Dr. Harwood is a member of the International Association of Dance Medicine and Science. He trained in New York City for three years of residency treating both dancers in training and professional dancers. His interests are in effective treatments that allow a performer to continue dance. He can in many cases develop a treatment plan that allows patients to continue to dance without further aggravating a condition or causing more serious injury.

What is Dance Medicine and Science?

Medicine is the science and art of preventing and alleviating or curing disease. Dance medicine and science is the application of that realm to the specific life and body of the dancer. As a discipline it investigates the causes of dance injuries, promotes their care, prevention and safe post-rehabilitation return to dance, and explores the 'how' of dance movement. Some specific concerns include the biomechanical, physiological, and neuromotor aspects of dance, nutrition, psychological issues, and the body therapies and somatics area.

The training and self-discipline necessary for the individual to become a dancer are potential sources of physical and emotional strain that may result in temporary or extended disability. The performance of dance, in whatever form, can result in physical injury that may be acute or chronic due to overuse.

Prevention of injury/illness is the concern of the educator and health care practitioner involved in dance medicine and science. Preventive recommendations are based upon:

1. The results of scientific analysis of dance technique and its impact on intensity of teaching, rehearsing, and performing.
2. The results of clinical studies which examine the mechanisms and course of injury rehabilitation and movement re-education.

When injury or other related disability has occurred in the dancer, rational rehabilitative techniques based on these recommendations make return to and continuation of dance possible.

DANCE FOOTCARE AT SOUTHEAST PODIATRY

Dr. Brent Harwood has been caring for dancers on the Gulf Coast for 18 years, treating dancers during and after their career to help them function and remain free of pain.

While the public sees the beauty of the art, ballet dancers suffer to bring excellence to the stage and their feet take the most abuse. Proper care and prompt treatment of injuries can help dancers insure they can continue to perform at their best.

Dancers must care for their shoes and feet just as any athlete must care for their body and equipment. Preventative measures can help minimize some of the pain and possible injury, but injuries can occur anytime. Even though most ballerinas wear well fitted pointe shoes, which is essential to preventing injuries, they still can face accidental injury. Taping the toes, padding pointe shoes with lamb's wool, gel or foam, and using toe pads are common preventative measures. Dr. Harwood works with his dance patients to develop the best preventative measures for the individual dancer.

It's important to note that most people don't realize that male dancers are equally at risk for injury. They put more weight and stress on their feet by jumping and lifting ballerinas. Early evaluation and treatment can lead to quicker recoveries, better long-term outcomes and less chance of other injuries for all ballet dancers.

Education, recognition and early treatment are all important for dancers because dance injuries can sideline a promising career of a young dancer or bring about and early end to a notable career.

Injuries and conditions such as these are common among ballet dancers:

Common Injuries of the Foot

Dancer's Fracture (5th Metatarsal Avulsion Fracture)

Causes
This is the most common acute fracture seen in dancers. This fracture occurs along the 5th metatarsal, the long bone on the outside of the foot. A small fragment of bone at the base of the 5th metatarsal is pulled off by a strong ligament that is attached to this part of the bone. The typical method of injury is landing from a jump on an inverted (turned-in) foot. The dancer will usually experience immediate pain and swelling. He or she may or may not be able to walk. This type of injury needs to be differentiated from a "Jones fracture" which occurs farther down the base of the 5th metatarsal and is related to repetitive stress to this area of the bone. A patient who suffers an acute rolling of their ankle* can also injure the base of the 5th metatarsal. This will produce immediate pain over the outside aspect of the foot. It can be associated with significant swelling and, over time, the skin can turn black and blue. It will be associated with quite specific local tenderness over the base of the bone on the outside of the foot.

Diagnosis and Treatment
When pressing on the outside of the foot, there will be marked tenderness at the base of 5th metatarsal. There may be tenderness over a large area of the outside the foot. However, the main tenderness will be at the base of the 5th metatarsal. X-ray of the foot will reveal an avulsion ("pulling off") fracture of the base of the 5th metatarsal. Treatment typically consists of ice, elevation, and limiting weight bearing activities. A Dancer's fracture is an injury that is usually treated non-operatively. If the patient has the ability to actively move the foot outwards (eversion), the injury will likely heal with non-operative treatment. A period of immobilization will be required while the injury heals. Typically, patients are placed in a walking boot. For the first few weeks, they will have to significantly limit their walking and should be given crutches. As the swelling settles and the fracture start to heal, they can begin walking more extensively in the boot. Usually by 6 weeks, there is enough healing to allow them to transition to a stiff-soled shoe with lots of padding. In very rare instances, where there is complete displacement of the fracture fragments and a lack of ability to actively evert the foot, operative surgery is required. In this case, the bony fragments are repositioned and stabilized with a screw. A Dancer's fracture is often confused with a Jones fracture. A Jones fracture occurs as a result of a stress fracture, due to repetitive loading of the outside part of the foot from the patient's underlying foot pattern or lower extremity alignment. Unlike a Dancer's fracture a Jones fracture may not heal and often requires surgery.

