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Dance Technique incorporating safe dance practice

Performing sequences relative to anatomical structure

Causes and prevention of injury

Common dance injuries

The foot and the ankle

Anatomy
Injuries
Prevention
Identification of injuries
Treatment
Skills and technique

Anatomy

The foot consists of twenty-six bones, twenty-nine joints, thirty-one muscles, and many ligaments, tendons, nerves, arteries and veins. The bones of the foot are divided into three groups; seven tarsal bones, five metatarsal bones and fourteen phalange bones. The two largest and most important of the tarsal bones are the talus and the calcaneus, (otherwise known as the heel bone). The lower end of the Achilles tendon is attached to the calcaneus and the talus sits on top of the calcaneus, the joint between them is known as the Subtalar joint. The upper part of the talus forms part of the ankle joint. The metatarsal bones extend out in front of the ankle to the based of the toes. The phalanges are the bones of the toes themselves, and each toe has three except for the big toe, which has only two.

There is a great deal of movement in the toes and in the ankle region but some of the other bones have very little movement between them. Another important joint for dancers is the Ankle joint, located between the talus and the inferior ends of the tibia and fibula bones. Both these bones have a downward projection, which enclose the talus and stabilise the ankle joint. The knob on the out side of the ankle (the projection of the fibula), is called the Lateral Malleolus, while the bony projection (part of the tibia), on the inside is known as the Medial Malleolus. The ankle joint is held together by ligaments. The most important of these are the Medial and Lateral ligaments which join the talus to the to the tibia and fibula. The lateral ligament is the one that you damage when you sprain your ankle and if it becomes completely torn, the ankle becomes very unstable.

The only movement that can occur in the ankle joint is pointing and flexing of the fool. The medical terms for these actions are Plantar-flexion for pointing of the foot, controlled by the Soleus muscle and Dorsi-flexion for the flexion of the foot controlled by the Tibialis anterior. Its counterpart is known as the Tibialis Posterior. Their tendons pass around the inner ankle and under the foot. An
accessory muscle to the Soleus is the Digitorum longas. The Subtalar joint provides the other movement of the ankle. The movement occurring in this joint is a side to side rolling movement, which allows you to adapt to a slop or uneven ground.

The muscles of the foot can be divided into two main groups; Intrinsic and Extrinsic. The intrinsic muscles are short and relatively weak and are contained only in the foot. The extrinsic muscles are powerful, and are found in the lower leg with their tendons passing through the ankle region exert their effect within the foot. The most powerful of the extrinsic muscles is the gastrocremius which acts through the Achilles tendon on the calcaneus and when it contracts it helps to raise the heel of the ground. There is a group of tendons that run behind the inside ankle joint, and whose main effect is to point the toes as well as a group that run down the anterior side to flex the foot as well as moving other parts of the foot. The tendons behind the outside ankle bone go to the structures on the outer side of the foot.

The foot has an arch, and this important for it’s normal function. There are three factors that help to preserve the arch of the foot: 1. The shape of the bones. 2. The ligaments that join the bones together, and in particular the Plantar Fascia, which stretches across the arch of the foot and is attached to the under side of the big toe. 3. The powerful extrinsic muscles in the lower leg whose tendons pass through the ankle into the foot and pull the arch upward. The most important of these factors is a muscle called the Flexor Halucis longas. It is the muscle that points the big toe. (Hence the Latin word “hallux”, meaning big toe.) The belly of this muscle is in the calf, and its strength is out of proportion compared with its neighbours.

Some of the other terms for the movement allowed by the foot muscles are; raising the inner bore of the feet, called Inversion, raising the outer boarder, called Eversion, turning the forefoot in towards it’s neighbour is called Adduction, Turning it away is called Abduction. A combination of adduction with inversion with a bit of plantar flexion is called Supination and abduction with eversion and slight Dorsi-flexion is called Pronation. Muscles that primarily evert the ankle are the Peroneus Longis and Peroneus Brevis.

