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

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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

When the toe extensors become short or tight.

Here is a really great video.

One of us was treating physicians for the Chicago Joffrey Ballet for a time in the early 2000’s. Feet like these were nothing new. For the most part there was amazing flexibility, amazing strength and occasionally some nasty bunions but not as often as one might think. What was clear however was that the majority of the population of feet seen were freakishly strong, amazingly flexible and with skill levels that most of us only dream of.

In this video we can see two things which we just highlighted. Full uninhibited ranges of motion and apparent strength. In order to have full ranges we usually see wonderful strength. When we see a loss of range of motion, frequently but not always, we see weakness of the muscles necessary to drive that range. In other words, if we had the strength we would have the ability to engage the full range because of that strength.

You have heard it here before, that when there is weakness in a muscle around a joint (since all muscles cross a joint) we will see a neuro-protective loss of range due to a neuro-protective tightening (we are using the word TIGHTENING very carefully, note we did not use the word SHORTNESS) of some related muscles in a response to attempt to stabilize the joint. It is not a perfect remedy, but what other strategy do we have ? Sadly, it is usually the strategy of the owner of the broken part to try to stretch that tightened (again, note we did not use the word shortened) muscular interval which then presents the joint again with the afferent detection that the joint is unstable and unprotected. So, more tightness develops and the vicious cycle continues. It is our hope that those that find they need to stretch daily will someday have a light bulb moment and see that they are doing nothing to remedy the vicious cycle. That searching for the weakness that drives the neuro-protective tightness (as opposed to true “Shortness”, which is truly physiologic loss of the length-tension relationship) is where the answer lies to remedy the joint imbalance.

Here this client has generous ranges of motion and highly suspected appropriate strength. The two often go hand in hand unless the client has the phenomenon commonly referred to as “double jointed” which is truly just a collagen abundance in the passive restraints (lets leave this as a merely generalized term for now, it is a topic of another blog post).

What we wanted to talk about here today was the plethora of tightness AND shortness we see daily in the extensors of the toes. How many of your clients have the flexion (toe curl, at all joints) range of the toes that this client has ? Not many correct ? But most have near full extension ranges of the toes correct ? This can only come down to one theory that must be proved or disproved. That being that the toe extensors are either tight because the flexors and plantar intrinsics are weak OR that the toe extensors are short because they have been in this environment of flexor-plantar weakness for so long that the tightness eventually morphed into a more permanent reduced length-tension relationship.

Go ahead, see if you can flex your toes or those of your spouse or clients as far at this dancer can. See if you have full range at the metatarsophalangeal joints like this dancer does. Very likely you will notice a nasty painful tension and stretch across the top (dorsum) of your foot. This is reduced length of the long and/or short toe extensors and likely fascial connective tissue as well. Heck, what else runs across the top of your feet ? Nothing else really. So, what is one to assume ?

Digit extensor tightness is rampant in our society. We have been in shoes and orthotics and stable shoes for so long that our flexors and foot intrinsic muscles have become pathologically weak. As the opposing pull of the flexors and extensors across the end of the foot at the metatarsalphalangeal joints becomes so imbalanced our foot has no other choice but to express this imbalance.

Is this why we see bunions, hammer toes, even gentle flexion of our toes even at rest ?

Yup, the mass population of feet we see are slowly going into a coma. The pattern we see most commonly is even a bit more complex however, it is not quite as simple as tight-short extensors and weak flexors and intrinsics. Looking at the functional neuro-pathology of the hammer toe proves the complexity of our compensations. Here is the most typical pattern (and hence the hammer toes that are taking over the earth):

• weak long toe extensors
• strong short toe extensors
• weak short toe flexors
• strong long toe flexors

This combination ends up in a functional/flexible hammer toe, and if left alone to fester, a rigid hammer toe in time.

From this combination you should now as the question, “So, when I attempt to put my foot and toes in the flexion positioning of this dancer in the video above what is the tightness i feel across the top of my foot ?”

Answer: functional tightness (and possibly shortness if it has been there long enough, which is likely for most folks) of BOTH the long and short digit extensors (EDB, EDL). Think about it, in the hammer toe position both are short, but for different reasons. The EDB because of the resting extension position at the metatarsal phalangeal joint and the EDL becuase it is wrapped around two distal chronically flexed interphalangeal joints in the presence of an ALREADY extended metatarsophalangeal joint ( which takes up EDL length).

This phenomenon occurs rampantly in the upper limb as well across the elbow, carpals and finger joints. It is a big component of TOS and carpal tunnel and of the multitude of functional problems that the elbow such as medial and lateral epicondylitis.

Why do you care ? After all we are The Gait Guys. Well, because most of us swing our arms during gait and what is pathologic in the upper limb can affect the lower limbs and gait. It is all connected after all, according to the song ……

Chronic disruption of the length-tension relationships of the toe extensors.

It is a bigger problem than you think.

Shawn and Ivo. Discussing the distal sister disease of polio……… affecting just the toes of course. Ever hear of Tolio ? (pronounced……Toe-Lee-oh). Just kidding.

Today, something a little different.  I worked for the world famous Joffrey Ballet Dance company on an off for a few years treating the dancers before shows and productions.  These folks always had the most amazing strength (try this one ! bet you cannot do it……in fact, don’t try it…..you will probably dislocate your MTP (metatarsophalangeal joint; the big knuckle joint) of the big toe.)

These folks also had many problems with their hips, knees and spine mechanics from the demands of turn out, jumping, overuse and the demands of things like en pointe.  This is an example of what is referred to as “en pointe” which means “on the tip”.  There is “demi pointe” which means on the ball of the foot which is much safer and we will do another video on that another time to explain some critical components to it right, there is more to it than just getting up on the ball of your foot.

En Pointe is a  terrible challenge in our opinion. 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.

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 video 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 as you see occurring here in her right foot if your joint line has a more aggressive angulation (genetics).  You can already see the deforming force that is creating a valgus toe position here. 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 (see ** at end of this post).  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).  So, if you think that loading your entire body mass axially on the small joint surface of the big toe is a great idea, that is fine, just do not bring your kids to our office and expect to get a happy face sticker at the check out counter.  We are going to read you the risks that are born from logical thinking.  This is not meant in any way to take away from the amazing feat that this is for dancers, but it just is not a smart thing to do if you want a healthy first joint (MPJ - metatarsophalangeal joint) and foot for that matter. After all, 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.

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 etc. 

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. 

Shawn & Ivo……. Dreaming of Sugar Plum fairies…….. (ok, maybe not)  but knowing your biomechanics of the foot and gait are an integral part of dance as well.

* and after watching this video, if your next thought was……“ I wonder what the incidence of posterior ankle impingement injures occur in dancers” or if you said under your breath……. “hey, extreme plantarflexion at the ankle loads the Lisfranc joint pathomechanically ….. I wonder if that joint is ever an issue in dancers……. ?"   then you will clearly be on the route to becoming one of……… The Gait Guys

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** Hallux Valgus in Dancers. A Myth ? 

Abstract: Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.