Sesamoiditis

The two semilunar-shaped seamoid bones aid the foot in locomotion. They are two very small bones (about the size of a kernel of corn) on the underside of the forefoot near the big toe. These two sesamoids provide a smooth surface over which tendons controlling the big toe are located. Sesamoid bones are unique in that they are not connected to any other bones in the body.

Causes
The tendon that runs between the sesamoids can become inflamed, causing sesamoiditis, a form of tendonitis. Pain is focused under the big toe on the ball of the foot. With sesamoiditis, pain may develop gradually. There may be pain while bending and straightening the big toe. The sesamoids provide a support surface while the dancer is on demi-pointe and the move will become increasingly more painful with sesamoiditis.

Treatment
When pain in this area, or while performing demi-pointe, becomes more noticeable, it will be important for the dancer to call us so that a sesamoid fracture can be ruled out and treatment can be started to prevent further injury. It may take several months for the pain associated with sesamoiditis to be completely relieved. Surgical intervention to remove the sesamoid bones will be considered after all conservative measures have been exhausted. It will be important for the dance to rest and take time off from rehearsals to decrease the pain and inflammation and accelerate healing.

Hallux Valgus and Bunion

While Hallux valgus and bunion can be seen in the general public, dancers generally develop this condition at a younger than typical age. This injury usually has a gradual onset and is often associated with other postural and or biomechanical faults. It is characterized by medial movement of the first metatarsal head (big toe), where a bunion bump will gradually form. Consequently the phalanges of the great toe will shift towards the other toes.

Signs and Symptoms
The dancer will notice a gradual onset of foot pain at the area of the big toe or ball of the foot. Pain will be greatest with weight bearing and particularly jumping activities. Typically, dancers will notice pain with excessive pressure to the affected area, sometimes to the point where the slightest contact causes exquisite pain.

Treatment
The best course of action is to identify a hallux valgus condition as early as possible and clarify its structural and/or biomechanical causes. Conditions that are caught early on can be treated with either strengthening exercises, stretching and/or orthotic prescription. Often, a toe spacer between the first and second toes can help with alignment and prevent further progression of the injury. Conditions that develop into significant structural changes can be very difficult to manage and may require surgical intervention. Attention to a dancer's technique with pliè, relevè, and jumping is essential to limiting the progression of hallux valgus once it has been identified.

Hallux Rigidus (or Limitus)

Causes
This condition is characterized by pain and/or restriction of movement at the joints of the big toe. To achieve full demi-pointe the metatarsal phalangeal joint must be able to make a 90 degree angle. Dancers who start later in life may lack this much mobility. A dancer without mobility who forces a high demi-pointe will cause the bones in the joint to impinge on each other. If this is done repeatedly, bone spurs will develop leading to even further decreased motion in the joint, inflammation and eventual degeneration of the joint. Compensations for lack of full mobility include sickling. This position will decrease impingement but it is not an esthetically acceptable line and puts the dancer at risk for ankle sprains*. An acceptable and safe compensation for this condition is a half demi-pointe position. The dancer must learn to rise onto the ball of the foot without forcing the foot into full demi-pointe.

Treatment
During the acute stages, rest and ice are helpful to reduce pain and inflammation. A good way to ice this injury is with an ice massage for 5 minutes. Stretching of the foot can be done to help improve flexibility. The stretch into a demi-pointe position can be done in a non-weight bearing position, in a pain free range and should be held for 30 seconds. The dancer should assess the available pain free range of the joint and learn to work within that range. Taping the great toe to restrict full demi-pointe can be effective in relieving symptoms. The tape should be applied so that the toe remains slightly downward (plantarflexed).

