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"Ballet Dancers"

Dancers are a unique breed of athletes, especially ballet dancers.  They are not just dancers…they both athletes and performing artists. The art form demands that a dancer be esthetically pleasing…slender to the point of being fragile; flexible yet strong, powerful, and resilient.

There are many factors involved in keeping a dancer’s body healthy…especially the feet of a dancer. The issues that will be discussed here include: dancer’s mindset, common foot injuries, nutritional factors, footwear inside and out of the studio, and preventative measures.

Dancer’s Mindset: As with other athletes, many dancers are stubborn and determined to  push through pain as long as possible in order to not disappoint the teacher or director, or perhaps lose favor with them. Dancers at the highest level can not afford to appear weak or dispensable and oftentimes injury will go undetected or untreated for too long. They are used to pain and ‘suffering’ and easily conclude it’s just part of the life, so addressing foot pain is often put off for too long.

What are some of the common injuries?

Common Foot Injuries and Conditions: Aside from trauma to the integument, or skin (blistering, callusing, broken nails), there are several common foot complaints among ballet dancers. These include metatarsalgia, stress fractures, sesamoid pain, plantar fasciitis, bunions and bunion pain, and Achilles tendonitis….issues also commonly seen in women who have worn high heels most of their lives.

Classical ballet dancing requires the foot to remain in a snug, leather or canvas slipper so that the dancer can ‘feel’ the floor. As a female dancer progresses, she will spend 4-6 hours a day in pointe shoes which confine the feet and toes in a very small space. On top of this, she must perform repetitive, challenging motions and executions which place load, torque, and force on the feet.

Dancing on pointe requires the foot be maximally dorsiflexed for prolonged periods of time…. placing enormous stress on the peroneus longus tendon and on the 2nd metatarsal specifically. It also places a lot of stress on the Achilles tendon complex, especially during relevés…a term used to refer to a dancer moving from the flat position of the foot on the floor, up ‘en pointe’ and back down. So here we have tight fitting, non-supportive shoes, petite and sometimes undernourished athletes performing intricate movements up and down on their toes throughout a huge range of motion over time and the following injuries can occur:

1. Sesamoiditis: The sesamoids (usually 2) are very small bones in the tendons connected to the big toe. They serve as a pulley and can be strained or even fractured. Bony feet, dancing on hard surfaces, excessive walking, jumping, and shock, and dancing on demi-pointe can lead to sesamoiditis. Pain is experienced under the ball of the foot and sometimes on top, especially on demi-pointe. Inflammation and pain may limit motion of this joint. Icing, rest, and footwear with a firm yet cushioned mid-sole are recommended. If pain continues, request an x-ray to ensure the bone is not fractured.
    
2. Hallux Limitus and Rigidus: Repeated strain on the big toe joint can result in stiffness of the big toe. Those who also present with bunions are more prone to hallux limitus. The shock and forces from dancing can lead to inflammation of the big toe joint, and over time cause stiffness and a lack of range of motion. Because of the pain and stiffness dancers will shift their weight to the outside of the foot during demi-pointe.  In extreme cases surgery may be necessary. Icing, rest, anti-inflammatory medication, and taping methods can assist in healing.
    
3. Bunions: A bunion is a bony protrusion on the edge of the big toe joint which develops when the big toe is forced to angle inwards towards the other toes. It may or may not produce pain and swelling. Some bunions (or hallux valgus) are hereditary however dancers often develop them due to the constant pressure of the tight fitting toe shoe against their feet, and the increase stress on the medial column as a dancer attempts to achieve more ‘turn-out’. The constant friction of a tight shoe can exacerbate bunion pain. Along with anti-inflammatory medication a gel-like spacer between the toes can help. The pointe shoe should be checked to make sure the toe box area matches the shape of the foot and is not too narrow. Bunion surgery is not recommended during a dancer’s career, as it can severely reduce range of motion.
    
4. Neuromas: A neuroma feels like a burning or tingling that can shoot from the ball of the foot to the toes. Numbness and cramping may be present as well. It is caused by impingement of nerve fibers between the metatarsals and toes, usually between the 2nd and 3rd toes but also between the 3rd and 4th toes. The nerves may become swollen and permanently scarred. Pain usually goes away when shoes are removed, suggesting the shoes are too narrow and excessively tight. Placing metatarsal pads in your street shoes is recommended. The toe box of the pointe shoes should be checked to make sure it matches the shape of the foot. A more square shaped toe box may be necessary, rather than a much tapered one. A doctor may also inject cortisone into the inflamed area.
    