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Injuries

Overview
March fracture
Hallux rigidus
Hammer toe
Toe sprain
Bruised big toe
Plantar fascial strain
Foot pronation
Ankle sprains
Flexor hallucis longus tendonitis
Achilles tendonitis
Achilles tendon rupture
Dancer’s heel
Os trigonum

Overview
Correct transmission of the weight becomes much more difficult with the feet turned out 180 degrees. If a turn out comes from the knee or the ankle rather than the hips, the proper alignment of the foot to leg to thigh is lost, and a disproportionate amount of weight comes over the inside of the foot causing it to roll. This bulging over the inner border of the foot can cause irreversible stretching of the ligaments as well as tendon strain. Many feel that rolling is responsible for chronic tendon problems, (particularly the Achilles and the posterior Tibialis tendons), since a malposition produces a malalignment of the tendon. It takes more than overworking the ankle in the opposite direction to compensate for the problem. The best way to combat a roll is to work on turning out from the hips and settle for a lesser angle of turn out than to push it and to develop the intrinsic muscles with appropriate foot exercises.

March fracture
A March fractures or stress fracture, hairline in size, refers tot he fractures of the metatarsal bone that is the consequence of accumulated impact and shock. Pain and tenderness are association with jumping; the symptoms subside with rest but resume with activity, which may additionally produces swelling and redness.

Hallux rigidus
This form of arthritis involves the joint between the foot and the big toe. Continued irritation to the big toe leads to joint enlargement and inflammation; gradually, over a period of time’ the toe can become permanently rigid. Pain and restriction of motion at this joint is a severe disability in that it limits the height of demi-pointe and seriously impairs jumping. Specialists may suggest helpful forms of treatment for both the early and the chronic conditions. Acute flare-ups are common and should be treated with great respect and care, including not only complete rest, but also manipulation by a trained physical therapist.

Hammer toe
Cramped toes can eventually lead to toe deformity, hammertoe being a good example in the dancer. In this condition, the first toe bones points upwards, while the second and third phalanges are flexed downward. This deformity is especially prevalent in the second toe, which is often slightly larger than the big toe and hence is bent down at the end when on pointe. Additionally, hallus valgus can cause the big toe to encroach upon it’s neighbour, again causing it to hammer.

The ends of hammered toes are typically well callused, as are the top surfaces from pressure against the shoe. Once hammering develops, there are no corrective exercises, and manual stretching of the flexed toe is not effective.

Toe sprain
Jamming the toes against a more worthy opponent, (e.g. the floor), is an occupational hazard of the dancer and is generally the cause of toe sprains. If the big toe is involved, attempts to resume working are often accompanied by the reassurance of pain, swelling, and disability.

Bruised big toe
A dancer, quite commonly, will jam her big toe on point in a way that causes bleeding and swelling under the nail and produces pressure build-up and pain. This injury is rather acute and can be simply healed by drilling a small hole into the nail, a painless procedure done by a podiatrist, which will allow blood to escape and relieve pressure. After a hot soak and antiseptic, the dancer may immediately go back on pointe without any difficulty.

Plantar fascial strain
Landing from leaps and jumps can triple or even quadruple the forces that the foot normally encounters. These jarring stresses can strain the plantar fascia, a sheet of fibrous tissue that extends from the heel to the bases of the toes, enfolding and supporting the muscle and other structures under the foot and assisting in maintaining the arch. Damage to this tough membrane causes pain and irritation of movement, and is considered by many physicians to be one of the most common serious injuries for dancers.

Foot pronation
Foot pronation is a very important shock absorbing mechanism. The Subtalar joint, just below the ankle, is a primary factor in transmitting various forces from the foot to the leg, and it defines how the foot pronates in reaction to these forces. Excessive pronation is commonly associated with malalignment, as well as many overuse injuries and developmental foot deformity. Controlling the pronatory factors may decrease the deformity, and is definitely advantageous in reducing the overuse injury potential.