Dancer's Heel

Signs and Symptoms
This condition, medically known as Posterior Impingement Syndrome, occurs when the tissue become compressed at the back of the ankle*. This pinching or compression is caused by a bony formation at the back of the ankle*. The pain may be triggered by an ankle sprain* or by the tissue being trapped between the ankle* and heel bone. When the soft tissue at the back of the ankle* is pinched it becomes inflamed and painful. Posterior Impingement Syndrome is common among ballet dancers. The dancer generally feels discomfort at the back of the ankle* when the toe is pointed or in relev

The doctor will move your ankle* to see what movements or positions cause your pain. The doctor may push your foot downward or have you rise up on your toes if a posterior impingement is suspected. The doctor will probably order X-rays if impingement is suspected. You may be asked to squat down or rise up on your toes during the X-ray. This helps show if impingement is due to bone pinching the soft tissues. A bone scan may be recommended in select cases, such as when surgery is being considered. In general, MRI scans are not helpful for impingement problems, but they may be ordered to check for other ankle problems* that could be causing your pain.

Treatment Resting the ankle* may be required for a short time to reduce swelling and pain. A special walking boot or short-leg cast may be recommended to restrict ankle* movement for up to four weeks. Mild pain medications and anti-inflammatory medicine may also be prescribed. An ice pack may be advised to help alleviate swelling and encourage a faster return of normal ankle* movement.

Your doctor may administer a steroid injection into the painful area, to help relieve irritation and swelling in the soft tissues that are being pinched, reducing their tendency to get pinched. Additionally, your doctor may suggest working with a physical therapist familiar with dance medicine to help you regain normal use of your ankle*. Patients often progress in a series of exercises including stationary cycling, range of motion, and ankle* strengthening. If nonsurgical treatments do not work, surgery may be recommended. The type of surgery will vary depending on the location and cause of ankle impingement*.

Plantar Fasciitis

Causes
Plantar Fasciitis is an overuse injury affecting the sole of the foot. The tough, fibrous band of tissue (fascia) connecting the heel bone to the base of the toes becomes inflamed and painful. Most often people will experience pain first thing in the morning when they step out of bed. Dancers will often experience an increase in pain after class, or following lengthy weight bearing activities. Plantar fascia pain can also be influenced by tightness in the calf or the Achilles tendon, or dancing on a hard surface or a non-sprung floor.

Treatment
The earlier plantar fasciitis is treated, the quicker it can be resolved. Rest and ice are the first treatments for plantar fasciitis. Anti-inflammatory medication can also be helpful. For persistent conditions, physical therapy or athletic training treatments to assist with tight tissues and identify weakness is indicated. Chronic conditions respond well to the use of an overnight splint (issued by your physician or clinician) to provide a long duration stretch to the affected tissues.

Metatarsalgia

Causes
Metatarsalgia is characterized by pain and tenderness along the ball of the foot. For dancers, this is commonly caused by instability in the joints of the smaller toes. Repeated sprains and overstretched ligaments can lead to laxity, or increased flexibility in these joints. For a dancer, years of overwork and forcing of extreme motion in the foot can increase laxity and may cause subluxation of these joints.

Treatment
As with all acute inflammatory conditions, ice and rest are appropriate. Strengthening the muscles that control toe flexion can be helpful. This can be done with towel scrunches (using your toes to grab a towel placed on the ground and drawing it towards you). A metatarsal pad just behind the balls of the feet can help prevent subluxations and may relieve pain.

Common Injuries of the Ankle*

Achilles Tendonitis

Tendonitis can occur in any of the tendons about the ankle*, including the flexor hallucis longus tendon (the dancer's tendon), the peroneus brevis tendon, and the peroneus longus tendon. It most commonly occurs, however, in the body's longest tendon—the Achilles tendon. Able to withstand forces equal to and greater than 1000 pounds, this tendon connects the calf muscles to the heel bone (calcaneus) and is responsible for plantar flexion of the foot to achieve releve and performing jumps. Due to its' heavy workload in the dancing population, it is prone to inflammation (tendonitis). It unfortunately is also the most frequently ruptured tendon in dancers and non-dancers alike.

