II. INJURIES, PREVENTION AND CURE

Chapter 2. The Feet

As might be expected feet figure more largely amongst complaints in the ballet class than anything else, knees running a close second. Amongst the younger children it is as well to make sure that the ache or pain is the result of exercise in the class-room. The author remem­bers a small boy who came to her complaining of pain over his instep up the front of the leg, and on top of his knee, who remembered on being questioned that he had gone for a walk on Sunday, climbed a tree and fallen in the descent! The un-typical position of the site of the pain would arouse the suspicion of anyone familiar with the pattern of ballet strains. When, however, a child complains of pain along the inner border of the foot when standing at the barre this, one concludes, belongs to ballet. It will most likely be found that it is due to the effort of correcting a "roll". It is not important unless it persists. If after a day or two it has not disappeared, it is better to take the child off work for a few days. Many children correct rolling feet with no resulting discomfort, but in the exception persistent pain indicates that the ligaments of the foot are feeling the strain of adjusting to the new position, and ligaments in the foot are quicker to react and slower to recover from strain than are muscles. This will often be so in the highly arched foot where the muscles are not sufficiently strong and undue work falls upon the ligaments in standing. In parenthesis it may be pointed out that it is perhaps more important that flexible highly arched feet should be trained from the very beginning to hold the correct position on the floor, ball of big toe, ball of little toe and heel, than any other type, since it is one way of strengthening the muscles of the sole of the foot which have such an important part to play in maintaining the arch, and which tend to be weak in the foot which is beautiful to look at but difficult to train. If in such, during the first few years persistent "rolling" is left unchecked, we have the soft mobile foot that gives way on pointe, and has no push off in elevation.

Apart from the pain along the inner side of the foot, various small aches may be found in young children for which a couple of days' rest from class is usually all that is needed. Simple home remedies need not be neglected, e.g. bathing in hot water, in which a good handful of Epsom salts has been dissolved is a simple and effective relief for many foot troubles. It can also be useful for older students, amongst whom from time to time more definite pains arise. It is not always possible to locate exactly the site of a strain in a structure so bound together by ligaments as is the foot. As work becomes more advanced there are more possibilities of pressure here or a pull there, and if such arise the most helpful procedure is to find the exact position or exercise that produces it. Eliminating this for a few days is often all that is required, and perhaps working in a light bandage when including it again in class. The elastic net type of bandage is more suitable than crepe for this pur­pose, giving greater support, without bulk or undue restriction of movement. Should the pain be persistent, then strapping with adhesive strapping is more efficacious, put on by an expert, from whom also advice should be sought as to the length of time to wear it.

Strains of ligaments in the foot are felt mostly on the supporting foot, i.e. in weight bearing, and in springs, less so in holding en l’air or in such movements as battements frappés, battements tendus and so on. There are one or two muscles which may also be the source of trouble, but the pain will then be felt on movement rather than in standing and especially when on pointe. The usual place that the dancer will point to is just behind the inner ankle, (figure 23.) It occurs most often in the highly arched foot with loose ankle joint and it is fairly safe to say that it is produced by some degree, however small, of "sickling out" either on pointe or in other exercises or positions. It is especially necessary to deal with the cause, which harks back to faulty technique, for this strain may become a tiresome and recur­ring inflammation in the tendon of the muscle concerned, the Tibealis Posterior muscle as it is called. Having come down the outer side of the leg, its tendon winds round the inner ankle, spreading out into smaller tendons under the foot. Its action is to point the foot and to turn up the inner border. The stretch put upon the main tendon then is obvious if the foot is sickled out, more especially when weight bearing. Any inflammation in a tendon should be the signal for rest, and in this particular case, taken at once it will clear up in a week. If the pain is at all severe it should be seen by a doctor who will no doubt strap the foot in the exact position which speeds up recovery.

The fact that this particular strain is practically confined to the more delicate type of foot reminds us that strength and flexibility rarely go hand in hand, and it is important to work for the building up of strength in the one type and flexibility in the other. Nothing is more important to the over-mobile foot than the correct use of the resistance of the floor. It is too easy for its owner to neglect this, showing the end result of e.g. a battement tendu without the strong slide of the foot on the floor before arching the foot, and in steps of eleva­tion—assemblés, etc.—the same tendency. It is in part at least the reason for the better elevation in the dancer who has had to work to produce a good arch than in the one who is by nature so endowed.