Ankle sprains
The are many cause of ankle sprains, perhaps the most common cause is inadequate rest from a previous ankle sprain, another is poor technique in landing from jumps, particularly with the foot supinated. Certain dance steps also seem to carry a higher risk for ankle sprains. At the end of a long day when fatigue is a factor, rehearsing new, unfamiliar and advanced steps can be a very real threat. Other disorders of the feet and ankles can predispose to ankle sprains, and uneven ground surfaces and/or hard surfaces are also a large factor.

Sprains are classified into three grades, one being the mildest and three being the most severe. A grade one sprain means there has been a slight tearing in the fibres of the ligaments of the muscles. Grade two involves a more severe tear. A grade three is a complete disruption or tearing of one or more ligaments.

Flexor hallucis longus tendonitis
The flexor Hallucis Longus tendon, (FHL), runs behind the medial malleus of the ankle, along with the tendons of the posterior Tibialis and the flexor Digitorum Longus. This muscle and tendon can be thought as the Achilles tendon of the big toe. The FHL tendon is unique among the three tendons mentioned above in that it passes through the fibro-osseous tunnel just behind the malleolus. This is one of the reasons why the tendon is so involved in tendonitis. Hallux Rigidus (see above), pronation, Malalignment, poor technique and lack of strength around the ankle area are main causes but occasionally, nodules form on the tendon, resulting in triggering and snapping of the big toe.

Treatment primarily consists of anti-inflammatory medications; thermotherapy in the form of ice massage and/or ultrasound, electrical stimulation to decreases swelling and inflammation and stretching and strengthening the FHL tendon with physical therapy techniques may also be required. Rest and care of the foot is essential.

Achilles tendonitis
The Achilles tendon is attached to the to a facet in the calcaneus. The tendon is shaped somewhat like an hourglass. There is no true synovial tendon around the tendon, rather it is covered by fascia, and the fascia forms a sheath. There are numerous factors, which contribute to Achilles tendonitis, tightness of the heel cords, which is quite common in dancers because most work is done in plantar flexion. Anatomical variation of the Achilles, with persons having smaller and thinner Achilles tendons being more susceptible to strains. Supination or pronation of the foot, hard or uneven surfaces and forced turnout. Additionally, the prominence of the posterior superior portion of the calcaneus may cause mechanical irritation and tendonitis of the Achilles. Chronic tendonitis may result in nodule formation or adhesions at the tendon. Not only is an improperly cared for stain susceptible to becoming a chronic bother, but prolonged, non-traumatic, irritate stresses can also result in tendonitis.

Non-surgical management includes anti-inflammatory medications, ice massage, ultrasound with electrical stimulation to reduce oedema, contrast baths, and range of motion only up to the point of mild discomfort not pain. Resting of the foot and ankle is essential for a while.

Achilles tendon rupture
This is probably the most dreaded and feared injury that befalls a ballet dancer. With a complete tear due to overuse, extra stretch to a maximally stretched tendon, or a direct blow, early surgical repair is necessary. Immobilisation in plaster will last approximately a month. Common sense and precautions can help avert this dance disaster Routine stretching and warm-up of the calves and Achilles should always be a high priority; an Achilles strain should be treated with rest and care, and superficial temporary relief for the Achilles tendon problems by injections should never be considered.

Dancer’s heel
Dancers who do a lot of pointe work on a hard floor will sometimes develop pain above the calcaneus in the area of the Achilles tendon; this condition, commonly referred to a dancer’s heel, is apparently caused by inflammation secondary to trauma in the joint between the calcaneus and the talus. Pointing the foot, making pointe work with the knees properly straightened; difficult brings about the pain. Since standard physical therapy techniques sometimes have little effect, the most appropriate treatment is rest, which, practically speaking, means working flat-footed or rising only so far as not to cause pain.