Causes
Most cases of Achilles tendonitis are due to overtraining of the dancer, particularly heavy training during a short period of time. Other contributing factors for Achilles inflammation would be:

• Returning to dance after a long period of rest
• A natural lack of flexibility in the calf muscles
• Dancing on a hard surface or a non-sprung floor

Aside from pain over the area of the Achilles, dancers with Achilles tendonitis can also notice:

• Mild pain after dancing that worsens
• Tenderness in the morning located ½" above tendon attachment to heel bone
• Stiffness that fades once tendon is sufficiently warm
• Swelling and inflammation

Treatment
As with all overuse injuries, the sooner the injury is addressed, the more positive the outcome. Rest and ice are immediate treatments for conditions that do not allow for any pain free activity. Active stretching of the Achilles is helpful. However, dancers need to exercise caution with stretching the Achilles beyond the point of comfort. Strengthening exercises should be introduced gradually. For chronic conditions, the use of an overnight splint to assist with dorsiflexion range of motion can be helpful. Orthotic prescription can be helpful to correct any structural imbalances in the foot. However, if a dancer has no correctable faults, orthotics may not assist with symptom relief.

Trigger Toe/FHL Tenosynovitis

Trigger toe occurs most commonly in female classical ballet dancers. It results when the flexor hallucis longus (FHL) tendon on the inside of the ankle* moves irregularly through its anatomical pulley mechanism around the ankle*. Sometimes, the tendon actually locks distal to the tendon canal (near the big toe) and prohibits a dancer from using the strength in her big toe when en pointe.

Causes
Trigger toe can be the result of inflammation or a partial rupture of the FHL tendon, accompanied by swelling along the sheath in which it's contained. The tendon may become frayed and scarred down, adhering to the sheath and creating friction, inhibiting its smooth gliding motion. The condition may present as non-painful and annoying for a period of time before becoming painful. Pain is typically noticed as a dancer lowers from demi-pointe to flat.

Treatment
Early identification of trigger toe can assist in its recovery. Dancers should use ice, particularly ice massage as a way to decrease local inflammation. The dancer should take the time to perform slow, gentle stretching of the great toe prior to dancing. More significant cases may require surgery to release the ligamentous portion of the FHL sheath and repair the tendon.

Anterior Impingement Syndrome

Causes
Anterior impingement syndrome involves the top of the ankle* where the shin bone (tibia) meets the ankle* (talus). There can be direct contact between these bony structures. With hundreds or thousands of pliés, this direct contact can eventually result in a bony formation at the front of the ankle*. This bony formation compresses the soft tissue and creates pain. A dancer will typically notice pain with deep pliés, as well as significant swelling at the front of the ankle joint*.

Treatment
Early recognition of symptoms is extremely important because anterior impingement syndrome is not reversible. Ice and/or anti-inflammatory medications can be helpful to reduce local swelling. Your doctor can assist with re-establishing normal joint mobility or identifying areas of inadequate strength or flexibility. A dancer may want to try some simple ideas to help relieve stress to the tissues during class or performances, including:

• perform in street shoes
• use one-quarter to half-inch heel lifts
• discontinue forced pliès

With advanced cases, surgery is sometimes pursued. It should be understood by the dancer that surgery very often leads to a recurrence of the bone formation within three to four years.

Lateral Ankle Sprain*

Ankle sprains* are the most common type of ankle injury* for dancers. Ankle sprains* involve the lateral (outside) structures of the ankle* and occur when the ankle* is inverted (turned or rolled outwards). A lateral ankle sprain* is the result of tears to any of the lateral stabilizing ligaments. Sprains are graded 1st, 2nd, or 3rd degree (3rd degree being the most severe) depending on the involvement and integrity of these ligaments.

Causes
Ankle sprains* are usually sustained upon landing jumps, either improperly or landing on an object or another dancers foot. It is common for significant sprains to also produce an audible 'pop' sound. Other related factors that can contribute to ankle sprains* include:

• working close to the limits of strength
• a slight loss of balance
• a lapse in concentration

Upon sustaining an ankle sprain*, a dancer will usually notice swelling and pain over the lateral ankle*. The severity of these symptoms will vary depending on the severity of the sprain. Some dancers are able to walk, some are unable to bear weight at all. Bruising over the lateral ankle* can emerge within 1-3 days following an ankle sprain*.

Treatment
As with any injury that involves inflammation, apply the RICE treatment protocol:

• Rest - avoid using the ankle* to prevent further damage.
• Ice - apply ice or cold packs to the ankle* for 15-20 minutes each hour to help reduce swelling.
• Compression - wrap a tensor bandage around the ankle* to help reduce swelling.
• Elevation - elevate above the heart and support the ankle* while resting to prevent blood from pooling and increasing swelling.

