Orthopedic surgeon specialized in dancers

Common dance injuries

Posterior Impingement Syndrome

The posterior impingement syndrome refers to deep pain at the back of the ankle. It is seen in patients who practice sports involving hyper plantar flexion such as dance.

It can manifest in different ways :

The posterior impingement may involve the soft tissues at the back of the ankle, which can get pinched between the tibia and the talus.

The posterior impingement can also be mixed with a bony involvement including :

• A long and thick posterolateral process of the talus (Pellegrini Stieda)
• A os trigonum, which is an accessory bone of the talus
• A fracture of the posterolateral process of the talus

The flexor hallucis longus, which allows the locking of the foot and ankle en pointe, can also be painful in case of impingement with the posterolateral process of the talus, or in case of muscular ectopia.

The muscular ectopia of the flexor hallucis longus prevents the tendon from gliding in its sheath, because the muscle has too low a tendinous insertion.

Metatarsal Stress Fracture

A stress fracture can occur when the stress placed on a bone exceeds its capacity to adapt.

A stress fracture usually occurs in a healthy bone, following repeated and intense trauma, for example after a significant and sudden increase in sports training.

Unusual and prolonged exercise can also cause a stress fracture.

Stress fractures of the 5th metatarsal are common in dancers; treatment is usually orthopedic.

Avulsion Fracture of the 5th Metatarsal

Avulsion fracture of the 5th metatarsal corresponds to a fracture of the styloid of the 5th metatarsal.

The peroneus brevis tendon inserts on the styloid of the 5th metatarsal; during a violent contraction of the peroneus brevis muscle, the tendon can pull off its insertion, taking with it a bone fragment of variable size.

This type of injury can be seen after landing jumps.

Treatment for these injuries is generally orthopedic.

Hallux Valgus

Hallux valgus is common in dancers.

A muscular foot tends to be compressed inside the ballet slipper at the forefoot, and may begin to deform at the big toe.

Hallux valgus can be painful, but it is also problematic for dancers because the deformity causes a loss of strength in the flexor hallucis longus, which is highly solicited when en pointe and demi-pointe.

Hallux valgus in dancers is not necessarily caused by dancing; it can be congenital or juvenile.

In congenital forms (hallux valgus present from birth) or juvenile forms (hallux valgus present at puberty), there is a dysplasia of the hallux metatarsophalangeal joint with joint instability. The risk of progression of the deformity is therefore higher in these two forms.

Tendinopathies

Several types of tendinopathies can occur in male and female dancers.

Achilles tendinopathies are promoted by contractures of the calf muscles, the gastrocnemius. The triceps surae is very powerful in dancers; contracture is common, even though the range of motion is significant.

Peroneal tendinopathies are classic. The tendons can be inflamed, which is called tenosynovitis, or they may show fissure injuries, mainly behind and beneath the lateral malleolus.

Tendinopathies of the flexor hallucis longus are part of the posterior impingement syndrome, and mainly consist of tenosynovitis.

Peroneal Dislocation

The peroneal muscles are stabilizers of the ankle. The peroneal tendons are therefore highly solicited, and certain violent muscular contractions can cause tendon dislocation.

The peroneal tendons then come out of their initial osteofibrous groove. It is rare for them to remain permanently dislocated; they tend to evolve towards instability of the peroneal tendons instead.

Surgical procedures for dancers

Surgical treatment in posterior impingement syndrome

As a first step, medical treatment is undertaken.

It consists of stopping sports activity and taking painkillers and anti-inflammatory medications. Ultrasound-guided injections may be tried.

Modification of technique, when possible, can help relieve symptoms.

If medical treatment fails, surgical treatment is proposed.

This involves a posterior ankle arthroscopy allowing for the assessment and treatment of lesions:

• Tenolysis of the flexor hallucis longus
• Resection of an ectopic flexor hallucis longus
• Resection of an os trigonum
• Smoothing of a long or fractured posterolateral process of the talus
• Tissue release

Surgical treatment of hallux valgus

Surgical correction is proposed for dancers if the pain is too great to allow them to dance.

This is a major issue, as even a minimal postoperative joint stiffness can be detrimental.

The principles of surgical treatment are the same as for non-dancing patients: performing a corrective osteotomy of the first metatarsal, possibly combined with a phalangeal osteotomy.

Returning to dance is generally considered 4 months after the operation, depending on bone healing assessed by X-rays.

Dislocations and instabilities of the fibular tendons

In cases of dislocation and instability of the fibular tendons, surgical stabilization of the tendons is proposed.

The procedure can be performed arthroscopically, with tightening and reattachment of the fibular retinaculum, possibly combined with deepening of the bony groove.

If fissure lesions of the fibular tendons are present, they need to be repaired during the same procedure. Returning to dance will then take a long time, and can generally be considered without restriction at 6 months postoperatively.

Ankle instability complicating ankle sprains

If ankle sprains can cause ligament injuries resulting in ankle instability, this instability is relatively well tolerated by dancers.

If the ankle is too unstable to allow dancing, a surgical stabilization procedure may be proposed.

However, an ankle ligamentoplasty can lead to a loss of plantar flexion of the ankle postoperatively.

Ankle and foot surgeon for dancers in Nice

For dancers, it is necessary to consult a orthopedic surgeon specialized in ankle and foot pathologies. Just like for other high-level athletes, specialization is essential to understand the specific constraints of each discipline.

The joint flexibility required for dancing may call into question certain surgical indications that could lead to even minimal limitation of joint movement.

The foot clinic in Nice

We specialize in medical-surgical pathologies of the ankle and foot in athletes, especially dancers.