An interetsing article....... Foot and Ankle Injuries in Dance Nancy J. Kadel, MD Department of Orthopaedics and Sports Medicine, University of Washington, Box 356500, 1959 Northeast Pacific Street, Seattle, WA 98195, USA ‘‘The instrument through which the dance speaks is also the instrument through which life is lived.the human body.’’ Martha Graham, 1979 Dance is an art that combines athleticism with artistry. The demands placed on dancers’ lower extremities leave them at risk for musculoskeletal injuries. Previous studies have reported injury incidence rates of 67% to 95% among professional ballet dancers and 17% to 24% in modern dancers [1–6]. The foot and ankle of a dancer are particularly vulnerable to injury and represent 34% to 62% of all injuries reported [1–6]. Female ballet dancers have a higher incidence of foot and ankle injuries than male ballet dancers or modern dancers, in part because they dance sur les pointes. In professional musical theater dancers, foot and ankle injuries have been re- ported as comprising 23% to 45% of all injuries [7–9]. The extreme positions created when dancing on pointe, or on the tips of the toes, or in the demi-pointe position, on the balls of the feet with the an- kle plantar flexed, can lead to both acute and overuse injuries of the foot and ankle. Although dancers develop overuse injuries common in other athletes, they are also susceptible to unique injuries. This article reviews common foot and ankle problems seen in dancers and provides some basic diagnosis and treatment strategies. Types of dance Today, dance encompasses various techniques and styles such as hip-hop, tap, musical theater, jazz, folk, ethnic, modern, and classical ballet. Al- though footwear is usually specific to the technique or choreography, most dance shoes rarely include a shock-absorbing sole, and some tech- niques, such as modern, are performed barefoot. Causes of dance injuries Anatomic alignment, poor training, technical errors, unfamiliar choreog- raphy or style, and environmental factors including flooring surfaces and the- ater temperature have been implicated as contributing factors to dance injuries. The female athlete triad, amenorrhea, disordered eating, and low bone density, has been implicated in an increased risk of stress fractures in dancers [10–13]. Delayed menarche, common in ballet dancers, has been shown to have an association with increased risk for stress fracture [12]. Rigorous rehearsal schedules, lengthy show runs, and intensive summer dance programs that require an increase in daily class and rehearsal time have been associated with a higher frequency of injuries. Dancing on pointe The female ballet dancer often dances in the full pointe position, requir- ing marked ankle plantar flexion with the toes in a neutral position relative to the longitudinal axis of the foot (Fig. 1). Significant ankle plantar flexion and strength of the intrinsic muscles of the foot and the muscles surrounding the ankle are needed to successfully dance on pointe. The support of the body weight on pointe is borne in the ankle joint along with the tips of the first and second toes. Plantar pressures at the toes on pointe vary with the relative length of the first and second toes and range from 0.14 to 0.58 MPa. When the dancer stands on pointe, the total plantar pressure un- der the toe box of the pointe shoe is 1.5 MPa. Toe pressures account for 20% to 30% of the total pressure measured at the toe box on pointe [14].  In pointe work, the stiff shank and hard toe box of the pointe shoe sup- port the foot. In a cadaveric study of sectioning of Lisfranc’s ligaments, the stability observed in the pointe shoe demonstrated that the shoe and the closed pack position of the foot in the pointe shoe, share in the remaining 70% to 80% of the load. This supports the hypothesis that the shoe acts as an additional major stabilizer of the foot on pointe [15]. Today’s pointe shoes are made from similar materials as their predeces- sors in the last century. The pointe shoe is composed of layers of paper, glue and fabric such as satin, canvas, or leather [16]. The toe box is initially quite hard, but most pointe shoes are quickly broken in and become soft and pliable with use. A principal dancer may use two to three pairs of pointe shoes during a single performance. Dancers describe poor-fitting pointe shoes that are too soft or worn as dead; dead shoes can contribute to injury. .......More tomorrow....
Posted on: Fri, 09 Aug 2013 12:24:36 +0000
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