En Pointe, Demi Pointe, Posterior Impingement ?

When we see pictures like this most of us are triggered to look at the toe and the challenges to the 1st MTP joint.  But what about all that compression and crowding in the back of the ankle ? Posterior compression is a reality in athletes who spend time at end range plantarflexion or pack much force and load through end range plantarflexion.

This is a photo example of what is referred to as “en pointe” which means “on the tip”.  “Demi pointe” means on the ball of the foot which is much safer for many areas of the foot, but this requires adequate 1st MTP (metatarsophalangeal joint range). We discussed this briefly this week on social media regarding hallux limitus and rigidus.

En Pointe is a terrible challenge. So if you are thinking of putting your darling children in ballet…… just beware of the facts and do some logical thinking on your own when it comes to allowing the “en pointe” axially loading of the entire body over a single joint, a type of loading that this joint was never, ever, designed to withstand. This joint is a great problem for a great many in their lives, why start playing with the risk factors so early ? Let them dance, into demi pointe, but pull them once they are being forced in to En Pointe, if you want our opinion on the matter.

En pointe or classical point ballet it typically done in point shoes or slippers which have a reinforced toe box that allows a more squared off stable surface to stand in pointe position.  It does not however allow a reduction in the axial loading that you see in this picture and it certainly does not help with proper angulation of the big toe, if anything the slipper will gently corral the toes together rendering abductor hallucis muscle function nearly obsolete.   The box will also not stop the valgus loading that typically occurs at the joint. Despite what the studies say, this is one we would watch carefully.  Now, there are studies out there that do not support hallux valgus and bunion formation in dancers, we admit that.  However, we are just asking you to use common sense.  If you see a bunion forming, if the toe is getting chronically swollen, if the toe is drifting off line then one must use common sense and assume that the load is exceeding joint integrity.  Prolonged and excessive loading of any joint cartilage is likely to create a risky environment to crack, fissure, wear down or damage the cartilage or the bony surface underneath (subchondral bone).  If you screw up this joint, toe off will be impaired and thus the windlass effect at the joint will be impaired thus leading to a multitude of other dysfunctional foot issues in the years to come.

Now, back to the “en pointe” position.  Did you try it yet ? Heed our warning ! Just trust us, this is bloody hard.  Since serious foot deformities can result from starting pointe too early, pre-professional students do not usually begin dancing en pointe until after the age of 10 or so , remember, the adolescent foot has not completed its bone ossification and the bone growth plates have not closed.  Thus, damage and deformity are to be expected if done at too young an age.  If you asked our opinion on this, we would say to wait until at least the mid-teenage years……. but by that point in the dance world a prodigy would miss her or his opportunity.  Thus, we see the problems from going “en pointe” too early in many. In the dance world, there are other qualifications for dancers before En Pointe is begun. Things like holding turnout, combining center combinations, secure and stable releve, 3rd position, 4th position, 4th croise and 5th position all of which are huge torsional demands on the hips to the feet. Do you want your child undergoing these deforming forces during early osseous development ? 

Achieving en pointe is a process.  There is a progression to get to it.  Every teacher has their own methods but it is not a “just get up on your toes” kind of thing.

Are you a dancer with posterior ankle pain, impingement or disability. The Os trigonum and protruding lateral talar process are two common and well-documented morphological variations associated with posterior ankle impingement in ballet dancers. 

Think this stuff through. If you are going to be treating these things, you have to know the anatomy, loading mechanics and you have to know your sport or art. Dr. Allen was a physician for the world famous Joffrey Ballet for a few years, he knows a thing or two about these issues dancer’s endure. And he still has a few nightmares from time to time over them. 

Dr. Shawn Allen

reference:

Clin Anat. 2010 Sep;23(6):613-21. doi: 10.1002/ca.20991.Pathoanatomy of posterior ankle impingement in ballet dancers. Russell JA,Kruse DW, Koutedakis Y, McEwan IM, Wyon M

Curse of the Bunion

Hi Dr. Allen,

My husband was able to stop using his orthotics by utilizing the exercises he learned from The Gait Guys on YouTube so I thought I would send you an email to ask your opinion about my daughter’s foot issues. She is 14 years old and a serious dancer (eight hours of class per week plus up to eight hours of rehearsal). She has developed a bunion which is starting to cause her significant pain in the joint of her big toe. We took her to an Orthopedist who gave her a Cortizone shot in her joint and suggested she will need surgery. Considering she is only 14 and surgery would take her out of dance for at least 3-4 months, we do not view it as a viable option. Is it possible to fix a bunion without surgery and is that something you have had success doing? I know she is not currently a patient of yours but I would be interested to hear your opinion on the issue.

