Tendinopathy of the foot and ankle in dancers: A brief overview

Tendons are fascinating structures, but injuries to this tissue can be debilitating and lead to time off from dance.  It has been reported that tendinopathy is one of the more prevalent musculoskeletal issues in ballet dancers 1.  So, first off, what does a tendon injury consist of ? The term tendinopathy is now standard terminology used to describe a tendon when it becomes pathological usually with the distinguishing characteristics of pain, possible histological/tissue changes, decreased load tolerance and subsequent loss of participation in dancing activity.  Currently, it’s thought that tendinopathy exists along a patho-etiological continuum.  The original model proposed by Cook et al. describes stages of pathology based on pain, histological changes, and the functional limitations of the patient 2.  The continuum model is a helpful guide to make appropriate decisions regarding rehabilitation strategies and interventions based on the individual and how they present.   

Within the dancing population, the long tendons of the foot and ankle and the patellar tendon comprise the most common tendinopathies in females and males respectively.  A higher incidence of peroneal and flexor hallucis longus (FHL) tendinopathy in the foot and ankle has been cited in ballet dancers 1, but the focus of this blog will be specifically on the FHL and posterior tibialis (PT) tendon. Both of these tendons run along the medial ankle and often considered in the differential diagnoses in a dancer presenting with medial ankle pain.

How do tendinopathies develop?

An acute spike in the physical activity and subsequent load through the tendon in a given day or over a period of time is a typical mechanisms of injury throughout all tendinopathies.  An alteration in training remains consistent in the development of FHL and PT tendinopathy in the dancer population.  Specific to the dance population, those who dance en pointe are thought to have a higher incidence of any foot or ankle injury 3. The FHL and PT are working harder to control foot and ankle when rising and lowering from flat to the en pointe position.  

Other considerations involved with shoe wear as a contributing factor include switching pointe shoe makers, dancing in “dead shoes”, dancing in flat or character shoes.

Reports of intrinsic risk factors for PT tendinopathy exist.  Biomechanical influences associated with anatomical variants, inherited or acquired systemic factors, and trauma are all intrinsic risk factors that can have an influence in the development of tendinopathy 4,5   

Management strategies

1. Advice and Education

Guiding the dancer in any modifications they need to make to their dance activity needs to be done to manage their acute phase of pain.  Advice on activity restrictions will differ from a dancer with tendinopathy who needs to take time off to those dancers who are still expecting or are expected to perform.  The latter situation may be more complex and involve coordinating with other members of the dance company.  Specific strategies regarding optimal loading and activity are usually best made on an individual basis as many factors are considered.

2. Technique

A “winged” position (plantar flexion, abduction and eversion) of the foot may predispose the FHL/PT tendon to increased strain as this places the tendon in a lengthened position 4. This position can especially compromise the FHL and PT at the ankle as they make a sharp bend around the tibia into the foot. You will want to assess the control of this winged position both when the lower extremity is the working leg and when it is the supporting leg.  Check out an article in this month’s Pointe Magazine titled ‘Winging 101’ for advice on how to achieve a healthy winged foot/ankle.

Of course assessing the dancers hip external rotation strength and lumbopelvic control is preliminary as torque from the turned out position can influence the strain into the FHL/PT.  Read our previous blog about exercises to strengthen the hip external rotators and to reinforce turn out from the hips.

3. Strengthening

Strengthening or loading the tendon can begin immediately and is based on the sensitivity and tolerance to load.  A dancer’s current activity level (daily activity and dance schedule) should be accounted for before prescribing exercises as they may not be ready for specific loading exercises.

The specific muscle actions, in this case 1st MTPJ flexion for the FHL and foot/ankle plantar flexion/inversion for the PT as well as a heel raise/releve are used to build back tolerance to load.

Strength and conditioning principles and tolerance to loading are used to guide the progression. Depending on the individual and situation, starting points may be different and the parameters below will vary.  These are some variables to consider when designing and implementing exercises: 

Intensity

a. The amount of load

b. Type of contraction

c. Range of motion

Duration

a. Holding time (if isometric)

Frequency

a. Daily vs. a couple times a week

Finally, a graded return to activities that were modified are initiated and again needs to be based on the individual’s circumstances and overall tolerance to that activity.  Keep in mind to observe the dancers movement coordination and control when reinstating ballet activity.

Don’t forget the psychological component that time off from dance can affect.

Encouragement and reassurance that the dancer can make a full recovery back to performing at a high level is key.  One way Westside Dance remains confident in our tendon knowledge is staying up to date by reading the blog posts over at tendinopathyrehab.com, and we encourage you to check it out!

REFERENCES:

1. Smith TO, Davies L, Medici A et al.  Prevalence and profile of musculoskeletal injuries in ballet dancers: A systematic review and meta-analysis.  Physical Therapy in Sport 19 (2016) 50 – 56.

2. J L Cook, C R Purdam.  Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.Br J Sports Med 2009;43:409–416. doi:10.1136/bjsm.2008.051193.  

3. Russel JA. Preventing dance injuries: current perspectives.  Journal of Sports Medicine 2013:4 199–210.

4. Angoules AG, Boutsikari EC (2013) Posterior Tibialis Tendonitis in Dancers. Clin Res Foot Ankle 1: 103. doi:10.4172/2329-910X.1000103

5. Beeson P. Posterior Tibial Tendon Dysfunction. What are the risk factors? Journal of the American Podiatric Medical Association. Vol 104 No 5 September/October 2014

6. Cook JL, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?  Br J Sports Med 2016;50:1187–1191. doi:10.1136/bjsports-2015-095422.