Physiotherapy for Dancers

Dancing is an activity that can place enormous strains through the body. Dance involves repetitive movements that require open chain movement of the lower limb. This challenges balance, control and stability of the body. Unlike most sports that involve open chain movements of the upper body with the lower body making contact with the ground, dance requires high levels of dynamic control as more often than not one leg is off the floor as you perform a move. If you are dancing without your full concentration, a fall or poor technique is far more likely. This will often be a predisposing factor to injury.

Injuries are often caused by high impact, repetitive stress and may be the results of years of overuse, or by one fall with a bad landing. Injuries most commonly affect the foot and ankle, knee, hip or lower back. Overuse injuries of the lower limbs are common due to the constant pounding from performing. Training on a hard surface or dancing without adequate warm up are big no-no’s. The more stable your core (through Pilates) the less likely you are to suffer from pain in the hips and back. Dancing with biomechanical dysfunction or muscle imbalances including flat feet, tight calf muscles or with weak quadriceps can develop a serious problem that can force you to break from routines, performing and even dance altogether if not addressed properly.

The Physiotherapists at KTB will ensure that as part of your rehabilitation you are thoroughly assessed for biomechanical alignment, muscle imbalance, hypermobility and areas of potential injury. We will advise a mat based exercise program for you incorporating stretches, strengthening moves and core stability exercises to prevent further injury and enhance your dancing ability. We can also work with your dance teacher to advise a return to performing after the acute symptoms have subsided through effective treatment.

We will now outline some of the common dancing injuries that we treat.

Common Injuries of the Foot

Dancer’s Fracture
This fracture is common in dancers and often occurs from landing from a jump on a turned-in foot.

Sesamoiditis

The sesamoid bones in the foot provide a support surface while the dancer is on demi-pointe. With over use of this position the tendon that runs between these bones can become inflamed, causing a tendonitis known as sesamoiditis.

Hallux Valgus and Bunion

This injury typically has a gradual onset and is more common in individuals with flat feet, or a tendency to roll the foot in during a turnout position. Pain will be felt with pressure to the affected area. Ill fitting shoes are another common cause.

Hallux Rigidus

This condition is characterized by pain and/or restriction of movement at the joints of the big toe. To achieve full demi-pointe the joint of the foot to the big toe needs to bend to 90 degrees. If a dancer does not have this natural flexibility then the stress will lead to inflammation and ultimately degeneration of the joint.

Plantar Fascilitis

This overuse injury affects the tough tissue in the sole of the foot. Inflammation of this band occurs with prolonged weight-bearing, pain often increases towards the end of a day of dancing. Dancers with tight calf muscles or Achilles tendon are more likely to suffer as are those who dance on a hard, non-sprung surface.

Metatarsalgia

Often caused in dancers by instability of the toe joints, this problem gives pain and tenderness in the ball of the foot. The instability in dancers is often caused by repeatedly forcing the foot into extreme ranges of motion which stretches structures including tendons and ligaments. This increased laxity leads to joint instability. Instability often leads to pain as fatigue sets in.

Common Injuries of the Ankle

Lateral Ankle Sprain

This most common ankle injury in dancers occurs when the ligaments on the outside of the ankle are torn as a result of the ankle rolling outwards under pressure. The sprains are typically acute in nature occurring after a landing jump goes wrong.

Achilles Tendonitis

The largest tendon in the body and the most commonly ruptured in dancers. The achilles tendon at the back of the ankle takes enormous stresses with the constant pointing of the foot. It is important for dancers to stretch the calf muscle effectively and avoid dancing on a hard non-sprung surface.

Trigger Toe

A common injury in female classical ballet dancers. The inflammation of the flexor hallucis longus tendon on the inside of the ankle will affect a dancer’s ability to en-pointe.

Posterior Impingement Syndrome ‘Dancers Heel’

This condition involves compression of soft tissues at the back of the ankle. Stretching the calf and achilles tendon will relieve the stress. Pain is often brought on by pointing the toe or coming into relevé.

Anterior Impingement Syndrome

Compression at the front of the ankle caused by bony formation from the overuse of pliés. Swelling is often noted and pain with deep pliés. Appropriate strengthening and stretching is important in rehabilitation.

Shin Splints

An overuse injury causing pain in the front of the lower leg this pain is often caused by repetitive jumping or running. With repetitive loading the muscles fatigue and these tired muscles then place more stress or load onto the bone. Stress fractures may occur if shin splints are not treated early and if not may develop into bone fractures. Spending too long in pointe or demi-pointe will increase the pressure and stress to the front of the shin. Dancing on hard surfaces also increases the risk of trauma.

Knee Injuries

Anterior Knee Pain and Chondromalacia Patellae and Patella Dislocation

Anterior knee pain is caused by a weakness in the quadriceps muscle group at the front of the thigh. Weakness, or in fact tightness, of this muscle group places stress on the knee cap and pulls it out of its natural groove in which it glides. This is more common in adolescents for a number of reasons. One reason is a common sudden increase in training intensity and another is a growth spurt causing the bone to grow before the muscle and therefore stretching the muscle causing it to weaken. Behind the knee cap is a lining of cartilage which allows smooth gliding. If due to the abnormal pulling of the quadriceps muscle the cartilage becomes worn, a condition called Chondromalacia Patellae occurs. When this happens pain and inflammation are a result. This pain is often caused over a period of time and is made worse by activities that involve repeated bending of the knee including prolonged sitting. Dancers will often notice pain during a session, especially with jumps and grande plié. If the kneecap slips out of the groove temporarily then this is known as subluxation, if the kneecap does not return after it slips out it is known as dislocation. A dislocation is often due to direct trauma. Both will need extensive thigh strengthening and avoidance of overuse during class.

