Ankle Pain In Dancers
by Dr. Amber Roberts, PT, DPT
Ankle injuries are among the top two most common injuries seen in dancers. The extended amount of contact hours to sport, the amount of force that the ankle is accepting and the increased range of motion required for a dancer can lead to dysfunction resulting in injury. Below are listed the most common diagnosis seen in this population and what treatment can address the dysfunction in hopes to allow an athlete to have a long, healthy season!
Common Injuries seen in Dancers:
Ankle Sprain
Lateral ankle sprain – The most common type of ankle ligament injury observed. Secondary to an inversion injury (foot flaring inward). There are 3 different ligaments on the outside of the ankle that resist inversion.
Medial ankle sprain – typically occurring secondary to a forceful eversion + dorsiflexion injury (foot flaring out and up). The deltoid ligament is the structure impacted and consists of 4 different ligaments. Avulsion injury (pulling away of a portion of the bone at the tissue attachment point) may accompany these injuries.
High ankle sprain (syndesmotic injury) – excessive eversion paired with dorsiflexion can cause this type of injury. Planting the foot and completing a forceful cut (external rotation) may also lead to this injury
Ankle Instability – commonly observed after a ligament sustains an injury. The ligaments have lost their tensile strength subsequently causing extra instability and laxity.
Foot hypermobility – the foot has many different joints that all work as a team to dissipate and transfer the force accepted here up the chain. If these joints compensate for a lack of motion elsewhere or just have more mobility this can lead to less efficiency in force acceptance, creating pain.
Lack of medial arch support – the medial arch of your foot is predominantly supported by a muscle (Tibialis Posterior). If this muscle is unable to control the arch of your foot during high force movement it leads to over pronation of the foot. Pronation makes the foot less efficient when accepting weight and increases the overall stress placed on the joints and other support tissue.
Achilles tendinopathy – when the force of the calf muscle is exceeding the tensile strength of the tendon creating irritation and microtearing. This inflammation of the tendon can lead to pain with movement and can progress to failure of the tendon.
Flexor Hallucis Longus tendinopathy – when the force of the flexor hallucis longus muscle exceeds the tensile strength of the tendon.
Peroneal tendinopathy – when the force of the fibularis longus/brevis (depending on where the pain is) is exceeding the tensile strength of the tendon.
Ankle impingement – can be occurring anteriorly (front portion of ankle) or posteriorly (back portion of ankle); occurs when soft tissue is being caught at the end range of motions secondary to the talocrural joint (ankle joint) not having the proper amount of motion.
Stress fractures – occur due to recurring force that exceeds the strength of the bone.
Plantar fasciitis - can occur due to overpronation in the foot, placing an increased amount of force through the plantar fascia.
Treatment strategies for THese injuries:
Eccentric loading to improve overall resilience of connective tissue – Eccentric loading has been proven in research literature to assist in regeneration of tensile strength within tendons. This type of loading specifically targets the collagen that forms a tendon to allow it to accept force more efficiently.
Strengthening stabilizing musculature in hips and abdominals – If the trunk and pelvis is not stable and strong during dynamic functional movement, everything down the lower extremity chain can be impacted in a negative manner. If the pelvis is unable to stay level in a single leg stance, a common tendency is for the knee to collapse inward, then forcing the foot into excessive pronation. This chain reaction can lead us to the root cause of an individual's ankle pain.
Manual Therapy to improve the quality of movement within soft tissues, increase overall range of motion available, and reduce pain – Manual therapy techniques include soft tissue work, active release techniques, joint mobilizations, manipulations, instrumented soft tissue work, cross friction massage and dry needling.
Proper jump mechanics – If an athlete is having instability this can cause poor biomechanics during the landing of a leap or jump placing unnecessary force on tissue that is not made to accept that type of energy. This can lead to ankle, knee, hip or low back pain
Dynamic balance training – Being a dancer requires a large amount of body awareness. Kinesthetic sense and proprioception are two concepts that dancers tap into frequently to achieve the motion and postures the sport requires. By training these two factors, overall quality of performance and global strength should increase, improving the athlete.
Home exercise program – This will allow the athlete to become as independent as possible with their treatment plan!
Complementary training - After your symptoms have resolved, using a team of practitioners as ongoing support for your dancing will help the dancer continue to get stronger as well as recover from rigorous training and performance periods. Dancers are no different than traditional sports athletes in that they need extra support to continue performing. A strength program (weight training, Pilates) and maintenance visits with a physical therapist and/or a massage therapist will go a long way in helping to prevent recurrence of the injury. Not only that, but a dancer can certainly elevate their skill sets by getting stronger and staying healthy.
Sources:
Li F, Adrien N, He Y. Biomechanical Risks Associated with Foot and Ankle Injuries in Ballet Dancers: A Systematic Review. International Journal of Environmental Research and Public Health. 2022; 19(8):4916. https://doi.org/10.3390/ijerph19084916
Hung Y, Boehm J, Reynolds M, Whitehead K, Leland K. Do Single-Leg Balance Control and Lower Extremity Muscle Strength Correlate with Ankle Instability and Leg Injuries in Young Ballet Dancers? Journal of Dance Medicine & Science. 2021;25(2):110-116. doi:10.12678/1089-313X.061521f
Skwiot M, Śliwiński Z, Żurawski A, Śliwiński G. Effectiveness of physiotherapy interventions for injury in ballet dancers: A systematic review. PLoS One. 2021 Jun 24;16(6):e0253437. doi: 10.1371/journal.pone.0253437. PMID: 34166414; PMCID: PMC8224967.