There is one other tendon which can give trouble, the Achilles tendon which joins the calf muscles to the heel. Pain in this should always be

Figure 23. Site Of Pain Likely To Be Caused By "Sickling Out".

dealt with at once. It can occur in both boys and girls, usually not before  twelve years old, but occasionally earlier in boys. The complaint is either a pain above the heel in pliés and fondus or when pointing the foot; and at a later stage on turning the foot upward. It may be caused by lack of a good demi-plié especially with a stiff type of foot, or if there exists a short Achilles tendon. Whatever the cause, all work should be stopped at once, and as a precaution it is wise to have the limb strapped for a week to ten days and for work to be resumed for a day or two before the strapping is removed. A week is the minimum rest for this condition and there should be no remnant of pain when beginning again. Nor should a full class be attempted, rélevés, springs and of course all pointe work omitted for at least another week. Treated thus, this inflammation subsides but regarded as unimportant it can be one of the most disabling of the dancer's strains, becoming in time a real synovitis, with creaking in the tendon and severe pain. It is worth being on the cautious side to avoid this possibility. The doctor or other expert by whom the strapping should be put on might question the neces­sity of binding the limb from heel to knee for such an apparently slight condition, yet in view of the special stretch to which this tendon is subjected in ballet it is wiser to take extreme precautions immediately and so to prevent the likelihood of any recurrence of the trouble.

These strains of ligaments and tendons that have been mentioned do not of course exhaust all possibilities that may occur in the class­room, but they cover the main types which are due to the nature of the work, rather than any extraneous cause. In addition there is of course the ordinary sprained ankle, ruptured fibres in the calf muscle and in the Achilles tendon. These last two are never met in younger students. They belong to the adult dancer and need immediate medical attention. The sprained ankle may occur at almost any age, but it is an injury rather than a strain. In its mild form a very few days' rest from work is all that is necessary, but should it be severe it is quite a serious injury.  The most common site of damage is that of the ligament on the outer side of the ankle, divided into three bands of which the front or middle one is the most likely to suffer damage, either by overstretching or the rupture of a few of the fibres. The result is pain which can be intense, swelling which comes up within a few minutes, and bruising sometimes well up the leg. Cold compresses, or alternate hot and cold bathing are emergency measures, but as soon as possible it should receive medical attention. In a severe case there is always the chance of a small fracture of the lower end of the fibula, or of the 5th metatarsal bone, for which reason no doubt the doctor in charge would secure an x-ray. A fracture, if present, would delay return to work but would not leave any perm­anent damage. The ankle is a good healer and the victim of this injury need not feel that it will not be as good as ever in a relatively short time. The usual treatment consists in strapping from forefoot well up the leg and encouraging the owner to go about life as usual, adding possibly some form of physiotherapy later on. To any exercises which may be given at the clinic, the dancer can add with advantage those of her own which use the joint fully without weight-bearing, such as battements frappés, and battements tendus; and a few days later gentle rélevés, demi-pliés and so on. As soon as possible a return to class is advisable, but, pointe work should be omitted until all swelling has disappeared. The sufferer from this injury may take comfort from the fact that for any residue of pain that may persist, there is no better treatment for it than a good session at the barre.

The actual bones of the feet rarely figure on the casualty list but yet the author has come across two cases which would be considered rare, one in a girl of twelve years old and another of fourteen. There is such a thing as a spontaneous fracture of one of the long bones of the forefoot, arising from no known cause and presenting as symptoms pain and swelling over the front of the foot. It cannot of course be treated except by the doctor and may keep the child off work for a month or more, but eventually training can be continued without any after effects.

One other minor condition that occurs occasionally is an extra growth of bone at the back of the heel. The heel becomes red and a soft bursa may form from the friction of the shoe. Indeed the whole condition may be caused by just that, so that it is important to ex­amine all the footwear in use, including ballet shoes and the exact place the ribbons contact the heel when tied. With the relief of all pressure, including a protective pad if necessary, the swelling may subside, but otherwise the exostosis as it is called may have to be dealt with surgically.

Finally come complaints of pressure pain under the heel, or under the big toe. It may be caused merely by a hard ballet shoe and this should be investigated first. It is especially bad for a hard ridge of the shoe to be allowed to press into the soft flesh under the ball of the foot, as in an extreme case inflammation of the sesamoid bones embedded in the tendon of the muscles can be set up. These small bones do not become fully hardened until well on in the teens, and inflammation in them can be difficult to cure and result in leaving the foot unsuitable for training. This is a rare occurrence but not unknown.

Eliminating this source we come to the pain which is the precurser of the occupational hazard of the ballet dancer, hallux valgus. The first symptom may be pain on the under side of the big toe or on the outer, either on standing and especially when on the half-pointe. The immediate question that arises, as has already been stressed in the last chapter, is not about the toe but about the shoes in use. For ballet children more than any it is of paramount importance that all footwear should leave room for all the toes. The slightest shortening is sufficient to start off this trouble, the slightest lack of width at the toe end is enough to press the big toe towards the centre of the foot. Appearance is of secondary importance to the urgent necessity that there should be room for the toes to grow in the natural direction, with no pressure on any, especially on the big toe. And socks or stockings must be equally carefully watched. Two or three months' growth in a young child may necessitate replacements for both, and no economic reasons must stand in the way, hard though it may be. This is the first investigation to be made when a child complains of pain under or around the big toe joint, remembering that boys are no less immune from this trouble than girls if wrongly shod. All shoes, outdoor, indoor, ballet and even bedroom slippers should be examined. A very early hallux valgus may correct itself when given foot space inside the shoes. At a later stage little can be done for it.

