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Battling Ballet Injuries

The dancer, like the athlete, experiences substantial physical demands related to movement and impact. The injuries sustained in dance – as well as the measures taken to treat, rehabilitate, and prevent these injuries – are similar to those encountered in sports. Sports medicine personnel are sympathetic to the need for continued activity, dynamic treatment and rehabilitation, and the use of so-called relative rest in handling injuries. Just as an improved understanding of the stresses placed upon the body in athletic activity has improved training techniques, enhanced performance, and decreased the incidence of injuries, the scientific study of dance is expected to yield similar benefits.

Studies of ballet dancers show that 90% of professional dancers and 63% of student dancers have had a dance-related injury at some point in their ballet career. Of these injuries, 60% – 80% include the knee, ankle, and foot.

There are numerous and varied explanations for the high incidence of injuries in the ballet/dance world. It appears, however, that the majority of ballet injuries are related to training errors and biomechanical imbalances caused by technique flaws. Ryan and Stephens in their book, Dance Medicine a Comprehensive Guide, report that forcing the feet to achieve turnout position beyond what the hips will allow is probably the most serious training error a dancer can make.

Ballet Turnout

Ballet turnout refers to the outward rotation of the legs and feet. There are five basic ballet positions of the feet. All ballet movements begin, end, or pass through at least one of these positions. In all five positions, the knees are straight and the legs rotated outward from the hips (figure 1).

In ballet, the generally recognized ideal turnout of 180 degree took several centuries to become commonplace. In fact, in the 17th century the standard angle of turnout was only 90 degrees. Greater degrees of turnout gradually developed because of their aesthetic appeal and the freedom of movement they allowed the turnout leg. By the 18th century, the angle of ideal turnout had reached the present-day standard of 180 degrees. Dancers ideally achieve 180 degrees of 2 –legged turnout. Typical ballet dancers have significantly less than 70 degrees of outward hip rotation. Studies demonstrate measurements  between 40 – 52 degrees of outward rotation. Realistically, few dancers can achieve this angle without compensations elsewhere in the body. These compensations may be allowed and even encouraged by dance instructors who stress the importance of ideal turnout. Unfortunately, forceful compensation for reduced hip outward rotation can, and often does, lead to many of the injuries seen in dancers.

Many patterns of compensation can increase a dancer’s ability to turn out. Three of the most common patterns of compensation are through the back, knees, and feet. Ironically, these three areas are also the most commonly injured in dance.

How can you determine if a ballet dancer’s turnout is being compensated inappropriately? Have a physical therapist or certified athletic trainer measure the actual passive external rotation of both hips. Then have the dancer assume their standing turnout first position. Trace their feet and measure the angle of turnout (figure 2). If the total functional turnout of both feet is greater than the total passive external rotation of both hips, then the dancer is compensating at the back, knee, or feet. Dancers should have at least 70 degrees of passive hip external rotation at each hip to obtain 180 degree turnout.

We recommend that dance instructors reduce the potential risk of injury to dancers by encouraging students to limit their functional turnout to a position that does not markedly exceed the total amount of outward rotation present at the hips. Teachers should encourage students with compensated turnout to decrease their turnout, and to increase their stretching and strengthening regime with the goal of improving their hip outward rotation as much as possible over time. Many dancers will never achieve the ideal turnout, yet can still enjoy the practice and performance of ballet.

En Pointe

In the ballet world, teachers are now very aware of the stresses they have to bear when training for pointe work. Pointes are shoes that support the dancer on their toes (mainly the great toe (See Figure 3)). Many years ago in the middle of the 18th century, dancers were looking for ways to increase the line of their legs while on stage. The highest position in the early part of the 18th century was the demi pointe which is where you stand on the ball of your foot.

As ballet progressed, new movements were required. A dancer would show her elegance by pointing her toe, holding that position then standing on the ball of her foot as she stepped forward. The natural progression from this was to stand on the toe from that pointed foot. The trouble is toes are not anatomically made for standing on. Many dancers from this period seriously hurt their feet, by pushing joints out, tearing tendons, rupturing blood vessels, breaking toes and causing permanent damage. Young dancers could be crippled for life if they went up on their toes too early, as the long-term damage without proper support could be serious.

This all changed ten years ago with the release of revolutionary designed pointe shoes from America – the Gaynor Minden. Brainchild of Eliza Gaynor Minden – an ex-dancer who desired comfort and durability from her shoe – the Minden has a specially designed high-tech interior designed to protect the feet. The thin inner and outer linings, made of shock-absorbent urethane foam, ease discomfort and reduce injuries. Elastomerics provide the cushioned toe and heel and a molded, strong supportive shank. And what is more, Mindens last three to five times longer.

What injuries commonly affect dancers?

