Don't hurt your dancing feet

Jodie is an 18-year-old student who loves to go for ballet and contemporary dance classes, as well as cheerleading sessions.

I first saw her early last year when she was in the midst of preparations for a ballet exam. She was referred to me for pain at the back of her right ankle, which had started about two to three months earlier.

Due to the increased frequency and intensity of her practice sessions, she had started feeling pain there, especially when going en pointe.

Jodie initially dismissed it, thinking it was ankle strain, but the discomfort intensified and impeded her dance performance.

Her mother was worried that the nagging discomfort was a sign of a more serious problem. Jodie was also very concerned that she would not be able to pass the exam.

After checking Jodie's right foot and reviewing her X-rays, I could tell she was suffering from a painful condition known as os trigonum syndrome.

Os trigonum refers to a small bone at the back of the ankle that forms in young children between ages eight and 13.

It typically fuses to the talus, which is the bone in the ankle joint that connects the leg and the foot, but in some cases, they do not.

When they don't, the un-fused bone can be impinged between the heel bone and the shin bone when the patient goes on the tips of her toes, causing pain and swelling.

I first treated Jodie conservatively with a rest period, anti-inflammatory medication and a course of physiotherapy.

Her symptoms improved after six weeks and she went back to her ballet classes. However, the pain came on again after just two sessions.

She came back to me to seek help as she really wanted to dance again. This time, I performed a keyhole surgery to remove the os trigonum at the back of her ankle.

She recovered well, went back to her ballet classes and was subsequently able to clear her exam.

Ballet dancers are especially prone to os trigonum syndrome and they usually find out after dancing for a while.

Dance can take many forms and range from the more traditional ones such as ballet, ballroom dance (salsa, cha-cha, tango) and lindy hop to modern varieties such as jazz, funk and hip-hop.

Even fitness dance forms such as zumba, K-pop X, piloxing and pole-dancing have been well-received of late. Singapore has also seen a rise in the number of studios catering to these activities.

However, as dance gains popularity here, more people have also sought help for dance-related injuries.

Over the past three to four years, my clinic has seen an estimated 20 to 30 per cent increase in such injuries.

Certain dance forms such as salsa, zumba and pole-dancing can be rather vigorous and I have had patients who sustained foot or ankle injuries during such classes.

They can be due to a misstep, poor conditioning or the patient pushing beyond his or her limits, among other reasons.

According to an orthopaedic surgeon, common conditions affecting dancers include ankle sprain, Achilles tendinopathy (overuse injury causing pain in the Achilles tendon), Achilles tendon rupture, plantar fasciitis (the most common cause of heel pain), inflammation of the big toe tendon, and fractures of the foot and ankle.

Although these represent a diverse group of foot and ankle conditions, dance injuries usually happen in one of two ways.

Acute injuries such as ankle sprains and fractures are associated with a single traumatic event. Chronic injuries such as Achilles tendinopathy are due to overuse and degeneration.

What I find common in the dancers I treat is that many of them try to persist with dancing despite their symptoms. They have a "the show must go on" mentality.

However, one should seek professional medical help if there is persistent pain, discomfort or swelling in the ankle or foot, or if one has difficulty walking.

Not getting enough rest or not seeking treatment early may worsen the condition or injury, resulting in pain and functional impairment.

Occasionally, it can lead to irreversible joint arthritis. Seeking treatment late may also result in a need for more invasive treatment such as surgery.

Treatment options for dance injuries can be divided into two main categories: conservative and surgical. Most dance injuries are managed conservatively with rest, analgesia, activity modification, physiotherapy and orthotics such as ankle braces.

For severe injuries or recalcitrant cases that have failed conservative treatment, surgery may be needed.

The type of surgery depends on the injury. For instance, those with os trigonum syndrome may benefit from minimally invasive techniques, which are less painful, have fewer wound complications and cause less scarring.

Dancers should note that many foot and ankle injuries can be prevented.

One way is to first get the technique right. Getting a professional instructor is especially important for someone new to dance. A good instructor will be able to teach proper techniques and monitor the dancer's performance and rehearsal load, as well as his or her fitness level and general health.

It is also important to adequately warm up before dancing. The warm-up session should include gentle pulse-raising activities to increase cardiorespiratory and metabolic rates, joint mobilisation in which you gently move various joints through their range of motion, and dynamic stretching exercises.

Being progressive in one's dance regimen - that is, increasing intensity and complexity at a reasonable pace - to avoid unnecessary stress on an unconditioned ankle or foot, as well as knowing one's limitations, can go a long way in preventing injuries.