The question is always do these athletes choose dance or does dance choose them? Many believe, it is a self-selection process, as inherent ligament laxity is a typical trait of the adolescent and professional dancer, (as well as for gymnasts, and skaters), where extreme flexibility and joint position demands are high. These extreme ranges are not typically required by most other sports. Age appropriate and safe flexibility and strength exercises should be included in early dance training by the dance teacher or other dance medicine specialist. Most dancers choose to do static stretching during warm up, and although it may reduce some muscle damage, it has been studied that dynamic stretching is best and does not cause strength loss like persistent static stretch holds [4].

Strengthening, the foot intrinsics and extrinsic muscles can be done by using traditional rubber tubing. The dancer can easily store a piece in the dance bag (Figs. 30.2, 30.3, 30.4, 30.5, 30.6, 30.7, 30.8 and 30.9). Cross training work with Pilates, weight training, or yoga can also help all dancers improve dynamic movement patterns. Pointe work requires incredible strength, balance, and technique along with proper alignment of the foot, knee, and hip. Abdominal and hip strength can be tested statically on the table in parallel and turned out positions including second position (Fig. 30.10) also by front and side planks, double leg lowering test, and some dance jumps. General balance and coordination will present itself within these other tests, but may differ among dancers of different ages, especially in pre and early teen years, as these abilities may regress a bit while the dancer moves through growth spurts. Discussion with teachers and parents will help to soothe worry away, as things will return to normal in time.

Due to the nature of the various forms of dance, the foot and how it functions is an extremely valuable asset. From the classic ballet dancer, the hip hop dancer to the theatrical dancer, foot alignment, functional aesthetics, and how it works, will get the dancer far as it relates to injury and possibly job security. The best shape for the ballet dancer’s foot is having all the toes or at least the first three toes the same length. Reports of varying toe lengths may predispose this dancer to stress fractures and other soft tissue injury [5]. A nicely formed longitudinal arch is ideal, however some unnatural and extreme arched feet have emerged as the “new norm.” Dangerous practices of extreme foot stretching exists as many young ballet dancers will strive to get that aesthetic, as they work the arch by stretching it and potentially injuring the precious ligaments in the midfoot, all to produce the extreme degree of that “arched” attitude needed for the pointed position.

Stressing the importance of safe and progressive stretching is paramount, and rather best to teach the dancer on proper plumb line alignment, and proper strengthening of the foot muscles that actually plantarflex the foot, to give it a strong and beautiful arched position. In regards to weight bearing stresses, during a technique class, a dancer will endure up to 200 jumps, and may put upwards of four times body weight on each foot per jump with only a ballet slipper on. While en pointe the dancer will sustain upwards of 12 times body weight while jumping [6, 7]. Laboratory studies have shown, that a 115 lb. dancer who sickles only 2° rather than being perfectly on the flat part of the box of the pointe shoe (or perpendicular to the floor), will transfer an additional 40 lbs. to the lateral ankle, which is most vulnerable to sprains [8]. This technique problem has profound effects on alignment and potential injury. Add some of the above listed intrinsic or extrinsic factors and it is easily realized why there are so many injuries in dance. For the ankle joint, normal adult plantarflexion is approximately 50°, but for a dancer approximately 90° is needed for proper pointing positions and dance movements.

A quick check for alignment and plantarflexion of the ankle can be done using a pencil test laying the pencil on the talus, when the foot is fully pointed, the pencil should line up parallel with the tibia [9] (Fig. 30.11). The midtarsal joint is also called the “coup de pied”. This joint rotates plantarly as the talus plantarflexes. Proper movement at this joint is attained by the help of the five secondary plantarflexors: Peroneus longus, Peroneus brevis, Tibialis posterior, Flexor digitorum longus, and Flexor Hallucis Longus. These muscles all insert distal to the talus thus allowing a proper lever arm for the forefoot to have a strong plantarflexory moment, to allow for an esthetically strong pointed foot. Ligament laxity from extreme stretching through the midfoot, or having weak secondary plantarflexors will all promote an undesirable (over arched) pointed foot position. This foot may look at first glance to be very arched with extreme pointed alignment, however functionally it will not stand the test of time and will potentially break down, causing injury (Figs. 30.12 and 30.13).

Also when these secondary plantarflexors, are not strong, the two primary plantarflexors; Gastrocnemicus and Soleus, will cause the calcaneus to be continually pulled into equinus, allowing the talus to slide down and forward creating a “locked” like affect, thus not allowing the midtarsal joint to rotate plantarly. Many dancers with these weaknesses, will complain that they feel like their foot is not attaining the pointed position they desire, or they may complain that they feel like the foot and ankle is “jammed”. Proper strength of those 5 “other” muscles is imperative to correct this problem, as it is often overlooked in the exam, or by dancers in general.