimes when the sheath is not in- is the most common fault.8 dition among foot and ankle problems, volved there is no pain. When the sheath 4. Non-resilient flooring that is with the Achilles tendon the predomi- is involved there is usually pain. not springy enough and therefore nant injury site. Therefore, the Achilles A number of factors contribute to does not absorb some of the shock tendon will be discussed in detail as a tenosynovitis of the Achilles tendon: produced by dance movements. model of the principles that are com- 1. External friction produced by 5. Biomechanical problems, exces- mon to tendinitis in general. the counter (back) of the ballet shoe sive pronation (foot turns inward too or the ribbons which are tied around much) or supination (foot turns out- the ankle. ward too much). It could be either The Achilles tendon is a cord of a rela- 2. Short Achilles tendon and calf structural (constitutional) or faulty tively less elastic tissue, within an muscles that over-stretch. This is notice- technique such as sickling in or epitendon (sheath). It connects the calf able especially in young girls who prac- out.7,9,10 muscles to the calcaneal (heel) bone. tice only classical ballet – performing 6. Excessive wearing of high heel When it over-stretches, especially when repetitive plantar flexion (toes pointing shoes that shorten the tendon as a re- the dancer has not sufficiently warmed- downward), contracting the muscle and sult of their forcing the foot and ankle up, either a partial or full tear of the tendon (and shortening them), such as into an unnatural position.9,10 tendon can result. Tendinitis means an in relevé, en-pointe, tendu, and so forth, 7. Relative ischemia – the older inflamed tendon. The tendon may rup- while the muscle tendon complex is not one gets the more the blood supply ture spontaneously after long periods of stretching enough. This demonstrates to the tendon decreases. This process chronic painful inflammation. Tenos- the need for special exercises in addi- is further aggravated in smokers, those ynovitis is an inflammation that pro- tion to the technique performed in class. with high cholesterol levels, and those duces fluid between the tendon and the Additional risk periods are during with arteriosclerosis. sheath. The exudate (fluid) and the growth spurts, because during this time The typical complaint seen in cases swollen tendon are both confined bones lengthen more rapidly than the of Achilles tendinitis is pain at the back of the ankle. At the beginning the pain Itzhak Siev-Ner, M.D., is in the Orthopedic Rehabilitation Department, intensity is worst in the first steps in the Rehabilitation Center, Sheba Medical Center, Affiliated with the Tel-Aviv morning or on starting exercises and University, Sackler School of Medicine, Tel-Hashomer, Israel. may ease during the day or during class. Later in the course of this disorder the Correspondence and reprint requests: Itzhak Siev-Ner, M.D., The Israel Performing pain remains throughout activity and Arts Center, 30 Ibn Gvirol Str., Tel-Aviv 64078, Israel. when the condition worsens, the pain

49 50 Journal of Dance Medicine & Science Volume 4, Number 2 2000 is sustained after activity as well. In se- coagulation problems, or liver or kid- However, all of these treatments are vere cases it exists throughout the day ney problems). The dancer should con- rendered inadequate if the faulty tech- with any activity. sult a physician and not use NSAIDs nique, biomechanics, or any of the Diagnosis is made by taking a de- for more than few days. There is a risk other risk factors that caused the dis- tailed history, which should include that the treatment will mask the pain order are not corrected; if the mecha- the type of pain and whether the pain and allow full activity, with the result nism of injury has not been elimi- has forced any limitations in activi- that the unresolved tendinitis will fur- nated the dancer risks reccurrence of ties. Additionally, it is important to ther damage the tissues and increase the the disorder. For malalignments such inquire whether there have been any risk of a chronic condition. as pronation or supination, insoles changes in activity habits, such as Topical drugs may help and it is rec- can be specially prepared by a podia- rapid increase in time or intensity of ommended that they be applied 2 to 3 trist or skilled orthotic technician, but dancing (new teacher or choreogra- times a day with massage. There are a since they cannot be fitted to bare- pher, intensive rehearsals before au- number of NSAIDs available in creams foot dancers, taping is more appro- dition or performance, and so forth). and gels. Iontophoresis and ultrasound priate. Physical examination usually