Hyperextension of the Knee

if the knee is straightened too much so that it bends backwards an increased stress in placed through the joint. The ability to do this is often linked with a laxity of the ligaments and is not usually isolated to one joint. The hyperextension of the knee is said to improve the aesthetic of the leg with a pointed foot and therefore is often encouraged. Joint hypermobility or ligamentous laxity however should be taken seriously. Please see our web page on Hypermobility Syndrome under Chartered Physiotherapy.

Jumpers Knee

Patella tendonitis (or jumpers knee) is caused by overuse, often from jumping. The tendon below the knee joint is inflamed and painful.

Meniscus Tears

Following trauma, for example jumping and landing with a twist, injury to the cartilage meniscus in the knee may occur. Following this injury the knee will be stiff and will lock. A synovial tissue on the inside of the knee known as the plica, is exposed to trauma when the knee is bent. Inflammation of the plica can present like a meniscus tear but there is no swelling and locking is felt only after sitting for a long period of time.

Ligament Tears

Ligaments form an important stabilising role of the knee. With a sudden unexpected twist or landing the ligaments are stressed and can tear. Pain and immediate swelling often result and weight bearing will be painful. Treatment should be immediate and long rehabilitation may be required for severe sprains.

Hip Injuries

Trochanteric Bursitis

Presenting as pain in the side of the thigh over where this inflamed bursa sits this may arise from acute injury or impact or with no known cause. Management should include a detailed investigation into training programmes to rule out overuse, structural assessment of the lumbar spine, muscular strengths and lengths of the lumbar spine, hip and pelvis. Leg length should also be measured.

Snapping Hip

This snapping usually occurs as a muscle or tendon passes over a bony structure and is normally painless. Instability or muscle imbalance can be a cause and should be explored. This is common in dancers due to the overload through the joints and increased flexibility often leading to instability.

Iliacus Tendonitis

This is often diagnosed in younger, modern dancers where there is an increased emphasis on hip flexion and internal rotation. The pain is felt in the front of the hip and groin.

Piriformis Syndrome

Due to the nature of dance and the emphasis on hip rotation and turnout, the piriformis muscle can become tight and restricted in dancers. The proximity of this muscle to the sciatic nerve can cause pain to be felt into the buttock and leg.

Osteoathritis (OA)

The ends of the bones where they meet to form a joint are covered in a layer of cartilage for smooth gliding between the bones and shock absorption. When this cartilage becomes worn, degeneration is caused. When advanced enough to cause pain and restricted movement osteoarthritis is diagnosed. This presents with pain, swelling and stiffness. Dancing puts excess stress through the joints and this may lead to early OA in some, especially those who suffered injuries when dancing.

Injuries of the Spine

Low Back Muscle Strain and Muscle Spasm

Straining a muscle in the back is common in dancers and can occur after falling or lifting or through tiredness after performing a repetitive move. A tear in a muscle causes muscle guarding or spasm that causes pain. Movement that uses this muscle will be painful. Management will be to allow the muscle to heal and then strengthen the core through Pilates to prevent recurrence.

Spondylolysis

This is attributed to repeated stress of the lumbar spine. Dance puts repeated stress to the lower back due to the repetitive hyperextension and over-stretching of the back. Pain will typically occur with port de bras or cambré backwards.

Spondylolisthesis

This is the forward slipping of a vertebra on the one below. Repetitive hyper extension of the back or a direct or sudden twist causing a direct force to the back are potential causes. Pain and stiffness is typically felt in the back. Pain may refer to the buttocks and is aggravated by activity. Dancers with spondylolisthesis usually display a significant lumbar spine curvature (lordosis) with tightness in the hamstrings.

Prolapsed (slipped) Disk

Each vertebra of the spine is separated by an intervertebral disk. These provide cushioning and absorb shock. With age the centre of the disk loses its water content and this cushioning role id=s less effective. Cracks also form in the outer part of the disk and with an acute strain or over time through overuse part of the centre of the disk can be displaced into these cracks. This causes pain and muscle spasm. If the herniated lumbar disk presses on the nerve ‘sciatica’ develops. This causes symptoms into the leg.

Sacroiliac Joint Sprain

The pelvis is often a source of pain in dancers due to the open chain demands of routines and movements. If the pelvis is not stable then inflammation can result and pain occurs when one leg is lifted as the pelvis cannot stabilise properly due to pain. Pelvic pain can refer to the back, groin or into the leg. Stability and muscle imbalances must be assessed when rehabilitating pelvic dysfunction.

Interspinous Sprain ‘Baastrup’s Syndrome’

This is a condition in which the spinous processes of adjacent vertebra touch. This is brought on by injuries that involve sudden, forceful flexion of the spine. Degeneration is another factor. Dancers will often notice restriction to both forward and backward lumbar spine movements.

Schuermann’s Disease – Juvenile Kyphosis

This deformity of the mid back in children involves wearing away of the spine so that the natural curves are lost. Signs of this will be a roundening of the back not caused by poor posture. Dancers will say that their back aches at the end of a days dancing.