En Pointe: Common Foot Injuries in Ballet Dancers

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Whether you’re a dancer who is considering starting pointe work soon, a dancer who has just bought their pointe shoes after the pre-pointe assessment has been passed or a family member of a dancer who has begun making regular remarks on the discomfort felt when even just sliding your foot into a pointe shoe, this blog is for you: En pointe - common foot injuries in ballet dancers.

“Can I take my shoes off yet?”, was something I found myself thinking often when adjusting to the Bloch ‘Heritage’ pointe shoes - my first pair of pointe shoes. Commencing pointe work is tough in many aspects just by virtue of the sheer demands and load on the feet.

This usually brings a whole new sense of discomfort and pain as your lower limbs adjust to the foreign hard Paper Mache objects of pointe shoes. However, there are specific types of pain that you should be paying close attention to and seeking guidance from a health professional for. In this blog, I’ll be touching on some common injuries of the foot and ankle that may present in ballet dancers starting their journey onto pointe or merely enduring pointe in general!

This blog will cover:

  • Two common foot injuries in en pointe ballet dancers
  • Risk factors for foot injuries in en pointe ballet dancers
  • Preventing foot injuries when going en pointe
  • Treatment options for foot injuries in en pointe ballet dancers
  • Handy side tip on bunions in ballet!
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Thinking of Going En-Pointe?

You might need a Pre-Pointe Assessment.

Find out the 4 common injury risk factors identified in PRE-Pointe Assessment, with this FREE resource.

Find our physio clinic in Brisbane Tarragindi

Our Brisbane Physiotherapy Clinic, services areas including: Brisbane, Tarragindi, Mount Gravatt, Holland Park, Rocklea, Yeronga, Annerley, Camp Hill, Carindale, Coorparoo, Salisbury, Sunnybank, Greenslopes, Seven Hills, Acacia Ridge, Indooroopilly, Woolloongabba, etc.

Because of our expertise in hip conditions, dance injuries and performance, and hypermobility, we also have people visiting us from all over Queensland, Australia and even international visitors. We also have a telehealth service for remote patients.

Two Common Foot Injuries in En Pointe Ballet Dancers

Flexor Hallucis Longus tendinopathy or tendonitis

What is FHL Tendinopathy?

Tendinopathy simply refers to a 'painful tendon'.  Most of you would be pretty familiar with what a tendon is - a fibrous structure that joins a muscle to a bone - in this case the FHL tendon joins the flexor hallucis longus muscle to the end of the big toe.  This condition may also be referred to as flexor hallucis longus tendonitis or tendinitis.1 The sheath or lining of the tendon can also become inflammed - this is called tenosynovitis.

FHL tendinopathy or tenosynovitis is usually related to a change in the tendon or the sheath that due to either too-much-load-too-soon or too much load for the tendon’s current capacity. This can cause pain and reduce function of the muscle and tendon itself.

Tendinopathies can be very tricky to manage and require targeted exercise approaches and activity modification in the short term to ensure the tendon isn’t being loaded too little or too much for the pain to settle down. This can be guided through physiotherapy management to ensure it doesn’t happen again as well!

What does the flexor hallucis longus muscle do?

The FHL muscle helps you to pointe your whole foot (plantarflexion) and specifically flex/ or point the big toe downwards.

What are the signs and symptoms of FHL tendinopathy?

Pain location is usually at the back of the ankle, bottom of the mid foot, base of the big toe or slightly inside the back of the ankle. This condition may even cause muscle weakness locally at the foot or ankle due to pain and discomfort. The inability to go en pointe or even point the foot without pain being present is another sign.

Sometimes you might be able to feel warmth and a crunchy feeling behind the inside ankle bone as you point and lift your toes - this is usually related to tenosynovitis.

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Posterior Ankle Impingement

What is posterior ankle impingement?

Posterior ankle impingement is an rritation in the back of the ankle joint either caused by a bony structural issue or a soft tissue (tendon or ligament) issue.1

What are the signs and symptoms of posterior ankle impingement?

Pain related to posterior ankle impingement most likely occurs at the back of the ankle which can also spread to the inside and/or outside of the ankle. Posterior ankle impingement can produce a sensation of pain or pinching when pointing the foot, particularly en pointe where more load is being placed through the foot and ankle.

What's the connection between FHL tendinopathy and posterior ankle impingement in dancers?

These two common conditions I’ll be walking you through in this blog are somewhat interconnected. Here’s why: posterior ankle impingement can be caused by several things and sometimes we don’t even know why but one of the causes can actually be FHL tendinopathy. So even though we can have a tendinopathy in the FHL tendon by itself, it can also then go on to cause or contribute to Posterior Ankle Impingement.

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Risk factors for development of foot injuries in en pointe ballet dancers

You might be thinking: Am I at risk? ... Let’s talk risk factors.

This can be where it gets a little confusing so let’s break it all down to make sense of what is occurring in the tendon and ankle joint to create this pain and what to do if you think you may already be experiencing this.