The severity of the ankle sprain* will dictate the amount of protection and immobilization the ankle* requires. A Grade 1 sprain may only need the support of an ace wrap bandage or an Aircast splint. A Grade 3 sprain may need to be immobilized with a splint and the dancer will likely need to use crutches or a walking boot for ambulation. Ankle sprains* should be evaluated by a physician to rule out any fractures. Follow-up treatment with a physical therapist or athletic trainer is crucial to develop strength and balance prior to returning to dance activities and thus reduce the potential for recurring sprains.

Shin splints, stress reactions, and stress fractures

Shin splints, stress reactions, and stress fractures are all overuse injuries of the lower leg* usually associated with forceful, repetitive activities such as running or jumping. Shin splints involve pain at the front of the lower leg* in the shin region. The pain is caused by an irritation of either the periosteum (the lining of the tibia, or shin bone) or the muscles and tendons in the area. A stress reaction is defined by accelerated remodeling or re-absorption of bone. A stress fracture is a small crack or cracks that occur as a result of repeated loading of the bone when muscles are fatigued. Fatigued muscles transfer more of the load to the bone. Shin splints or stress reactions can progress to stress fractures if left untreated. Stress fractures can progress to complete bone fractures if left untreated. The feet are the most common site of stress fractures in dancers, and the tibia is the most common place for stress reactions or shin splints.

Causes
All three conditions result in an aching pain that may become more severe during activity. Intensive dance rehearsal and a high percentage of time dancing on pointe or demi-pointe will increase the stress and pressure on the foot and tibia. As muscles become fatigued the dancer may have difficulty maintaining position, and the muscles transfer stress to other soft tissues and bone. When the bone is repeatedly stressed and has low bone mineral density levels, it can eventually result in a stress fracture. Dancing on hard floors increases the risk of stress fractures and stress reactions.

Treatment
Treatment of shin splints may involve various techniques, which include: resting the area applying ice to control inflammation physical therapy/athletic training treatments correcting any underlying postural distortions that may aggravate or contribute to the injury (knee hyperextension, weak abdominal muscles, anterior or posterior tilted pelvis, pronation/supination of the foot, etc.) With stress fractures, rest for the injured area is the only treatment that will allow the bone to heal. It may be necessary to unload the stress for a period of time by using crutches or a walking boot. A lack of pain does not mean that the bone has healed (many people do not report symptoms). A dancer should consult with their physician prior to returning to dance. Upon return to dance, the dancer should not experience any pain. If the dancer resumes activity too quickly, the stress fracture is more likely to progress to a complete bone fracture.

Other common foot condtions that dancers encounter

• Corns, which can ulcerate
• Calluses
• Thickening or ingrown toenails, torn or ripped off toenails
• Fungal infections
• Blisters
• Bursitis
• Cuts and bruises

When these conditions persist and do not respond to common treatment by the dancer, the podiatrist should be contacted. Allowing any of these conditions to get out of control will make the medical treatment take longer and returning to optimum condition will be more difficult.

Proper warm up, practicing proper techniques and paying attention to pain, all need to be part of the dancer's daily routine. The goal of Dr. Harwood and Southeast Podiatry is to offer a complete treatment plan to be able to return dancers back to normal activities in a safe and timely manner.

These may include structural and biomechanical evaluations, nutrition, shoes, rehearsal intensity, strengthening and flexibility.

All dancers work hard to prevent injury. Proper warm up, practicing proper techniques and paying attention to pain all need to be part of a dancers daily routine. Our goal is to offer a complete treatment plan, work together with the dancers and return them back to normal activities in a timely and safe manner.

* Definition of Dance Medicine and Science provided by the International Association of Dance Medicine and Science (www.iadms.org(1)). Text cited from the Dance Medicine Resource Guide, Second Edition, J. Michael Ryan Publishing, Inc. Written and edited by Marshall Hagins, PhD, PT.

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Fairhope Location

23937 US Hwy 98, Suite 1, Fairhope, AL 36532
Phone (251) 928-6768
Fax (251) 517-0501
Office Hours: Monday - Friday 8 am - 5 pm

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Atmore Location

1318 South Main Street, Atmore, AL 36502
Phone (251) 928-6768
Fax (251) 517-0501
Office Hours:Wednesday 9 am - 3 pm & Thursday 8 am - 4:30 pm