What You Should Know About Dance Injuries

   In recent years, dance medicine has become increasingly separate from the traditional sports medicine culture. As dance injuries are being evaluated and studied from many different medical perspectives, it is becoming more apparent that there is a serious need for dance medicine specialists to educate not only the dancers but the dance company managers and teachers.    Awareness of injuries among dancers and their need for proper treatment and rehabilitation has become more accepted by the dance community. Prompt evaluation and treatment can facilitate long lasting benefits for dancers, and reduce the risk of damaging or career threatening injuries. Early intervention and treatment can save money, time and potential long-term disability. Intervening with young dancers can set a positive tone for future injury prevention and knowledge.    Dancers, like professional athletes, operate in a very competitive environment. Given this competitive culture, paranoia can set in for dancers. When they suffer injuries, they may seek medical care outside of the company’s medical staff and pay out of pocket in order to conceal an injury. Dancers realize that their contract may be scrutinized for past injury history and may ultimately lead to dismissal. It is understandable why this occurs as the average age for a dancer to retire may be in the mid- to late 20s, which is similar to the average retirement age of professional football players.    Fortunately, these attitudes towards medical care for the dancer are changing, due to intervention by doctors, physical therapists and company managers. Accordingly, this helps promote longer, healthier careers.

What About The Etiology Of Overuse Injuries?

   There are two types of injury mechanisms: overuse and traumatic. Dance injuries typically fall into the overuse category. Given the numerous repetitive movements in dance, there is a higher incidence of overuse injuries, which usually occur during class or rehearsals as opposed to happening during performance. Approximately 50 percent of overuse dance injuries are foot and ankle injuries. Injuries of the lower extremity comprise the vast majority of all dance injuries as well. Most injuries increase seasonally as the rehearsal and performance schedules increase.    Other contributing factors to overuse injuries include …    Age. Often, dance students start out very young and if they are pushed along too quickly, they may not have the ability to perform at a certain level, neurologically, structurally and/or emotionally.    Nutritional status. Unfortunately, as with other sports, aesthetics are very important and having a certain body type is expected. Young dancers may have a tendency to restrict food either by cutting calories, purging or over-exercising, which will lead to performance failure, injuries and the possibility of other developmental, mental and emotional problems.    Strength and flexibility issues. As the dancer matures, so does the technical difficulty of the dance class. When flexibility and strength are compromised, injury can ensue. It is very common for a dancer to have left and right-sided strength disparities, which one should address immediately. Going up onto pointe before a dancer has developed proper strength may lead to injuries. Physical therapy and classes like Pilates may help the dancer to improve these areas quickly. Many dance schools offer strengthening classes that are incorporated into the weekly dance schedule.    Biomechanical imbalances. Turnout is especially crucial among ballet dancers. It must come from the hip and not from the foot or knee. When bad turnout habits occur over a period of time, the dancer will often have problems. The soft tissues of the knee, hip, ankle and foot joints may be affected. Scoliosis may also be a detriment to a dancer as this may affect balance, aesthetics and create overuse back injuries.    Shoes. Proper fit of the ballet and other dance shoe is very important. As a dancer goes up on pointe (usually around 11 to 12 years of age), she or he should be evaluated and fitted by a professional. Although pointe shoes are expensive and have a short life span of approximately 10 to 12 hours of dancing, it is critical to have the correct shoes. Shoes that have been fitted incorrectly will accelerate issues with calluses, blisters, toenail trauma and, inevitably, bunions and hammertoes. Many dancers without properly fitted shoes will resort to stuffing various padding items into the shoe in attempting to adjust the fit, often making matters worse.    Flooring. Flooring may be the most subtle etiology of overuse injuries. A hard, unforgiving floor may predispose the dancer to increased stresses through the lower extremity. The important properties of good flooring are resiliency, shock absorption and surface friction. Many floor companies use techniques and products that achieve these properties. Most professional companies travel with their own flooring and use it for rehearsals and performances.    Class schedule. It is not uncommon for dancers to be taking classes five or six days a week and for three to five hours at a time. This type of schedule may infringe on proper eating habits, and may create fatigue and even burnout. It may be best to space out classes throughout the week when the body can recover more properly.    Non-healed injuries. Typically, the healing of injuries takes time, thorough evaluation and medical care. Many companies and dance centers are becoming familiar with preventive medical care and early detection of common injuries. However, if the dancer returns too soon after an injury, other muscles and joints may compensate and result in additional injury. Dancers typically are tough athletes. They endure pain and injury, and continue dancing even when it exacerbates an injury.