reveals might increase and facilitate the absorp- local tenderness, swelling (lump-like) tion of the medications into the tendon. Flexor Hallucis Longus (FHL) in the tendon, and fullness in the This hypothesis, though, is not univer- Tendinitis sheath. The overlying skin may be red sally accepted. Topical therapy has fewer This is a relatively rare condition in and warm. side effects, if any, except local skin irri- sports and other activities but rather Ultrasound examination as well as tation in rare cases. Should complica- common among dancers — so com- magnetic resonance imaging (MRI) tions occur, the treatment should cease mon, in fact, that it gained the synonym, can diagnose tears, swelling, and ex- immediately. Capsaicin is available as “dancer’s tendinitis.” There are a few cessive fluid (edema, inflammation). cream; it is extracted from chili (hot specific risk factors that predispose danc- Treatment should address healing pepper) and has a good analgesic effect. ers to FHL tendinitis. The most impor- of the tendon and sheath as well as High doses may burn and thus caution tant risk factor is “rolling in” (prona- elimination of the causative factors.6,11 should be taken. tion of the feet usually as a result of Treatment protocols include physio- Acupuncture has been used to en- over-“turning out” thus performing ex- therapy, ultrasound, electro-galvanic hance analgesic and anti-inflamma- treme external rotation beyond the ana- stimulation, whirlpool, deep-friction, tory effects. tomical range) and compensation in the and so forth for at least 3 times a week Resistant cases should be immobi- feet.8 Since the FHL is a primary stabi- for 3 to 6 weeks. The dancer should lized in a plaster cast for 3 to 6 weeks lizer of the subtalar joint against prona- learn to deep massage the tendon twice and thereafter physiotherapy should tion (rolling in) it is affected when it is daily for 10 minutes and use ice to fa- continue. Immobilization has the dis- over-stretched.15,16 cilitate treatments and reduce pain. advantage of diminishing capabilities The FHL also has an important When pain subsides the dancer should such as muscle strength and range of role in stabilization of the ankle me- start a stretching and strengthening pro- motion. Local osteoporosis may oc- dially in relevé and en pointe. There- gram with a stretching aid such as Flex cur and therefore, if possible, immo- fore, sickling or any repetitive move- Wedge® or even on a simple step. Exer- bilization should be avoided. ments due to bad technique or cises with Theraband® serve the same During the acute phase of tendinitis weakness or instability, will impair the goal. These methods of stretching are dance activity should be modified. If the tendon. In plié the tendon provides also recommended for prevention.12-14 condition is mild, the dancer should be plantar flexor stability to the big toe. Local ice packs or even massage with instructed to refrain from jumping but The repetitive movements from plié an ice cube reduces pain and swelling. can otherwise continue full activity with to relevé and pointe strain the tendon Alternating heat and ice are not in concomitant treatment. In moderate and make it vulnerable to injury.15,17 contradiction even though it might conditions, dance and physical activity In the medial aspect of the ankle, seem so – the dancer should use which- should be reduced, and a rehabilitation under the medial malleolus, at the pos- ever feels better. program should be personally tailored teromedial aspect of the talus there is a During the acute phase, insertion of by the physician or physiotherapist to- tunnel formed by fibrous tissue in which an insole under the heel in the regular gether with the dancer. Preferably the the FHL passes downward and forward. shoes relieves the tendon of stretching teacher or choreographer should be in- During each dorsiflexion of the big toe and absorbs shock. It can be reduced volved. Severe cases should refrain from (such as in relevé), the tendon and the gradually when the tendinitis improves dancing, and the dancer should be en- distal muscle fibers move in that tun- and the tendon is better able to stretch. couraged to practice Pilates-based or nel. The repetitive movement, especially Non-steroidal anti-inflammatory similar exercises, undergo hydrotherapy, if there are technical malalignments like drugs (NSAIDs) may be used if the swim, or even cycle (with the seat el- sickling and rolling-in, causes the muscle dancer does not have contraindicated evated to avoid stretching of the ten- fibers and the tendon to become in- conditions (such as peptic ulcers, blood- don in dorsiflexion). flamed and thickened and the smooth Journal of Dance Medicine & Science Volume 4, Number 