Ankle Impingement Syndromes in Ballet Dancers

What is Ankle Impingement?

Overuse injuries account for approximately 68% of injuries in ballet dancers.  Ankle impingement is an overuse injury from the repetition of specific movements required in dance. Ankle impingement can be classified into two general categories, namely anterior and posterior impingement.  Anterior impingement syndrome (AIS) is caused by compression of structures in the front of your ankle from osteophyte formation or soft tissue impingement.  AIS is common after experiencing an ankle sprain, particularly if you do not allow full recovery. With AIS, the dancer may feel pain in the front of his or her ankle during a plie or any movement that requires taking off from a jump or preparing for a turn.

Posterior ankle impingement syndrome (PAIS) can result from excessive bone formation or soft tissue irritation in the back of the ankle. Bone changes include an accessory bone termed the os trigonum or the presence of a stieda process on the talus bone.  An os trigonum is present in approximately 12-23% of the population.

Ballet requires repetitive weight bearing in extreme plantar flexion.  While dancing en pointe, the os trigonum can become impinged causing a bony block in the back of the ankle.  Irritation of the flexor hallucis longus (FHL) tendon can occur with the presence of an os trigonum due to the proximity of this tendon to the accessory bone. This can lead to further tissue compression and pain. In PAIS, the dancer may be unable to attain full pointe or complain of pain in the back of the ankle with releve.

How is Ankle Impingement Treated?

Conservative intervention such as physical therapy is a good place to begin treatment for anterior and posterior ankle impingement. Physical therapy will focus on what the dancer’s impairments and may consist of re-education of ballet technique including the plie or releve.  Treatment also involves improving ankle stability and joint or soft tissue mobilization.  Activity restriction may be necessary depending on the dancer’s presentation.  If conservative treatment is not successful, surgical intervention may be necessary.

Surgical intervention could include removal of osteophytes or the os trigonum in AIS and PAIS, respectively.  Repair of the flexor tendon may be required to treat posterior impingement. Following surgery, physical therapy would be recommended for the dancer to maximize his or her functional ability. Generally, post-surgical outcomes are good with 89% of dancers being able to return to ballet class, rehearsal, and performances.

What can you do for your Ankle Pain?

Ankle impingement syndromes can prevent you from dancing to your full potential.  Pain with movements such as the plie or releve is common in dancers with impingement.  If you are suffering from ankle pain, schedule an appointment with a physical therapist specializing in the treatment of dancers.

Dance Injuries: Reducing Risk

Dance injuries are quite common, with approximately 68% arising from overuse injuries.  Studies show the incidence of injury ranges from 0.62-5.6 per 1000 dancing hours.  Injury can accumulate quickly with the amount of time a dancer participates in class or rehearsal. Overuse injuries can occur due to a myriad of reasons including overtraining (hours upon hours of dance class, rehearsal, or performances, with minimal to no recovery), improper dance technique, forcing turnout, progressing to pointe too early, and poor nutrition.

Reducing Dance Injury Risk

Decreasing the number of classes or rehearsals a dancer participates in each week may not be feasible. However, we can make sure he/she has good technique. Why does technique or proper form matter?  Let’s look at the plie for example. It is one of the most basic movements in ballet.  The plie is performed much more frequently than simply the first combination at the barre. It is also used during a fondue, to prepare for and land from turns such as a pirouette, piquet, and fouette.  The plie is also used to initiate jumps including sauté, changement and grande jete. If a dancer has improper technique with her plie, this considerable repetition can place her at increased risk of injury.

Dance turnout

Conclusion

To reduce the chance of injury, we need to focus on correcting individual muscular strength and flexibility imbalances.  A physical therapist who specializes in dance rehabilitation is best to evaluate the young dancer.  The goal is to keep the dancer on her toes.  It is also important to educate the dancer on proper form and not forcing her turnout.  Contact your physical therapist today if you are having pain with any movement or position, or would like a free screen to determine if your technique is safe for your body.