Thanks,  PG

___________________________________

Dear PG

Wow, that is great news for your husband ! Although we do not recommend taking our information as medical advice it is always nice to hear that by simply using our stuff to self educate oneself that people are fixing what therapy was unable to achieve.

I used to treat many in the dance company at the Chicago Joffrey Ballet along side a few other brilliant doctors (who are Gait Guys followers as well !) and we always cringed when a nasty bunion would walk and and cry for help.

Bunions are developmental for the most part. They are found paired with Hallux Valgus. This journal article has a real nice verbiage that we like:

“The first ray is an inherently unstable axial array that relies on a fine balance between its static (capsule, ligaments, and plantar fascia) and dynamic stabilizers (peroneus longus and small muscles of the foot) to maintain its alignment. In some feet, there is a genetic predisposition for a nonlinear osseous alignment or a laxity of the static stabilizers that disrupts this muscle balance.  Many inherent or acquired biomechanical abnormalities are identified in feet with hallux valgus. However, these associations are incomplete and nonlinear. In any patient, a number of factors have to come together to cause the hallux valgus.”

In working with dancers we found plenty that did not have bunions or hallux valgus.  So it is not always the dancing that is the culprit. But it can be a factor if the osseous alignment is suboptimal (the joint line architecture at the metatarsophalangeal joint at the big toe is angled to allow for lateral hallux drift or the intermetatarsal angle is predisposed (wider than optimal)).  

The main problem however in dancers is multifactorial:

• the “turn out” predisposes the foot to more pronation which can easily destabilize the medial foot tripod anchoring of the 1st metatarsal to the ground.  This will change the pull of the adductor hallucis causing the hallux to drift laterally and the 1st metatarsal to drift medially widening the gap between the 1st and 2nd metatarsals (ie. the intermetatarsal angle).
• dancers also axially load the hallux. This is called “en pointe”.  Please read our prior blog post on “en pointe” (click here). As you can see in the video above, the angle at the big toe (the 1st metatarsophalangeal joint) immediately begins to drift into hallux valgus.  Continuing to do this will render this poor gal a nasty bunion in time we highly suspect.  These are the challenges that dancers put into the foot. Once the hallux drifts laterally the first metatarsal loses more anchoring capacity at the medial foot tripod and the viscous cycle continues. 
• Remember, a bunion is a soft tissue adventitious mal-development.  It is often erroneously confused as a bony proliferation at the medial joint, the knuckle area.  This is not the case.  Hallux valgus drives the metatarsal head medially and exposes the head of the bone medially giving the appearance of a bump (the “bunion”). In fact, the bunion is an inflamed or adventitious bursal sac combined with the prominence of the MET head and angry inflammed skin, ligaments, joint capsule etc

To “fix the bunion” is a loaded issue.  Once these begin to develop they frequently progress in degree and pain.  They are very hard to correct conservatively but you have to give it a chance, surgery has to be the last road. Unfortunately if this is going to happen it must be determined if dance is a provoking factor, which is very likely.  Being in En Pointe will make this a quick trip into a nasty bunion we fear.  Use caution and logic on this one PG.  Your daughter has to live with these feet for many decades at the very least, and there is nothing like walking on painful incompetent feet for the rest of your life.  Further correction possibilities may come from determining if she can adequately form a good foot tripod and achieve competent strength in the muscles that stabilize the joint (FHL, FHB, EHL, EHB, ABD H., ADD H., tib posterior and anterior …… to name most of them).  A strong competent foot with excellent medial tripod anchoring ability will rarely develop into a bunion or hallux valgus. But you have to catch the incompetencies early and correct them before things get out of  hand. 

Good luck to you and  your daughter PG.  Find someone good at these things.  Find your local “Gait Guy or Gait Gal” and you will be in good hands (or should we say “good feet”).

The government needs to start a “Just say no to bunions” grassroots program. Although on second thought, maybe that is not a good idea. It would only get caught up in congress and the senate for years.

Warm regards,

Shawn and Ivo