2 2000 51 movement sliding through that tunnel a result of an ankle sprain or of the There is a characteristic pain in the lat- is impaired. The dancer feels a crepitous peroneus longus tendon slipping eral midfoot, which may be evoked by sensation and sometimes an audible and around the lateral malleolus. In this direct pressure on the plantar surface of palpable snap. In those circumstances a situation a surgical treatment is the cuboid. Since there is no good im- surgical thinning of the muscle and ten- needed. Fractures of the base of the aging examination to demonstrate it, don is required.16,18 fifth metatarsal (Jones fractures) are physical examination together with his- Pain may be present during relevé, carried by the powerful contraction tory of trauma should help direct the demi-plié, and grand-plié. In severe of the peroneus brevis muscle. Con- physician to the diagnosis. Treatment cases pain is sustained during daily servative management usually suffices. includes skilled manipulation, after activity. Pain can be evoked in dorsi- which taping for several weeks main- flexion of the foot with forced pas- tains the reduction.19 sive dorsiflexion of the first toe. The plantar fascia is a thin but strong The principles of diagnosis and band of connective tissue along the plan- Posterior Impingement treatment are similar to those in Achil- tar aspect of the foot stretching from Syndrome les tendinitis. If ankle instability is the heel to the base of the toes. Exces- The os trigonum is a normal anatomic suspected, proprioception exercises sive tension or pulling may cause mi- variant; it can be either a bony protu- (Wobble Board®, Theraband®) should croscopic bleeding. A non-resilient floor berance on the postero-medial side of be encouraged. that does not absorb shock contributes the talus or a separate bone. Usually it When evaluating possible causes, one to the micro-trauma. The presence of a does not affect the adjacent tissues. In should rule out an impingement or fric- spur anterior and on the plantar aspect those who perform plantar flexion and tion by a prominent os trigonum. That of the calcaneus can be either the cause especially in dancers who perform it bone, if present, may interfere with the of pain and fasciitis or the result of long- repetitively and to its extreme (in every sliding of the tendon behind and under standing irritation caused by the trac- relevé, en-pointe, or tendu), the bone is the medial malleolus. Sometimes, if the tion of the fascia. compressed between the calcaneus and bone is big and disturbing, it should be The typical complaint is of pain, the tibia and results in pain. It also removed surgically in order to avoid re- especially during the first few steps in blocks the full range of motion during petitive friction of the tendon.15,18 the morning or after rest. Stretching relevé. If the os trigonum is continuous the toes to dorsiflexion, such as in with the talus it could either break or Tibialis Posterior Tendinitis relevé, may aggravate the pain. cause ostheoarthritic changes owing to This condition is more rare in dance A “low-dye” strapping is a very help- pressure. A separate bone will just im- than in other sports. It is more com- ful method to alleviate pain from plan- pinge. Histologic examinations have mon when an accessory navicular tar fasciitis.14 If a calcaneal spur (heel revealed typical arthritic changes in the bone is present. The tibialis posterior spur) is present, one may add a foam or cartilage of the os trigonum.18,20,21 supports the arch of the foot. It passes felt pad with a hole cut in it to release The enlargement of the adjacent fat under the navicular to attach to the pressure between the spur and the floor. tissue may cause impingement by itself. plantar aspect of the metatarsals. If an Orthotics within the shoe may serve the Histologic sections of this tissue have accessory navicular bone is present it same purpose. There are also over-the- demonstrated marked fibrous changes may disturb the normal functioning counter insoles such as Viscolas®, and scars. Removal only of the soft tis- of the tibialis posterior tendon. Spenco®, Sorbothane®, and Linco® sys- sue has also been suggested.21 As some When the tendon is lax there is tems. Taping helps, especially if it re- os trigonum are asymptomatic, it is pronation of the foot and flattening stricts motion in the big toe. worthwhile initially to inject local ste- of the longitudinal arch that looks like When improvement is noticed, mild roids if it causes pain, especially in stu- “rolling in,” yet it is structural and not stretching, like rolling the foot over a dents who are not sure about how much a technical fault. Of course if the tennis ball, may be recommended. This