Posterior Ankle Impingement in Dancers
Ankle pain can be a challenging thing for ballet dancers to overcome. It might creep in during rehearsal, flare up after a long day of training, or stubbornly linger despite your best efforts to rest and recover. While many dancers are familiar with conditions like Achilles tendinopathy or ankle sprains, if you're feeling a nagging pain at the back of your ankle that worsens every time you point your foot, you might be dealing with a lesser-known culprit: posterior ankle impingement. Let's unpack what this is, how it presents, and — most importantly — what you can do about it.
In this blog, we'll discuss what posterior ankle impingement is, its symptoms and causes, and finally how to treat it.
This blog will cover the following topics on Posterior Impingement:
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What Is Posterior Ankle Impingement?
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What Causes Posterior Ankle Impingement?
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Reducing Your Risk of Posterior Impingements
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Treatments for Posterior Ankle Impingements in Dancers
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What Is Posterior Ankle Impingement?
The anatomy behind the pain
Dance has the reputation of being heavily associated with injuries, especially in the ankle. For many dancers, posterior ankle pain can be all too familiar, interfering with training and performances. Often, this pain can be caused by posterior ankle impingement. Simply put, posterior impingement is a compression of the sensitive structures at the back of the ankle causing chronic pain. Let's break down the anatomy! The posterior aspect of your ankle includes many soft tissue structures such as tendons, ligaments, the joint capsule that may become overly compressed by the bones at the back of the ankle.
At the back of the ankle, some people have an extra piece of bone or a larger-than-usual bony prominence (Os Trigonum or Stieda's Process). Most people never know it's there because it doesn't cause any problems. However, in some dancers it contributes to impingement when the foot points downward, leading to pain at the back of the ankle.
However! Bony anatomy alone is not enough for a posterior impingement to spontaneously appear. In fact, there is no good-quality evidence that correlates a relationship between imaging findings of an os trigonum and having posterior ankle pain. Research indicates up to 25% of the population has this bony structure with the vast majority never developing a posterior impingement. Similarly, people without an os trigonum can develop a posterior ankle impingement. Impingement of bony structures AND/OR soft tissue structures could be the cause of the pain.
Why dancers are particularly at risk
The incidence of posterior impingements in dance is incredibly high. This is mainly attributed to the repetitive plantarflexion or 'pointing' of the ankle that dance requires. The frequency of plantarflexion in dance is enormous! Every tendu, every pointed kick, every grande jete, every relevé on pointe OR demi-pointe involves plantarflexion and subsequently compresses the back of the ankle.
How does it present?
Posterior ankle impingement in dancers can come on gradually or is often experienced after an ankle sprain. The pain pattern of posterior impingements are a key part of their presentation. Typically, posterior impingement pain is worse when you first start dancing but then may improve or 'warm up' as you continue with your class. However, after you have cooled down, the pain will often return. This pain is commonly felt to the outside of the Achilles, however, can also be experienced more on the inside.
Posterior ankle impingement can often be mistaken for an Achilles tendon issue or general ankle soreness, and can be aggravated by activities such as pointing your foot, dancing on demi-pointe or pointe, jumping, or even just walking after a big training day. Because symptoms can overlap with other conditions, an accurate assessment is important.
Not sure if your pain is coming from a posterior impingement?
Book in with Millie, our Dance Physio today, for a comprehensive assessment!
Causes of Posterior Impingements?
As mentioned, posterior impingements don't arise from your anatomy alone. There is a many other reasons as to why this condition can develop in dancers.
Increased plantarflexion load
One common reason is an increase in plantarflexion load. This can look like doing more pointe work, having a routine with lots of relevé or pirouettes or simply just putting more hours in at the studio.
Ankle sprains
Another common catalyst for posterior impingements is a lateral ankle sprain. Ankle sprains can be shrugged off as 'no biggie!'. Often, cultural ideals or upcoming performances influence a dancer to feel the need to push through. Swelling from the injured ligaments can easily migrate towards the subtalar space (back of the ankle), causing posterior pain. On top of this, a lack of stability caused by the injured ankle ligament increases micro-movements between the talus and the tibia, causing further inflammation.
Inadequate strength and alignment
Posterior ankle impingement in dancers can also be contributed to by inadequate foot and ankle strength and alignment control. Your muscles should be working to control your foot and ankle, alleviating stress on the joints. Weakness in your ankle and foot musculature can put excessive force through the ankle joint leading to inflammation of joints and/or tendons. On top of this, 'Winging' or 'Sickling' your feet during rehearsals compresses these inflamed spaces further.
