The largest and strongest tendon in the body, the Achilles tendon attaches the triceps surae (gastrocnemius and soleus muscles) to the posterior aspect of the calcaneus (heel bone). It is used in locomotion by controlling the lowering of the forefoot once the heel strikes the ground and also to propel the heel off the ground during walking and jumping. Dancing on pointe, on demi-pointe, or in plié places force on the Achilles tendon. In fact, the tendon must transfer up to six times the body weight during jumping movements to propel the feet off the ground (Hodgkins, Kennedy & O’Loughlin, 2008); some researchers estimate this number to be even greater, up to 12 times a person’s body weight (AchillesTendon.com, 2016). While these forces are not abnormal in magnitude, the frequency with which these movements are performed by dancers places abnormal stress on the tendon. Achilles tendonitis (also referrred to as tendonopathy) is an inflammatory overuse injury experienced by many dancers.
Causes and Symptoms:
It is estimated that 24% of athletes develop Achilles tendonopathy (APTA, 2013). Certain individuals have pathologies (abnormalities) that predispose them to the chronic injury, such as excessive pronation, walking too far back on the heels, bowlegs, tight Achilles tendons, and abnormally shaped heel bones (Hodgkins, Kennedy & O’Loughlin, 2008). Age, discrepancies in leg length, ankle instability and previous injury are also associated with Achilles tendonitis (Gallo, Plakke, & Silvis, 2012).
The likelihood of developing Achilles tendonitis increases with improper technique (Motta-Valencia, 2006). Forcing your turnout causes the foot to pronate placing further stress on the Achilles tendon (Kadel, 2006). Failure to press the heels into the ground following jumps, or to rise completely to full 3/4 toe in relevé, shortens the tendon and puts the dancer at further risk for tendonitis and/or rupture of the tendon (Kadel, 2006). Futhermore, environmental factors such as dancing on improper surfaces or raked stages, too-tight shoes or pointe shoe ribbons, and placing an elastic loop on the back of pointe shoes can exacerbate tendonitis.
A dancer may complain of pain 1-2 inches above the heel that worsens with activity and upon waking first thing in the morning. If untreated, this pain may become pervasive and affect normal activities of daily living.
Preventative measures can be as simple as sewing elastic into pointe shoe ribbons at the point where they cross the back of the leg and tying shoes less tight, relieving pressure placed on the tendon (Kadel, 2006). Some dance companies provide an angled stretch box backstage or in the studio to give the dancers an opportunity to stretch out before* and after performing, or the dancer can extend the tendon off a stair or step stool (as shown). Instructors should be diligent in encouraging students to place the heels down while jumping and using proper alignment of the foot in turnout and jump landings.
*Note: there is conflicting evidence on the efficacy of stretching before exercise.
Treatments vary drastically. Minor treatments include strict adherence to rest, ice, strapping the tendon and anti-inflammatory drugs. It is imperative that the inflammation be given adequate time to subside. On occasion, this may require the use of a boot to immobilize the joint. More dramatic treatments include local cortisone injections, thermotherapy, laser therapy, and in few cases surgery. According to Hodgkins, Kennedy & O’Loughlin (2008), anti-inflammatory drugs and/or steroid injections should never be used to ennable the dancer to perform. They suggest that non-compliant dancers be casted to force the immobilization of the joint. Additionally, the long-term effects of steroid injections such as cortisone are not fully understood and could compromise the strength of the tendon.
A common misunderstanding is the difference between tendonitis and tendonosis. Tendonitis is an acute condition in which the tendon becomes inflamed. Tendonosis is a chronic condition in which persistent inflammation leads to degeneration and the formation of nodules on the tendon. Tendonosis can develop if acute bouts of tendonitis are not treated properly or the dancer does not take adequate time to rest. Dancers with tendonosis are at an increased risk of rupturing the tendon.
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