they are committed to dance. If an in- dancer is “rolling in” the condition can decreases the formation of a contracted jection is performed, the surgeon should further deteriorate. scar and enhances healing. be careful to avoid the tendons (Achil- The treatment is the same as with In adolescents a differential diagno- les and FHL) in order not to cause ne- other tendons but if the biomechan- sis of Sever’s disease should be consid- crosis and, later, tears in the tendons. If ics are not corrected the tendinitis will ered. The symptoms may be similar, the injection of local steroids does not recur. An orthosis may be fitted to though the pain may be more poste- help, surgery should be considered. Pri- support the arch and assist the ten- rior. In this case, however, fractures are mary surgery should, however, be con- don. uncommon and continuation of danc- sidered for professional and semi-pro- If orthotics or taping does not solve ing is allowed within the limits of pain. fessional dancers, if they present the problem, the extra bone should Cuboid subluxation should also be symptomatic impingement.18 be removed surgically. The peroneal included in the diagnosis of plantar The bulge of the os trigonum can tendons are rarely inflamed and when fasciitis. This condition, though not irritate the FHL tendon that passes over an inflammation occurs, it is usually common, is usually under diagnosed. it. Treatment should be directed to what 52 Journal of Dance Medicine & Science Volume 4, Number 2 2000 the physician evaluates as the source of reer because it does not permit relevé. mation and bursitis. Bursitis over the pain (in many cases both). In order to If only the dorsal part of the bone bunion is common when intensive assess the true dimension of the os trigo- edges is involved, resection of the work is done en-pointe. The defor- num, in addition to the routine radio- bone spurs (Mann’s operation) can mity also exposes the joint to osteoar- graphs, the physician should also ask for alleviate the pain and enable continu- thritic changes. Rolling-in (pronation an oblique view of the ankle taken when ation of work. Involvement of the of the foot) and sickling (same in the heel is elevated from the x-ray plate. entire joint demands a much larger relevé) enhance these processes and operation and places the dancer’s fu- therefore, should be avoided. If sig- Anterior Impingement ture career at risk. nificant osteoarthritis has occurred, an Syndrome Morton’s neuroma presents as a operation may be necessary to correct Repetitive dorsiflexion, such as in plié, burning, cramping, and shooting pain the deformity before irreversible and extreme dorsiflexion, as in grand- due to inflammation of the digital changes develop (such as hallux plié, may stimulate bone formation nerve from a benign nerve tumor be- rigidus). either in the anterior lower part of the tween the metatarsal heads. When the A Tailor’s bunion is similar to hal- tibia or in the upper and anterior part same condition occurs at the bottom lux valgus and occurs in the fifth of the neck of the talus. Forced dorsi- of the great toe it is called Joplin’s neu- metatarsophalangeal joint. Surgery is flexion such as in landing from a jump roma. In dancers, this condition is rarely indicated. To ease pressure, the may expose those bones to local caused by too narrow a pointe shoe bunion can be covered with a dough- trauma that initiates the formation of box. Walking with high heel shoes or nut pad. a spur. Tension of the joint capsule or shoes with narrow and pointed toes The sesamoid bones are two small ligaments, as in relevé, may also in- may further augment the problem. bones under the first metatarsopha- duce bone formation. The bone usu- Treatment starts with changing to langeal joint. They are attached within ally grows in the direction of the ten- more comfortable shoes so that the the flexor brevis tendons and biome- sion. Recurrent ankle sprains can also pressure from the sides will be de- chanically aim to unload forces. A first result in bone spur formation.14,15 creased. If the metatarsal (transverse) toe deformity contributes to mal-track- If symptomatic, the spur should be arch is collapsed, an insole with a ing of the sesamoids (such as in chon- resected, preferably by arthroscopy, metatarsal pad should be fitted within dromalacia of the patella), leading to which uses a small incision and allows the shoe. Even while barefoot, these grinding away at the cartilage and ar- speedy healing. pads can be placed under and behind thritis. Stress fractures as well as avascu- the metatarsal heads on the sole of the lar necrosis of the sesamoids have been Metatarsalgia and Pain in the foot. Elevating the metatarsal arch described.22 