Os trigonum
The Os Trigonum is a small bone, which may be either separated from or fused to the posterior side of the talus. Usually absent, it is normal anatomical variation, a completely functionless structure, which in the dancer may impede function. On full pointe, the posterior side of the calcaneus normally comes up to touch the lower end of the tibia. If the Os Trigonum are present, it may form a block between the two bones, nipping soft tissue structures, causing inflammation, and restricting full plantar flexion. The pain behind the ankle can often be mistaken for Achilles tendonitis. Surgical removal of the bone relieves the symptoms and entails approximately a three-month recovery period.

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Prevention of Injury

Prevention of injuries can be achieved by reducing risk factors, and by following appropriate steps to benefit and strengthen the body.
Warm up and cool down is a vital part of healthy exercise in that it prepares the body for the forces that we exert on the body during exercise. They mentally prepare us for physical activity and therefore better concentration may be achieved and therefore safer practices are performed. Warm ups should consist of:

  1. Gross motor skills and movements for increased body temperature and to raise the heart rate.
  2. Stretching; which benefits in that it reduces muscular tension. Enhances circulation, Increases muscle and tendon length and in creases the range of motion and suppleness.

Stretching is divided into three groups:

Correcting techniques aids in the prevention of injury in that good technique and safe dance practices often complement one another. Incorrect technique can cause injury that may prove serious, it can involve biomechanically unsafe and unsound movements, which place unnecessary, stresses on muscles, bones, and joints.

Overuse injuries usually result from repetitive, stressful activities. It has been estimated that about a third of most reported injuries are associated with overuse and 80% of those injuries occur in the lower extremities. Common causes are training error due to an increased intensity program with little adjusting time, inappropriate footwear and biomechanical and malalignment factors.

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Identification of injuries

Muscle injury symptoms can include:

Joint and ligament injury symptoms can include:

Bone injury symptoms can include:

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Treatment

Foot and ankle injuries, being so common and potentially disabling, are of the utmost importance to those concerned with dance medicine. Early and aggressive rehabilitation, stressing functional activities, full restoration of strength, range of motion, proprioception and endurance, and gradual return to dance activities, will serve to minimise disability. The importance of maintaining good general physical condition during the rehabilitation process cannot be over emphasised. Finally, appreciating that inadequate treatment often leads to re-occurrence of injury should cause us to look at these injuries more seriously. Allowing the entire body to become deconditioned because of an injury to a specific part is a common problem. It is also easily avoidable. In the case of foot and ankle injuries, swimming is often an excellent solution. Proper rehabilitation should consist of the acronym R.I.C.E.D, (rest, ice, compression, elevation and diagnosis), stretching, strengthening, conditioning, and training before returning to a lower level of training.

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Skills and technique

Safe dance practises require you to condition your body according to the demands of your style of dance and the health requirements of your body. Prevention of injury, (safe dance), requires some knowledge of the body system and knowledge of the individuals personal limits and boundaries. Warming up the ankles in the feet is rather important in dance because they are constantly worked during dance and they become the shock absorbers for the body. Following a proper warm-up pattern, including gross motor movement, stretching and skills related to the skills needed in the actual exercise. Warm-up is important in preparing the body for all the possible stresses it may come to encounter.

Simple technique exercises and skills such as open first positioning of the feet requires concentration and knowledge of what to do and what should be avoided. In first position the ankle must be kept in line over the feet, the feet should be at a comfortable degree of turn out and should not cause pain in the feet on ankles. The proper alignment of the feet and ankles are desired to keep the strength of the ankle and foot high, and to reduce the risk of the ankle collapsing or weakening.

Forced turn out is unsafe as it causes the feet to roll and can flatten the arch of the foot, it can also cause tendon damage and if the damaged is prolonged it is possible that the problem may become a chronic problem and will therefore be irreversible. It is important for dancers to feel the floor and move through it so that the feet can provide the body with the support it needs.

Cool-down is just an important as warm-up and should consist of the reverse of a warm-up. This will benefit the muscles and tendons and prepare the body for resting after the exercise. Remember that rest is just an important as technique is, it reduces the risk of overload.

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