| Pain In The Back of The Ankle |
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Hello Lisa I do hope this finds you well. Many thanks for your recent email about not using therabands for resistance when doing flexion and extension foot exercises. Another teacher I know also suggested avoiding this at a recent workshop I attended with her, facilitated by DANZ. I would be most grateful if you could offer me an explanation that I can pass on to students as to why this action with theraband resistance is now considered inadvisable. I understand it causes some interference with proprioceptors in the foot and as you state, causes tension in the back of the ankle. Any further clarification you can offer me would help me greatly in explaining the current thinking on this matter to my students. I have several of your printed and DVD resources, which my daughter and I have found invaluable and which I have made great use of in my body conditioning classes with my students. Thank you so much for making these resources so readily available and for all your YouTube items, which explain things so clearly. May I ask you one more question please? My daughter has been experiencing what seems to be termed 'Dancer's Heel' for a while and our physiotherapist here in Auckland has been working with her to mobilize the area with exercises and massage. Obviously, we have been avoiding working to her full range whilst this problem is persisting to avoid aggravating the situation. Any suggestions you may have as to other treatments for this condition would be greatly appreciated. Emma has suggested we consult a podiatrist and have X-rays to check for any abnormal bone growth, but she feels that as it is on both ankles, an Os Trigonum is unlikely. There has been mention of a possible injection of anti-inflammatory into the area, however, this is considered a last resort and other less invasive treatments are the preferred options. Any guidance or suggestions you may be able to offer us would be most gratefully received. Many thanks for giving my questions your consideration, Lisa.
So lovely to hear from you! And I can most definitely answer both questions. Firstly - quite a few people have been asking for more information about my recommendation of not pointing the foot into a resistance band, and there are several reasons for this, which I will explain as best as I can in an email.... The teacher that suggested avoiding this is because it decreases your proprioception is correct, however I would class this as more of a disadvantage, rather than a risk. There is less pressure on the receptors in the skin of the sole of the foot, and within the joint when pointing the foot against a band compared with doing single leg rises. Pressure on the receptors allows feedback to be sent up to the central nervous system which it turn sends messages back to the muscles around the ankle to correctly support it. The real reason that I do not like to see students perform this exercise is that they tend to loop the band over their toes, so that when they are in a fully pointed position, the toes are curled under. Anyone who has attended any of our workshops, explored the Advanced Foot Control Manual or The Perfect Pointe Book will know that curling the toes under when pointing is one of my pet peeves, as it sets dancers up for so many injuries. About 90% of the foot and ankle injuries that we see in the clinic come from this very issue (often masked inside ballet shoes!). In my videos demonstrating exercises such as “Pointe Through The Demi Pointe” and “Hooking The Big Toe” I explain just why this is such a problem.
This said however, it is possible to do the exercise without curling the toes under, if the student has good awareness. I still tend to avoid this exercise in that situation as the elastic tension has the capacity to compress the joint space at the back of the ankle when in a fully pointed position. There are lots of tendons passing through a small space at the back of the ankle, and any less space than normal can cause compression. For improving strength in the feet and ankles into flexion and extension, the much safer, and better option in my opinion, is simple Single Leg Rises in parallel. This develops a much more functional strength as the student must learn to control placement on demi pointe as well as developing core and hip control. It also helps set up the correct muscle firing patterns in the foot and ankle, in relation to the rest of the body. Pointing the foot, even in something as ‘simple’ as a Tendu, should be an entire body experience, including activation of the core, turnout and leg muscles as well as the feet. If students are not strong enough to do the single leg rises with good control, I usually start off with double leg rises to let them work through the foot to full range in good alignment. As you may have guessed, this leads perfectly into talking about your daughters pain in the back of the ankle. Overuse of the long toe flexors is one of the biggest causes of pain in behind the ankle, so the first thing I would be checking is whether there is any thickening of the Flexor Hallucis Longus or Flexor Digitorum Longus tendons. This can be done easily by gently pointing the ankle, and wiggling the toes, while feeling gently along the inside of the ankle. If these tendons are thickened, you will be able to feel them moving under your fingers. If this is the case, then we definitely need to take a close look at her technique to stop the clawing. Other reasons that there may be thickening of the tendons include rolling in of the back of the foot when standing, or, on the other hand, if she is trying too hard not to roll and gripping with the Tibialis Posterior tendon to stabilise the inner arch. This can also happen if she has been dancing in soft pointe shoes, or breaking in the shoe too low. Strengthening up the deep inner muscles of the foot is essential in offloading the thickened tendons.
One common reason for pain in the back of the ankle that is often overlooked is actually a blocking in the Subtalar Joint. If there is a restriction in this joint the ankle will feel stiff to point to full range, and so the dancer will try harder to get their normal full range. Working against increased resistance can in turn cause irritation in the back of the ankle. Ask the physiotherapist to assess this joint, as well as the other joints of the mid and rear foot, as correcting this can make a huge difference. I am assuming that the physiotherapist has ruled out inflammation of the Achilles Tendon (or paratendon) and it is more like a “Posterior Impingement” scenario. Achilles Tendonopathies are treated differently again – so I won’t go into that here. As a general rule, it is important to settle the information as quickly as possible, but we must also find the causative factors and correct these before getting her back to class, to prevent the symptoms from coming back. Acupuncture can be very effective in settling chronic inflammation so perhaps you could try this, before looking into any surgical options. Phew! What a list! But there are so many reasons for the back of the ankle to get blocked! I do hope that this helps you work through the issue with her therapist and get back to dancing fully in the near future! Kindest Regards Lisa
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Simply put, the muscles that curl the toes under do not actually have their muscle belly in the foot. The bulk of the muscle is up in the back of the calf and long tendons connect all the way down into the toes. If focus is made on curling the toes under when pointing, then this can cause overuse in these deep muscles, and result in tension and pain in the back of the ankle.
There is a possibility of an Os Trigonum in the back of the ankles, but if she has had full pain free range in the past, then this is not something that grows quickly. However, many dancers can have a small bone in the back of the ankle and have no symptoms, but when their work load en pointe intensifies, they start to feel pain. A simple plain film x-ray will tell you whether there is any blocking in the back of the ankle, but remember to have the films taken in both standing and with the foot pointed.
