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The question I chose to answer this week is from a Parent of a young dancer with pain at the front of her ankle en pointe...
Dear Lisa, HELP! We just don't know what to do! 

My daughter is 11 years old and started on pointe about 5 months ago.  She has been dancing since age six and does five 2 hour ballet classes a week (only 30 min on pointe) and a 30 minute private lesson a week.

For the last month her left foot (ankle high but draw a line to front of the foot) has been hurting.  We talked to her instructor who said it sounded like tendonitis and told us that pain goes with ballet so she just needed to work through it.  Well, she comes home limping and puts ice on it and it feels better until she goes on relevé or does pointe work and it starts over again.  So today I decided to take her to an Orthopedic Surgeon who did an x-ray and told us no fractures but probably tendonitis.  He said to stay off of it for about a month and then try it again but that it will probably come back.

His recommendation was not to do Ballet because it destroys your feet.  My daughter LOVES ballet but I have to say has had a hard time getting on her box completely since going on pointe and her foot does not look right in the ballet shoe.  We have tried all different types of ballet shoes.  She has a slim foot but when she goes up on pointe it looks like she needs a bigger toe box to hide possible sickling.  She swears that she is not sickling and the teachers have never thought she is sickling (if I can I would like to send you a picture).  We just don't know what the problem is and she is getting frustrated - Please HELP!  Do you know of a good instructor like yourself in Southern California that could evaluate her we would even drive up to Los Angeles? ANY help would be appreciated.

We bought your book but have only gotten through the first stretches.

Thanks for your help!

Stephanie

Hi Stephanie,

Thanks so much for your email – and I will do whatever I can to help. I will also contact some of the teachers and therapists I know in California and see if I can put you in touch with them...

If any readers in the area think that they may be able to help... please let me know.

First of all – Please rest assured that there is most likely a solution that does not involve stopping ballet permanently! Also, please note that any ‘tendonitis’ will not get better by working through it. If there is ever a diagnosis of a tendonopathy the dancer may need to have relative rest of that area while they retrain their technique to get back to dancing without pain, but they should not have to stop dancing.

It would be wonderful if you can send me a picture of her foot in her pointe shoe, and also out of the shoe fully pointed, as there may be several reasons for pain at the front of the ankle.

The first thing we need to do is look at the structures at the front of the ankle and work out which ones are actually causing her pain. I highly doubt that it would be a fracture, and the most likely candidates are the ligaments at the front of the ankle.
Often young dancers have not been using their full pointe range when working on demi-pointe and when they start into their pointe shoes, these ligaments can be stretched as the foot is pushed into its end range, without the strength to control this range.

This may be the case if she has quite a flexible arch, even if she is not able to use this en pointe.

One thing I would do is look at the shape of the front of her arch when she rises on two feet in parallel (as high as she can in no shoes) versus rising en pointe in parallel. If she has developed the appropriate strength to position her feet in pointe shoes then the shape of the front of the arch will be similar, however often in young students they will demonstrate a difference in range.

If she does not appear to be able to get up onto her box fully, then you need to work out if this is due to her actual pointe range... her strength... or an issue with the shoe...?

You will be able to test if it is her pointe range by doing the pointe range test in The Perfect Pointe Book. If she is unable to achieve the desired range, then I would work on improving this before attempting pointe work again.

If she has good pointe range out of her pointe shoes, but is unable to use this in a rise, either in bare feet or in her pointe shoes – then she definitely needs to work on improving her strength in the muscles that control the ankles. I would suggest working on the “Seated Rises” and the ”Pointe Through Demi-Pointe” exercises in The Perfect Pointe Book and the “Rises With Resistance Band”  exercise demonstrated HERE and as below.

 

If she has good pointe range, and can use it in a rise on demi-pointe, then it may be a problem with the shank of the shoe.

Has the teacher helped her break in the heel of the shoe as I describe in this video?  If the shank of the shoe is too stiff, young dancers will struggle to rise fully onto pointe against the strength of the shank. When fully en pointe the sole of the shoe should sit snugly against the sole of her foot.

 

If the shank is not conforming to the sole of the foot, the whole shoe may twist on her foot, giving the appearance of sickling that you describe.  The solution to this is simply in breaking in the shank of the shoe underneath the heel, or picking a shoe with a softer shank.  You may also need to adjust the angle and placement of the ribbons to make sure that this happens.

I would definitely never suggest getting a bigger box to ‘hide possible sickling’. Instead we need to work out why the foot is appearing to sickle and fix this, whether it is to do with weakness in the foot or the style of shoe.

In the mean time – I would definitely suggest using ice on the front of the ankles and avoid jumping and relevé in class. The slow rises used for strengthening should be ok, and she can practice doing these in class while the others are jumping. Also continue working through all of Stage One and Two of The Perfect Pointe Book with her to see if you can see any other restrictions or weaknesses that may be contributing to her pain.

Please let me know how you go, and I will be in touch with any details of someone more local that you can see! I hope this helps!

Kindest Regards,

Lisa

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