A Guide To Common Dance Injuries

   Anterior impingement syndrome. Typically anterior ankle capsule pain can be reproduced by demi plie. This impinges the capsule. It can become very irritated and “stuck,” as the dancer describes it. These injuries can result from a spur or oddly shaped talar dome.    Posterior impingement syndrome. When an os trigonum is present at the posterior ankle, going up onto pointe may become very uncomfortable. The ossicle or capsule can get impinged and the flexor hallucis longus tendon may get inflamed as well. If the pointed foot position is too far forward or ligamentous laxity is present, the tibia may ride too far back onto the talar dome and cause the impingement.    Stress fracture. Similar to athletes in other sports, dancers typically experience stress fractures of the second or third metatarsal. Increased jumping and landing may be the cause of this injury. Nutritional deficits or amenorrhea may predispose the dancer to this as well.    Dancer’s fracture. This is a spiral fracture of the fifth metatarsal. It usually occurs in the distal third of the shaft. This injury may occur while rolling off pointe, and may involve a lateral ankle sprain in addition. One can usually manage a dancer’s fracture conservatively with a walking cast.    Midtarsal joint/ Lisfranc’s ligament injuries. The proper pointe technique requires the dancer to plantarflex at the Chopart’s joint, which is the “coup de pied.” Many dancers force plantarflexion at the first/second metatarsal cuneiform joints and this will lead to instability and overstretched ligaments in that area. These injuries are chronic in nature and may result in hypermobility and chronic pain in that area.    Shin pain/posterior tibial tendonitis. This injury occurs when dance classes and rehearsals involve a lot of jump work, or when new or unfamiliar flooring is present. If dancers force turnout while they are pronated, it will lead to strain of the posterior tibial muscle. There may also be imbalances as footwork never involves an inverted position but instead creates a “winged” (abducted, non-weightbearing) type position, which results in constant stretching of the tendon.    Cuboid subluxation/peroneal tendonitis. Due to the turned out positions in dance, the peroneal muscles are often concentrically contracted, which can cause shortening and potential injury. They help the pointed foot have the appropriate “winged” appearance, etc. However, the tendons can get irritated or eventually slip out from behind the malleolus from strain or a tear of the retinaculum, and create snapping and subsequent instability. This injury may require surgery. The cuboid may sublux or rotate out of position, sometimes in association with an ankle sprain. This injury is quite painful. Cuboid padding and manipulation is the treatment of choice. One should rule out fracture if this injury is associated with trauma.    Metatarsal joint level conditions: capsulitis/metatarsalgia. These conditions are common among dancers and need immediate treatment. One should evaluate shoe changes (street and dance) during the treatment process.    Neuritis/neuroma. This is not unusual with all the pivoting and jumping. Traditional treatments usually work well. One should avoid surgery and emphasize correct shoe sizing for dance and street shoes.    Sesamoiditis. This condition is common with all forms of dance. A fracture should be ruled out. With all of these conditions, evaluate shoe fit and avoid walking barefoot. Strapping, padding and injection therapy may help.

Addressing Common Dermatological Conditions And Injuries

   Toenail bruising and injury. This occurs primarily when dance shoes are too tight. Excessive jumping on pointe will bruise the nails, especially the hallux nail. One should aspirate the nail and accommodate the toenail with padding in all the dancer’s shoes. Also tell the dancer to avoid jumping or pointe work for a few days.    Blisters. Increased friction on the foot may lead to blisters. Modern dancers dance barefoot and many suffer from increased blisters and calluses.    Corns and calluses. Corns may develop any time dancers have bony pressure. These can be especially difficult to accommodate with padding in pointe shoes because they are tight. Traditional callus care will keep the buildup to a minimum. One should encourage digital padding in street shoes.    Warts. These lesions are difficult to treat in the dancer especially if they are in an area of friction. They can be painful and difficult to manage. Encourage regular shaving and application of desired topical products on a regular basis.

Assessing The Treatment Options

   Treatment should always start with prevention. Screening the dancer’s biomechanics, flexibility and strength is essential. When a dancer is injured, early medical intervention can easily reduce rehabilitation time. Having physical therapy and medical services close at hand greatly facilitates immediate treatment. Traditionally, most injuries can be rehabilitated easily in house via physical therapy, massage or the care of a visiting physician.    Treatment should always be swift, with an emphasis on aggressive conservative care. One should consider the following treatment guidelines:    1. Institute RICE (rest, ice, compression, elevation).    2. Use antiinflammatory medication as needed.    3. Encourage early use of physical therapy modalities and massage therapy.    4. Consider homeopathic injection therapy, an excellent alternative to corticosteroids.    5. Prescribe relative rest with proper cross-training for cardiovascular support.    6. Evaluate and correct biomechanical imbalances.    7. Improve nutrition knowledge via handouts, short lectures or suggest visits to a nutritionist.    8. Dance pointe shoe changes can help, but keep in mind that advanced and professional dancers often find it difficult to accept or adapt to these shoe changes.    9. Recommend a revision of the dancer’s class or rehearsal schedule in order to accommodate rest days.    10. Strengthen weak or imbalanced areas.    Surgery is not a first choice for most dancers. While a loss of 5 degrees of range of the first MPJ after bunion surgery may not bother the general population, it can have devastating effects on a ballet dancer. If surgery is necessary, excisional type procedures work the best as they have quick recovery times.

Final Words

   The early intervention and treatment of dance injuries is becoming more commonplace. Many dance companies and studios are incorporating physical therapy, massage and podiatry care into their budget. This can save enormous amounts of time off, medical care costs and may allow the dancers to extend their careers for many years. Dr. Schoene is a board-certified sports medicine podiatrist, and a certified athletic trainer. She treats many dancers and performing artists of all ages and backgrounds. She is the podiatrist for the Joffrey Ballet of Chicago. For other articles on treating dance injuries, please see “How To Identify And Treat Common Ballet Injuries” in the April 2003 issue and “Treating Foot And Ankle Injuries In Ballet Dancers” in the June 2003 issue, or check out the archives at www.podiatrytoday.com