Orthotics and realignment Forefoot would spread the metatarsal heads and of the big toe by taping, together with Metatarsalgia is the term for pain in open the spaces between them thereby physiotherapy and a rocker bar on the the ball of the foot. It is a non-spe- decreasing the pressure on the digital sole of the shoe to relieve pressure, will cific complaint and a thorough exami- nerves. To treat the inflammation, a solve the problem in most cases.14 nation should be performed in order steroid can be injected into the space Stress fractures present as pain in to reveal the cause so it can be treated between the metatarsal heads, and if the forefoot. On physical examination properly. The first clue might come that does not help, the neuroma there is local tenderness over the af- through simple observation; when ex- should be resected surgically. fected bone (usually the second and amining the first toe it is possible to Bursitis is an inflammation within third metatarsals) and usually swell- distinguish two foot types: a fluid-filled sac. Nonsteroidal anti- ing of the soft tissues dorsal to the 1. In the Greek (or Morton’s) foot inflammatory drugs (NSAIDs) and bone with pain on the plantar sur- the first metatarsal is short and thus physiotherapy are the first choice for face.23,24 The sesamoids and calcaneus the big toe is shorter than the second treatment. Should no relief be may also be involved, although this is toe. In such case the toe might be too achieved, a steroid injection may be less common.25 mobile or, more importantly, it may helpful. However, the injection of ste- Radiographs are not useful because shift weight bearing to other areas. roids directly to or near tendons in acute cases there are no radio- 2. In the Egyptian foot the first should be avoided since it damages graphic changes. Only chronic cases metatarsal and toe are longer than the them and may contribute to hammer will demonstrate radiolucent foci and other toes. This long toe may cause toes. thickening of the cortex (this is almost jamming in the joint and, later on, Hallux valgus deformity is very a pathognomonic sign for most danc- an arthritis with or without spurs common among female dancers. Ana- ers – proving the amount of stress to might develop. That process limits the tomically there is lateral deviation of which those two bones are exposed). range of motion especially upward the big toe and medial deviation of A bone scan is the preferred mode for (dorsally) and is called hallux rigidus. the first metatarsus. The result is a diagnosis and is a very sensitive ex- For a dancer this restricted range of bunion (a bone bulge) that rubs amination modality. If a stress frac- motion might be the end of her ca- against the shoe and results in inflam- ture is demonstrated, detailed infor- Journal of Dance Medicine & Science Volume 4, Number 2 2000 53 mation can be obtained concerning Conclusion 14. Subotnic SI: Heel injuries. In: Sports the degree of damage. Once a diag- & Exercise Injuries: Conventional, Ho- nosis is made, the intensity of activ- Most foot and ankle injuries are a re- meopathic and Alternative Treatments. ity, any change in the training rou- sult of overuse. This fact highlights Barkeley CA: North Atlantic Books tine (sharp increase of load), and the importance of educating dancers, and Homeopathic Educational Ser- hormonal profile (menstrual history) teachers, and medical personnel in the vices. 1991, pp. 171-183. 26 etiology of these disorders and in the 15. Kleiger B: Foot and ankle injuries in should be investigated. Rest (4 to 6 dancers. In: Ryan AJ, Stephens RE weeks) is the most important treat- main modalities used in their treat- ment. It is important to keep in mind (eds): Dance Medicine: A Comprehen- ment. Healing of stress fractures in sive Guide. Chicago: Pluribus Press, certain bones (such as the talus) may that, “The prevention of the overuse is the control of use.” 1987, pp. 115-132. require longer rest periods (8 weeks 16. Oloff LM, Schulhofer SD: Flexor or more).27 During the rest period the hallucis longus dysfunction. J Foot dancer should be encouraged to swim References Ankle Surg 37:101-109, 1998. and exercise using Pilates-based or 1. Bronner S, Brownstein B: Profile of 17. Sammarco GJ, Cooper PS: Flexor similar rehabilitation techniques in dance injuries in a Broadway show: A hallucis longus tendon injury in danc- which a program can be tailored to discussion of issues in dance medicine ers and nondancers. Foot Ankle Int avoid loading on the affected bone. It epidemiology. J Othop Sports Phys 19(6):356-362, 1998. Ther 26(2):87-94, 1997. 18. Hamilton WG, Geppert MJ, Thomp- should be emphasized that for all con- 2. 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