Hypermobility without control
Hypermobility in the ankle joint, paired with inadequate control, can also act as a predisposing factor for posterior ankle impingement in dancers. Whilst having 'hyper-flexible' feet is often considered a bonus to create more aesthetic lines, this increase in range needs to be well controlled. If you have the tendency to 'sit' or 'hang' in your pointe, it will create excess shear forces and 'jam' the posterior ankle joint.
Ill-fitting or worn-out pointe shoes
Another commonly missed contributing factor to posterior ankle impingements in dancers is ill-fitting or old pointe shoes. Dancing in old shoes won't only work against you in terms of technique but also puts you at risk of injury. Your pointe shoes should support your foot at the box and the shank. If you feel like you are sinking in your box or the shank is twisting or bending at the wrong part of your arch, your shoes may be contributing to the problem.
Reducing Your Risk of Posterior Ankle Impingement
Whilst the nature of dance makes posterior ankle impingements a common injury, there are many strategies dancers can implement to avoid them entirely.
Strengthen your feet and ankles
The first thing you can do is to ensure your feet and ankles are strong! Simple exercises such as doming and calf raises will strengthen your foot and ankle stabilisers, putting less pressure through the sensitive structures at the back of your ankle. Also! It has the added benefit of assisting with your technique! Stronger foot intrinsics and stronger calf muscles will allow you to jump higher and balance for longer.
Address your technical alignment
Similarly, poor technical alignment and jumping mechanics can lead to compression of posterior ankle structures. Our dance physio can assess your alignment on demi-pointe, full pointe and with jumping to ascertain whether your technique could lead to injury.
Monitor your dance load
Another key way to avoid posterior ankle impingements in dance is by monitoring your dance load. This is not just how many hours you train a week, it can also look like how much plantarflexion or 'pointing' you are doing in your classes.
It's common for dancers to not recognise that certain routines may have more challenging or strenuous steps that can inflame the posterior ankle. For example, you may be dancing the same number of hours, but maybe you are working on a variation that has a lot more hops en pointe than your body is used to. An increase in load is not just the time spent in the studio, it is what you are doing in the studio too.
Don't ignore ankle sprains
A key contributor to posterior ankle impingement in dancers is a previous ankle sprain. Don't ignore them! Even a small ankle sprain that resolves quickly can lead to inflammation and instability. A combination of inflammation and instability is a key catalyst for the development of posterior impingement.
Instability causes shear loads, shear loads cause inflammation and inflammation often promotes further inflammation as well as pain. It can snowball! Our dance physio will address the ankle sprain when it is only an ankle sprain, to ensure that your symptoms don't morph into a new problem.
Check your pointe shoes
Checking your dance shoes is an under-appreciated, preventative measure. The fit of your dance or pointe shoes can make a major impact on your technique and your safety when dancing. Ensuring your shoes are supporting your heel and your metatarsals will avoid excess stress through the posterior ankle with the added bonus of helping your technique.
Experiencing pain at the back of your ankle, just outside the Achilles, or deep in the ankle joint? Finding pointing your foot, dancing on pointe or demi-pointe, jumping, or cooling down after class uncomfortable?
Book today and let Millie, our experienced PhysioTec dance physiotherapist assess your foot and ankle, identify the source of your pain, and create a personalised plan to restore comfort, strength, and confidence in movement.
Helping you move better and get back to the activities you love.
Treatments for Posterior Ankle Impingement in Dancers
Are you a dancer with posterior impingement or pain at the back of your ankle? Never fear! PhysioTec are here! Our physiotherapists will work with you to get you back to dancing at your best. We listen to your symptoms, concerns and your goals to form a tailored treatment plan.
Your physiotherapist will use an array of treatment modalities to improve your symptoms including load modification, exercise therapy, taping and manual therapy. They will look beyond the ankle and address any contributing weaknesses further up the kinetic chain, in the knee, hip or core.
Our dance physiotherapist utilises standardised physiotherapy measures but also uses more dance-specific skills to address all predisposing factors. She also will assess your pointe shoes. Pointe shoes have their own anatomy with different length vamps, wings and crowns to suit all different types of feet. She may recommend new or different shoes to help you in your recovery.
All our physio's will ensure your treatment is specific to you, addressing all contributing factors with the aim of restoring efficient biomechanical loading, strength and pain-free function.
Ready to take control of your posterior ankle pain?
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Author
This blog was written by Millie Jones, our Brisbane Dance Physiotherapists, here at PhysioTec. Millie has a special interest in dance health and safe training practices, and is known for her work in Pre-Pointe Assessments—proudly describing herself as a “pointe shoe nerd.” Millie loves helping dancers feel confident and prepared as they transition to pointe, combining tailored strengthening programs with specific shoe recommendations.
You can read more about Millie here.