Dancing and Physiotherapy

Common Injuries in Professional Dancers

Positioning/alignment requirements for a dancer during training and performing predispose them to a unique set of injuries. Excessive plantar flexion (esp. ballet dancers) places them at an increased risk of posterior impingement which is closely linked to both Os Trigonum Syndrome (if Os trigonum is present) and Flexor Hallucis longus Tenosynovitis. The movement quality and training load also predisposes dancers to Meniscal tears and Patella tendinopathy.

Meniscal Tears

(usually medial > lateral as medial is firmly attached to MCL and joint capsule and lateral is more mobile)

What is it? The meniscus is a fibrocartilaginous disk that lies on the articular surface of the tibia. The menisci function as shock absorbers of the knee and transmit loads while adding stability. Meniscal injuries can range from partial thickness fraying and/or tearing to total avulsion of the meniscus from the peripheral attachment (TN Scioscia, 2001)

Causes: In an acute meniscal tear, most dancers will describe a sudden event of twisting combined with weight bearing on a bent knee (plie) or when landing from a jump. In a chronic case, gradual wear and tear from poor biomechanics and/or overuse causes degenerative meniscal tears.

Presentation: A dancer will present with pain, swelling, potentially locking (in a more serious case and unable to straighten knee). A clear subjective history, Joint line tenderness + a positive McMurrays test + a positive Brush swipe test (indicating joint effusion) are indicative of a meniscal tear.

Management: Initially over the counter medication to manage pain and swelling and activity restriction. If pain and swelling have not subsided over 6 weeks, surgical intervention to either remove a portion or repair the meniscus may be necessary.
Post-surgery management involves swelling and pain reduction, progressing ROM, increasing strength in the knee and adjacent joints, challenging proprioception, dance specific function and a gradual return to training.

Patella Tendinopathy

(“Jumpers Knee”)

What is it? Dancers are exposed to the effects of repetitive jumping and leaping and are more likely to develop patella tendinopathy (Fietzer et al., 2011). Tendinopathy refers to degeneration of the collagen protein that forms the tendon. There are three distinct stages of a tendon pathology Reactive tendinopathy, Tendon disrepair and Degenerative tendinopathy. Load is considered to be the primary stimulus that drives tendon health back and forward along the continuum.

Causes: Overload, increase in training volume and intensity, age (degenerative). Interestingly, a dancer contends with aesthetic constraints, such as a vertically-aligned trunk during landing, that places greater demand on the knee extensor mechanism (Fietzer et al., 2011)

Clinical presentation: Anterior knee pain localised to the inferior pole of the patella (tenderness on palpation) (Schwartz et al., 2015). Patella tendinopathy presents as load related pain that increases with the demand on the knee extensor complex (especially in plie, deep squatting movements)

Management: Load tolerance focusing on pain reduction initially followed by progressive loading as tendons respond well to HEAVY, SLOW, RESISTANCE training

– NSAIDs are used in the acute management with some effect.
– Corticosteroid injection  If pain is persisting beyond expected time frame, a local corticosteroid injection may result in short term pain and reduced swelling and vascularisation of the patella tendinopathy

Physiotherapy: Stages of Rehab described by Malliaris et al. 2015
1. Relative rest from provocative activities (jumping, deep squats etc.)
2. Isometric loading ->to progressively load the tendon
3. Isotonic loading (Eccentric > Concentric) (Frohm et al. 2007) (Schwartz et al, 2015) -> Bilateral and unilateral squats on 25-degree decline board vs standard squat is associated with earlier return to sport.
4. Energy storing loading -> double leg and single leg
5. Return to dance -> Dance specific exercises, replicating the demands of training

Os Trigonum Syndrome

(especially for Ballet dancers on Pointe in excessive plantar flexion)

What is it? The Os trigonum is present from birth in some people (about 13% of pop). It is an extra/accessory bone behind the talus that failed to fuse during young adulthood (Walsh et al. 2020). Some people with an Os trigonum remain asymptomatic, however dancers will often develop Os trigonum syndrome due to excessive/ repetitive plantar flexion required in their movement.

Causes: overuse or traumatic event of rapid and excessive Plantar flexion

Clinical presentation: Load dependent persistent posterior ankle pain mostly occurring with plantar flexion, push off, jumping. Stiffness, weakness, and swelling may be in the area and tenderness on palpation between Achilles tendon and Peroneal tendons (palpable bony prominence in some cases), reduced plantar flexion ROM.

Diagnosis: Can be mistaken for an Achilles tendon injury, Flexor Hallucis Longus injury, ankle sprain or talus fracture (American college of foot and ankle surgeons 2023)
The Subjective history, Passive rapid plantar flexion test combined with X-RAY findings of Os trigonum are used to make a diagnosis

– Corticosteroid injections
– Surgery for Os trigonum removal if symptoms persist

Physiotherapy Rehabilitation
– Rest, Ice to reduce swelling and inflammation
– Strength exercises for the deep posterior compartment of the lower leg (tibialis posterior, flexor digitorum longus, flexor hallucis longus). By strengthening these muscles, the talus is shifted forward during plantar flexion and thus help to reduce compression in posterior ankle
– Proprioceptive exercises to correct malalignments of the lower limb (Albisetti et al. 2008)

Flexor Hallucis Longus Tenosynovitis

(closely related to posterior ankle impingement)
Note: FHL is compressed in demi pointe/ pointe and on stretch in Plie

What is it/ causes? The flexor hallucis longus (FHL) is a muscle originating from the posterior aspect of the fibula and interosseous membrane. FHL passes behind and below the medial malleolus through a fibro-osseous tunnel before it attaches to the distal phalanx of the great toe. Repetitive, forceful, and prolonged plantar flexion and dorsiflexion (pointing and flexing) manoeuvres can irritate the tendon causing it to become inflamed. Thickening or fibrosis may impede the normal gliding motion of the tendon, this creating pain and restricted ROM.

Clinical presentation: Most commonly the dancer presents with right medial ankle and mid foot pain and swelling which gets worse by jumping and landing, often accompanied by a clicking sensation of the ankle. Often the pain has either come on over time because of overuse or has occurred following a lateral ankle sprain. Pain on passive plantar flexion with pressure on FHL while moving the great toe into dorsiflexion (further irritated by inversion). Pain may also be brought on by resisted great toe flexion

Who’s at risk: Female ballet dancers are more at risk than males due to the nature of pointe work.

Diagnosis: Comprehensive patient history, physical exam, MRI and dynamic ultrasound. Can often be mistaken for/ combined with posterior ankle impingement syndrome, Os trigonum syndrome, Tarsal tunnel syndrome, Plantar Fasciitis

Management: May take 4-6 weeks of graded/ progress rehabilitation for recovery

– Relative rest: avoid demi pointe, pointe and excessive dorsiflexion for the inflammation to settle.
– Ice and NSAIDs
– Taping: to offload the FHL tendon
– Stretching: hamstrings, ITB, Piriformis, gluteals
– Non weight bearing ROM and strength: FHL, ankle AROM
– Improve intrinsic foot muscles to address potential poor foot function
– Rehab toward high level proprioception and dance specific movement

Common Dance Terminology – useful in rehabilitation

Pile (demi, grand)






Grand Battement

Grand Jete


Article written by Holly Doyle