Injuries in the amateur ranks are often due to the dancer trying to do things with their bodies that they are poorly suited to do. Injuries to professional dancers are usually related to the background and training of the dancer, length of time dancing, choreography (dance routine), tour schedule, type of stage or pattern and length of layoffs. The following are common injuries suffered by ballet dancers:

Spine:

–Kissing spines – interspinous sprain

–Schuermann’s disease – deformity of vertebrae

–Spondylosis – stiffness of vertebrae joint

–Spondylolithesis – partial dislocation of vertebrae

–Herniated lumbar disk

–Low back muscle strain and spasm

–Sacroiliac joint sprain – sprain in pelvic joint

Hip:

–Snapping hip – iliotibial band, iliopsoas (connective muscle and tissue)

–Bursitis – iliopsoas, greater trochanter (inflammation of connective tissue)

–Tendinitis – sartorius, rectus femoris, iliopsoas, pectineus, tensor fascia lata, piriformis, (tendon inflammation)

–Stress fracture – femoral neck (thigh bone)

–Arthritis – hip dysplasia

Knee:

–Patellofemoral pain, chondromalacia patella

–Patellar malalignment

–Patellar subjuxation/dislocation

–Tendinitis – IT band, quadriceps, patellar

–Osgood Schlatter’s disease – inflammation in knee

–acute muscle strains and ruptures – quadriceps, patellar tendon

–Meniscus tear – discoid lateral meniscus

–Medical plica, bipartite patella

–Osteochondritis dessicans – detached piece of cartilage

–Acute ligament sprain – ACL, PCL, MCL, LCL, posterior capsule

Leg:

–Perostitis – shin splints

–Acute muscle strain

–Stress fracture

–Chronic exertional compartment syndrome

Ankle:

–Anterior ankle impingement syndrome

–Posterior ankle impingement syndrome; often mistaken as peroneal tendinitis

–Achilles tendinitis

–FHL (big toe) tendinitis – dancer’s tendinitis; often mistaken as posterior tibialis tendinitis

–Trigger toe

–Os trigonum syndrome

–Painful accessory navicular

–Lateral ankle sprain – inversion injury

–Osteochondritis dessicans of the talus

–Fractures (acute and stress), dislocations, arthritis

Foot:

  • Acute muscle strains

Fractures

–a. stress fracture base of 2nd metatarsal (foot bone)

                  –b. stress fracture base of 5th metatarsal

                  –c. avulsion fracture base of 5th metatarsal

                  –d. acute fracture distal third of 5th metatarsal – dancer’s fracture

                  –e. sesamoid

  • Epiphysitis – first ray, proximal phalanx
  • Bunion
  • Cuboid subluxation
  • Plantar flexion sprain of the 1st MTP joint
  • Hallux rigidus – deformity of big toe
  • MTP joint subluxation; dorsiflexion sprain, gradual capsule stretching in older dancer
  • Avascular necrosis of the metatarsal (Freiberg’s disease)
  • Interdigital neuromas – abnormal tissue growths
  • Sesamoiditis – contusion, sprain, stress fracture, avulsion fracture of proximal pole, osteonecrosis, osteoarthritis, entrapment neuropathy

Skin:

–Fissuring – grooves in skin

–Callouses

–Soft and hard corns

Toenails:

–Subungual hematoma – blood beneath a nail

–Onycholysis – separation from skin

–Paronychia – toe infection

–Ingrown toenails – nail grows into skin of the toe

How are dancer’s injuries cared for?

Care for professional dancers is usually a team approach. The goal is prevention as well as treatment of injuries. The team may consist of a primary care physician, orthopedic specialist, sports medicine doctor, podiatrist, chiropractor, physical therapist, athletic trainer, massage therapist, dance teacher, technique coach, director and psychologist. The following are common treatments for chronic and acute injuries and preventative techniques:

  • NSAID, corticosteroids, analgesics – these will help reduce swelling
  • Warm up with moist heat and stretch
  • Use ice on injury after workout for 10-15 minutes
  • Sleeves, braces, splints, casting, orthotics, pads – these restrict mobility and lower stress on injured areas
  • Physical therapy exercises: motion and flexibility, posture, muscle, tendon balance, strength, endurance, balance and timing
  • Physical therapy modalities: ultrasound, estim, phono/iontophoresis
  • Massage Therapy, osteopathic, chiropractic manipulation, acupuncture
  • Surgery
  • Don’t rush back: begin with bar exercises, progress to floor, class then rehearsal and finally return to performing

First Position

FIGURE  1
with your heels touching stand in your best turnout. Let your feet melt into the floor to give your dancing secure roots

FIGURE 2

The Anatomy of a Point Shoe (FIGURE 3)

(1)   Platform of tip

(2)   Edge of pleats or feathers

(3)   Outer sole

(4)   Waist seam

(5)   Quarter or heel section

(6)   Vamp; top of the box that covers the toes

(7)   Pleats or feather; an area underneath the box where the satin is pleated to fit under the sole

(8)   Wings or supports

(9)   Shank or narrow supporting spine; attached to the back of the insole

(10) Stiffened box or block: made of layers of glue and fabric surrounding the toes and ball of the foot

(11) Drawstring knot

(12) Drawstring casing: piece of bias tape stitched around the edge of the shoe to contain the drawstring

(13) Insole

(14) Back seam: divides the quarters