Review Article Common Overuse Injuries of the Foot and Ankle 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- Achilles Tendinitis 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.