5. Plantar Fasciitis: The plantar fascia is a dense band of fibrous tissue that originates at the heel and connects to the base of the toes. It stretches and contracts each time the foot is used, and is prone to overuse especially if the arch is not supported by proper footwear. Dancers experience pain and swelling at the inside base of the heel and arch area. Stretching the gastrocnemius complex, icing, anti-inflammatory medications, ultrasound, taping methods, massage, and supportive footwear and orthotics outside of the studio are all recommended.
    
6. Stress Fractures: Fractures can occur in any bone but in dancers a stress fracture occurs typically in the 2nd metatarsal. Tremendous stress is placed on the shaft of this bone while on pointe when the foot is maximally plantar-flexed. A stress fracture is evidence of ‘too much too soon’, and with dancers may also indicate inadequate vamp height of the toe shoe.  The area around the fracture may appear tender and later on the involved area may become very swollen. Dancers are especially prone to stress fractures not only because of the physical demands of ballet but also the quest for thinness. Many young dancers with amenorrhea (also known as the Female Triad Syndrome) are not consuming enough calories, fat, and calcium to allow for estrogen production, which plays a crucial role in making strong bones.
    
7. Achilles Tendonitis: The Achilles tendon, the largest tendon in the body, extends down the back of the leg to the heel and allows the dancer to rise onto pointe. Not lowering the heel completely down between relevés, ribbons that are wrapped too tightly around the ankle, and drawstrings or elastic which is too tight around the heel can all contribute to tendonitis. Symptoms include tightness, soreness, and swelling of the tendon, pain during relevé, and sometimes a slight stretching noise. Icing, stretching, and anti-inflammatory medications are recommended. While wearing high heels outside the studio may help alleviate the pain of Achilles tendonitis, prolonged wearing of high heels will contribute to it.

Nutrition

As touched upon earlier, the Female Triad Syndrome is common among young female competitive athletes and is seen often in dancers, gymnasts, and runners. The triad consists of amenorrhea (lack of menstrual cycle), disordered eating, and bone density loss (osteoporosis). Many high level ballet dancers spend 4-6 hours a day in ballet class and rehearsal and will continue outside of the studio, in aerobic classes, Pilates, yoga, or other therapies. The combination of continuous exercise and poor nutrition or anorexia and bulimia stress the body even further. Lack of calories, fat, calcium, and adequate body weight decrease bone density and make a dancer prone to stress fractures.

Footwear

In regards to dance footwear, if a dancer does not already have adequate knowledge of the proper fit of ballet slippers and pointe shoes, it is important to seek advice from a teacher or more advanced fellow dancer to ensure the shape of the shoe matches the shape of the foot as best as possible. For example, a dancer with shorter, square shaped toes and less of an arch will wear a pointe shoe with a lower vamp and a squarer shaped toe box. A dancer with very long toes, a high arch, and slender feet will require a pointe shoe with a longer vamp and stronger shank.

Proper fitting footwear outside the studio is just as important as the right ballet slippers and pointe shoes. Wearing the proper size and type of street shoes is not easy for dancers as they are used to having their feet confined to tight fitting dance shoes. Many times dancers will wear very tight fitting street shoes in sizes that are too small. To preserve feet that are already stressed by the nature of ballet, it is important to allow the toes to spread out and the arch to be supported well by footwear. Though dancers are used to spending a lot of time on demi-pointe, it only feels natural to walk around in high heels. Over time this places additional stress on the balls of the feet and shortens the Achilles tendons. Wearing high heels will only increase the chance of developing bunions, metatarsalgia, sesamoiditis, and Achilles tendonitis. Supportive footwear such as walking sneakers or running sneakers with firm heel counters and firm outsoles are recommended. An ideal shoe for inside the house would be a slip-on clog or sneaker with orthotics, or a supportive shoe such as a Birkenstock or Stegman Clog.

Adding custom orthotics can enhance the comfort and health of your feet and will greatly help in healing plantar fasciitis, neuromas, and other foot pain.

Prevention

To help prevent injury it is important to wear the proper footwear inside and out of the studio, and to seek medical help sooner rather than later. Private lessons with a teacher who can work one on one with a dancer are beneficial. Areas of weakness can be strengthened and improper technique can be improved.