The shape of the foot undoubtedly has some bearing on the pre­disposition to hallux valgus. The dancers in illustration 18 who have escaped this trouble all have a broad front and toes of medium length forming a circular pattern on the floor. Their toes are also straight. One often finds in the early signs of pain around the big toe that the pupil has the very bad habit of curling her toes in barre exercises, a fault difficult to detect in shoes, but detrimental if persisted in, and a very bad introdution to pointe work, in which the straight big toe is of prime importance. The child with the highly arched foot and the one with little arch are both apt to cultivate this habit of clutching, the first because she cannot otherwise feel her toes and the second in the mistaken impression that it will improve the arch. The result is an imbalance in the pull of the two systems of muscles which preserve the straightness of the toes, and loss of that strength which is needed for both springs and pointe work. It is not un­likely that this has some bearing on the incidence of hallux valgus but whether or no, it should be checked as likely to lead to other troubles.

Once the big toe joint has become deflected it is impossible to cure but careful and correct technique is the best insurance against any progression of the condition. For early cases it is worth while trying the effect of wearing an appliance at night, obtainable at some shoe stores under the unattractive name of bunion springs, which by means of a slot for the big toe and an adjustable webbing round the forefoot, keeps the toe in a good position during sleep. This will not cure the condition but is sometimes successful in checking any increase. Nothing however is to be gained by wearing a rubber pad between the big toe and its neighbour. This is more likely to push the second toe out of alignment than influence the first, and claims made for it are quite fictitious. Other than this it is important to keep the joint entirely flexible and to remember that teen-agers, succumbing to the lure of fashion shoes with high heels which throw the weight of the body on to the front of the foot, and with narrow fronts which cramp the toes, are sacrificing the serviceability of their feet for allure, and giving every opportunity for the big toe to become a trouble maker.

One other difficulty with the big toe may be mentioned briefly, but it is less common than hallux valgus and the pain is felt almost exclusively on the demi-pointe. This is known as hallux rigidus and as its name implies, it is a stiffening of the joint due to some arthritic increase of growth in the bones. It does not occur in chil­dren. It is more painful in action than is the valgus deviation but does not increase with the same speed. A severe case would be obliged to give up dancing, but a very mild degree may be kept under with the aid of some form of heat treatment and the stoicism which is characteristic of the ballet dancer. Eventually it will defeat the bravest but there may be some years of work before this happens, and dancers are not apt to look too far ahead . . . which is perhaps fortunate!

Before leaving the subject of foot strains and the incidence of hallux valgus in particular, the oft-repeated warning must again be given against too early pointe work. Although the recognition of the danger is far more widely accepted than a few years ago, it is still possible to buy blocked shoes to fit a six-year-old and to find classes where they are allowed to wear them. It cannot be too strongly stressed that "pointe" work is the end result of slow and gradual training of the whole body, back, hips, thighs, legs, feet, co-ordination of movement and the "placing" of the body, so that the weight is lifted upwards off the feet, with straight knees, perfect balance, with a perfect demi-pointe, and without any tendency on the part of the feet to sickle either in or out. This moment will arrive at different times for different children, not only by virtue of previous training but according to their physical type, and in this may be included the growth of the bones. All the bones of the body begin as a relatively soft material known as cartilage which becomes progressively ossified into true bone at different times, being completed as late as twenty-five years. During this period there is a gradual hardening from the centre outward. In the long bones, such as those of the leg, forefoot and toes, the shaft ossifies first, the ends known as the epiphyses remaining connected to the shaft only by cartilage until the early teens (figures 24, 25, 26), with considerable variation as between one child and another as to the exact time at which the cartilage becomes bony. Ideally, if pointe work could be delayed until this time in children with poor bone structure, no doubt their feet would be safeguarded, but as this is a counsel of perfection, the most that can be done is to prepare the whole body as perfectly as possible, and to ensure that the introduction of the work on pointe is slow and gradual, in no case earlier than twelve years of age and preferably later. The fact that some feet can be found to have survived the abuse of tottering around on blocked shoes from the age of six on­wards is no criterion as to its safety. The author has met at least one case of a child whose strong feet were unharmed by "dancing" on pointe at six years old, but who succumbed with knee trouble. There is little doubt that the strain had been resisted by the feet but had been transferred to the knee joints.

Figure 24. An X-ray of 4 year old feet. X Note the big space filled with soft cartilage between the bones of the forefoot and those of the toes and the epiphyses of the bones of the toes appearing as flat discs and separated from the main shaft.

Figure 25. Feet at 11 years. X Note the forefoot bones are now less widely separated from the toes, but the epiphyses are still not joined to the shaft of the bones of the toes.

Figure 26. Feet at 19 years. X The bones of the toes are now in one piece and the space between the forefoot and toe bones is finally reduced. (Note also in this illustration there is a small degree of hallux valgus, showing the typical displacement of the upper end of the first metatarsal bone.)