Introduction

Ballet has all the elements of the arts in its makeup—drama, poetry, literature, painting, sculpture, design, music, and, of course, dance. Dancers, both male and female, are the physical means by which the choreographer sculpts a composition of expressive motion. The grace and art of the ballet performance belie the great physical strain on the body as a whole and the foot and ankle in particular. From an early age the dancer must learn to be an artist, gymnast, and athlete. Most ballet dancers train for a minimum of 10 years before attaining the skill set necessary to join a corps de ballet. Very few dancers develop into soloists and fewer still attain the role of principle ballerina. Throughout this time of training, the body is placed under great strain, and it is by a process of natural selection that those dancers who are flexible and technically proficient survive the rigors of training to advance further.

Female dancers spend a considerable time en pointe, or on the points of the toes (Fig. 21-1), whereas male dancers tend not to dance on their toes and spend much of their time in turning, lifting, and holding ballet dancers. As such, male and female dancers tend to present with distinct injuries. In addition to the myriad of physical injuries related to female dancers that follows, female dancers also are prone to the triad of anorexia, amenorrhea, and osteoporosis. This unfortunate triad stems from the significant pressure on dancers to weigh less and less. The most disturbing data suggest that female dancers weigh more than 15% below the ideal weight for height. This has metabolic consequences leading to stress fractures and slower union rates in injured female dancers.¹ In contradistinction, male dancers have fewer metabolic problems but are prone to overuse injuries from repetitive motion and to stress fractures from the sudden deceleration of large leaps, volé, sauté, or jeté.

Figure 21-1 Illustration of the en pointe stance.

Dancer’s feet are the instruments on which their art depends. They require, in addition to an extraordinary flexibility and strength, a particular anatomic profile. Over time a dancer’s foot will evolve and only the strongest will survive. Dancers’ feet typically are “intrinsic plus:” they have narrow metatarsal width with straight toes. (Intrinsic-minus feet have wider metatarsal splaying and clawing of the toes.²) Apart from muscle strength, dancers’ feet require great flexibility. In the relevé position (Fig. 21-2) the ankle is in a vertical position—90 degrees of plantarflexion of the ankle-foot complex. The dancer also requires 90 to 100 degrees of dorsiflexion in the first metatarsophalangeal (MTP) joint to go from relevé to en pointe. These are extraordinary ranges of motion and can only be achieved with years of practice, which mold the young ballet dancer’s bones during the bone growth phase.³^–⁵ As a result of endless practice barres, class, and training, dancers’ feet tend to be cavus and have thickened metatarsals to support when en demi-pointe. Calluses abound secondary to pressure demands on the skin.

Figure 21-2 Illustration of the relevé stance (demi-pointe).

In general, five types of dancer’s feet have been described:⁶

1 Grecian (also known as Morton) foot has a relatively long second and third metatarsal in relation to the first and fifth metatarsal. However, dancers do not have the same problems associated with transfer metatarsalgia as does the general population with this foot configuration.

2 Egyptian foot. Long first ray relative to the central metatarsals. This can predispose the first MTP joint to degenerative arthrosis or hallux rigidus.

3 Simian foot. Metatarsus primavarus with hypermobile first ray that causes transfer metatarsalgia to central metatarsal heads.

4 Peasant foot. Uniform metatarsal length, giving broad, square foot. Its stability makes it an ideal platform for dancing.

5 Model’s foot. This foot is long and slender with a taper exaggerated cascade from first to fifth metatarsal head. As such, it bears weight unevenly on demi-pointe and is a poor foot for dance.

The following is a review of the more common dance injuries and problems in the foot and ankle.

Metatarsophalangeal Joint

Bunions

Although dancing has been said to play a role in the pathogenesis of bunions, it is unlikely that this is the case. Dancers, like the rest of the population, can be either resistant or prone to develop bunions.⁷ In those dancers that are prone to develop bunions, it is imperative to delay surgical intervention for as long as possible. Bunion surgery adversely affects dorsiflexion of the first MTP joint, a critical motion in dancers. Most bunions can be treated with conservative methods, including toe spacers and horseshoe pads. The senior author has seen several aspiring young dancers whose careers were ended by well-meaning bunion surgery. If a bunion is precluding the dancer from activity and surgery is warranted, then a chevron osteotomy can provide pain relief and stability without compromising motion.

Hallux Rigidus

Any restriction to full dorsiflexion of the first MTP joint will prevent the dancer from performing relevé. Many dancers can accommodate by rolling out onto the lateral border of the foot, a process known as “sickling.”

The treatment of hallux rigidus depends on the grade of the disease (Fig. 21-3).

Figure 21-3 Illustration of hallux rigidus.

In grade I disease, the joint is preserved and marginal osteophytes can be resected, with excellent outcome expected.

In grade II disease, the joint is involved, with minor cartilage destruction evident as joint space narrowing on plain radiograph. Treatment involves resection of marginal osteophytes (cheilectomy). In addition, the dorsal one third of the metatarsal head is resected.⁸ Intraoperative dorsiflexion of the hallux greatly overestimates the degree of motion that can be expected following surgery. Just over half of what is achieved at the time of surgery will be evident in the postoperative follow-up examination. It is important that dancers understand that, although surgery will make the condition better, the joint will never be normal. In addition, the length of recovery time must be discussed with the dancer, because a full functional recovery often takes 6 months. To improve functional motion following surgery, a dorsally based closing osteotomy can be used (Moberg). This procedure improves dorsiflexion but at the expense of plantarflexion, and the dancer should be warned of this.

In some cases we also can use a shortening scarf osteotomy to decompress the MTP joint and allow reestablishment of the mobility.

Grade III hallux rigidus presents with dorsal and lateral osteophytes in addition to clear degenerative arthrosis on both sides of the joint. Arthrodesis, an acceptable surgical option in the general population, is not feasible in a career dancer. To preserve motion, a capsular arthroplasty can be performed with reproducible outcomes ⁹ (Fig. 21-4, A and B). It is important to select these patients carefully because transfer metatarsalgia is common in those patients with a foreshortened first ray.