Risk factors you can control more easily through prescribed exercise by a physio:

  • Poor foot or ankle control, including balance
  • Tight or weak muscles in the foot and leg
    • Poor calf endurance in ballet dancers has been shown to be a significant risk factor in the development of injury2
    • Weakness of the foot intrinsics (muscles within the foot), results in greater loads on the ankle muscles
  • Incorrect training technique
  • Previous injury is a major risk factor
  • Repetitive forced or loaded plantar flexion (pointing the ankle and toes); aka pointe work

Risk factors that are modifiable but sometimes more out of your control:

  • Training Activities – for those times your teacher asks you to practise Grand Pas Classique for the 20th run in a row – for those who haven’t learnt this variation, 3 words…hopping en pointe.
  • Recent changes to training (duration, intensity, or frequency)
  • The fit of pointe shoes
  • Fatigue – for example, let’s just rehearse that piece one more time even though it’s 6pm and you started dancing at 8am plus it’s a Friday
  • Inadequate Warm Up for class or rehearsals
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Preventing foot injuries when going en pointe

Prevention is always key, so how do we ensure we don’t develop foot injuries when going en pointe to begin with?

Graduated transition to pointe work

To ensure you aren’t increasing the risk of developing these conditions, a key element is appropriate increase in loading for the back of your ankle. Allow your ankle to slowly get used to working in this new position. Start with short durations of pointe work and avoid back to back days of pointe training initially - allow your muscle, tendons and the joint to have a little recovery time.

Ensure you have strength higher up in your leg

Ensure your hip and knee muscles are strong, to reduce the load that the ankle and foot have to take when en pointe in the extreme pointe position.

Considerations for dancers selecting pointe shoes

Another aspect to consider is the style of pointe shoe you wear. Here are some tips when selecting shoes:

  • Impact on technique: If you have shoes that don’t suit your foot type, this can cause some suboptimal technique. This may mean FHL has to work even harder than it really should have to.
  • Rubbing: If your shoes don’t sit well on the back of your heel, the satin can cut into and rub against the tendons in the area, including the FHL tendons. This can add to the pain and discomfort of going en pointe.
  • Try them all! Find which pointe shoe allows you to pointe your feet as comfortably as physically possible, so all muscles can more equally support your joints when en pointe.
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Treatment options for foot injuries in en pointe ballet dancers

If you already suspect you may have FHL tendinopathy or posterior ankle impingment, what are your treatment options?

  • Proper assessment by a dance physio (pick me, pick me) to discern whether you have one of these conditions or something else that may still need to be addressed.
  • Advice on appropriate training modification
  • Advice on what NOT to do - for example., a lot of dancers are doing lots of calf stretching, which may in fact be worsening this condition, rather than helping!2
  • Exercises to strengthen the muscles in your feet and ankles.
  • Accounting for any other deficits higher up the body in other joints, such as the hips or knees, that may be letting those poor feet and ankles down if they’re not pulling their weight.
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Handy side tip – Bunions in Ballet

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One more common issue that can arise at the start of wearing pointe shoes is the formation of bunions.

  • Firstly, a fun fact is that the fancy term your physio may use for bunions is ‘Hallux Valgus’.
  • We measure this objectively and will prescribe targeted exercises to ensure both the reduction and prevention of them using muscles in your big toe.
  • We also may suggest the use of toe spacers or even seeking advice from a podiatrist to support you through some better options for your feet and pointe shoe style.

Remember to always have these en pointe foot injuries checked by one of our amazing dance physio, Rhianna or Dave, so we can tailor your treatment to your individual feet and body!

This is only the tip of the iceberg, there are many other factors and conditions that can exacerbate or even cause injuries such as posterior ankle impingement and FHL tendinopathy, but that’s for another time or during your future appointment with us.

If you’re looking for a pre pointe assessment, come to PhysioTec and let me or another dance physio design the targeted program you need!

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Thinking of Going En-Pointe?

You might need a Pre-Pointe Assessment.

Find out the 4 common injury risk factors identified in PRE-Pointe Assessment, with this FREE resource.

Do you you need help recovering from an injury? Improving your performance? Or just getting back to doing the things that you love? Visit us at PhysioTec, and let one of our physios assess you and provide you with a personalised program to help you get on-top of your condition, and feel at your best.

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This blog has been written by one of our experienced PhysioTec dance physiotherapists. If you would like to book with one of our dance physio's, Rhianna or Dave, call 3342 4284 or click here to book online.

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If you are wanting to improve your flexibility, need advice on safe stretching practices suitable for you, or are noticing pain while stretching, our dance physiotherapists Rhianna and Dave are able to help you on your dance and flexibility journey.

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References:

  1. Ivanova V, Todd NW, Yurgelon J. Dance-Related Foot and Ankle Injuries and Pathologies. Clin Podiatr Med Surg. 2023 Jan;40(1):193-207. doi: 10.1016/j.cpm.2022.07.013. Epub 2022 Oct 19. PMID: 36368843. https://www.sciencedirect.com/science/article/abs/pii/S0891842222000696?
  2. Calves Are Key: Research shows that calf endurance can make a huge difference in injury prevention.. (n.d.) >The Free Library. (2014). Retrieved Feb 24, 2023 https://www.thefreelibrary.com/Calves+Are+Key%3a+Research+shows+that+calf+endurance+can+make+a+huge...-a0636515959