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Understanding and Addressing Ankle Pain and Sprains in Dancers

Are you or do you know a dancer who does relevé, jumping/leaping, en point, or wears heels? Do you realize the importance of strong and stable ankles? Dancing with ankle pain or limitations is no fun and can slow the ability to learn new techniques. In extreme cases, too many dancers find out the hard way that repetitive or overly severe ankle sprains lead to career-limiting or ending chronic ankle instability. Do you have some newfound motivation to protect your ankles? Good! Let’s jump right into sensible ways to reduce ankle pain and sprains.

Dancers who spend significant time with the foot in a plantarflexed position (heel raised off the ground) put a lot of pressure on support structures around the ankle. Yes, this includes relevé, take-off/landing, pointe work, and heels. Those support structures include ligaments (that connect bones) on the inside and outside of the ankle, and multiple muscles on the front, back, inside, and outside of the ankle.

An ankle that tends to roll inward or outward when in the heel up/toe down position is playing with fire for either ligament injury (aka sprains) or an overload on bones and muscles.

A dancer’s goal is to keep the ankle in a “neutral” position without too much rolling inward or outward. This neutral position requires contributions from not just ankle stability but also structures above and below.

Take time to look “higher”

Let’s not forget that muscle groups in the hip, pelvis, thigh, and knee make big-time contributions to the stability of the foot and ankle. A lack of this “central” control, commonly due to injury, fatigue, or pushing a dancer past the current level of muscle development, can lead to a higher risk of ankle sprain injuries.

Plie in Second Position – solid line shows hip above kneecap. Broken line shows kneecap above second toe.

When evaluating any dancer with ankle pain or sprains,  Dr. Chris Koutures always includes an assessment of hip, pelvis, and knee stability. And if he had to pick one favorite evaluation tool, I’d select looking at plie in second position.

A line that goes over the second toe shows the most acceptable alignment and hip/upper leg control.

If the knee is bent inward (line over or inside of the first toe), it can overload the inside of the ankle.

If the knee is bent outward (line over or outside of the third toe), it can overload the outside of the ankle with an increased risk of sprains.


Then look lower

The big toe can lead to big problems with the ankle. Some may question why this small joint (aka first metatarsophalangeal joint or first MTP joint) may cause such problems.

Well, let’s review why optimal big toe function is so essential for healthy dance performance.

In many dance positions and movements, including demi-pointe or relevé, a dancer should ideally achieve full big toe dorsiflexion.

Dorsiflexion: Movement of the big toe towards the shin. Limitations in big toe dorsiflexion, known as hallux rigidus, can lead to painful compensations at several joints including the ankle.

When going up on the toes or in a heel-raised position, a dancer with limited big toe dorsiflexion will cheat by rolling the foot outward and putting the ankle in a rolled inward (inverted position).


Rolling the foot outward (aka sickling) puts more pressure on the middle or outside of the foot

Not only is sickling aesthetically unpleasing (instructors aren’t going to be happy), but this position increases ankle sprains and damage to the bones on the outside of the foot. Sickling also can overload the outside of the knee and cause excessive hip internal rotation.

Here’s a simple way to evaluate first toe dorsiflexion in a standing position. Examiner lifts the big toes off the floor. In this case, the left toe does not go as high as the right.

Now, you may rightfully ask "what causes limited first toe range of motion?" This is a great question with an answer that provides a great segue to our next topic…

Paying attention to the inside of the ankle

Pain on the inside of the ankle is often due to pinching and limited motion of muscle tendons that are in the tarsal tunnel:

  • Flexor Halicus Longus (FHL)
  • Posterior Tibialis (PT)
  • Flexor Digitorum Communis (FDC)

The FHL goes from the inside of the ankle along the inside of the foot to attach to the underside of the first bone of the big toe. Restricted movement of the FHL causes decreased dorsiflexion of the big toe. Stretching of the FHL and friction massage can increase big toe motion and reduce ankle sprain risk.

Going behind the ankle

Moving into pointe or demi-pointe with the ankle in plantarflexion can narrow the space behind the talus (first bone of the foot) and the Achilles tendon. This is where soft tissues can be pinched together – what medical professionals call posterior heel impingement. The more time spent in these positions, the higher the chance of irritation. This pinching may involve the FHL and create the big toe motion limitations.

There’s a chance you’ve been told that an “extra bone” or a ‘bigger bone” may be part of the problem.

The red arrow is pointing to an extra bone prominence (aka os trigonum) Yes, an increased bone prominence can trigger impingement on the back or inside of the ankle which can limit the overall range of motion.


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