Certain foot positions play havoc with the Achilles tendon

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New, York's only academic medical center. I'm your host, Amber Smith. It makes sense that ballet dancers tend to have a higher incidence and frequency of lower extremity disorders compared to disorders in other regions of their bodies. One of the most prevalent types of injuries involves the Achilles tendon. A doctor of physical therapy from Upstate published research recently about Achilles tendon disorders in ballet dancers. Michelle Dolphin is here to share her work, along with one of the physical therapy students who assisted in this research, Nicole Harry. Welcome to The Informed Patient, Dr. Dolphin and Ms. Harry.

Michelle Dolphin, DPT: Thank you. We're excited to be here.

Nicole Harry: Thank you.

Host Amber Smith: Let's start with a description of the Achilles tendon and what its role is. Ms. Harry?

Nicole Harry: Yeah, absolutely. So this is a great place to start. The Achilles tendon is located in the back of the lower leg. Many people think of this region of the calf. The calf muscle actually has two parts, and both of these parts are going to attach to the tendon, which attaches to the heel bone. And so it's really the region of your heel cord.

Host Amber Smith: It's in the region of, what kind of cord did you call it?

Nicole Harry: The heel cord. So it's like the back of your heel.

Host Amber Smith: So this is the tendon that helps us flex and point?

Nicole Harry: Yes, absolutely. So this is going to help point your foot and plant or flex your ankle, is what it's called.

Host Amber Smith: I see. So is that its main role in the body, or is it necessary for ambulating, for walking?

Nicole Harry: Yes, correct. So this is the main role that the Achilles tendon has and is necessary for ambulating and walking and what we call push off during gait.

Host Amber Smith: Do you know what it looks like or what it feels like in the body? Have you seen one in person?

Nicole Harry: Yes. So, we kind of have a lab that we get to go in and see other people's tendons and see how they function. And then we also can see these in the cadaver lab that we have during our placement in school, in our education.

Host Amber Smith: Is it like a rubber band?

Nicole Harry: Yes. Similar, I would say. Definitely shinier and kind of stretchy.

Host Amber Smith: Now, regarding common injuries I've heard of tendonitis. Can you explain what that is?

Nicole Harry: Yes. So tendonitis, broadly, is inflammation of a tendon, and so Achilles tendonitis is going to be inflammation of the Achilles tendon.

Host Amber Smith: And then tendonopathy, what does that mean?

Nicole Harry: Yeah, so tendonopathy and tendonosis are just a little more common in older adults. They can be non painful. They can be painful. But there's less of an inflammation and more of a different disease process there.

Host Amber Smith: Now, Dr. Dolphin, why are Achilles tendon injuries prevalent among ballet dancers?

Michelle Dolphin, DPT: Thank you for that question. So from our research and our understanding in working with dancers, the Achilles tendon is what's going to help us get up over our toes. So for dancers that frequently dance, it's known as on releve, on the toes or the balls of their feet. This is frequently loaded. So we see a greater prevalence of injury among dancers.

Host Amber Smith: Compared with other athletes in other sports, right?

Michelle Dolphin, DPT: Well, that's a great point too. So we often see this in athletes who jump. So I've worked with patients who have had injuries related to volleyball, to basketball certainly. You can see some disorders in runners as well. And then, as Nicole mentioned, it also can be in folks who are non-athletic. So it can be, I had a patient who one time was just stepping onto a dock to get into his boat, and this may be likely that there was a disordered process in the Achilles prior to this injury. But to your point, dancers and athletes that do a lot of jumping, it's quite common.

Host Amber Smith: So jumping, or like you said,elevating your, on the balls of your feet or on the point. That's the move that sort of puts you at risk?

Michelle Dolphin, DPT: Yeah. It's due to an inadequate loading cycle. Like any muscle, like a muscle in your arm, if you exercise it consistently and you don't have any rapid change on training or excessive training, the muscle will respond. But sometimes in dancers there's an inadequate preparation. It could be too little exercise or too much exercise that can put this body part at risk.

Host Amber Smith: Does age or gender affect a dancer's risk?

Michelle Dolphin, DPT: We didn't see in our research a difference between, gender, between males or females. But what we did notice is adolescents can experience this based on the frequency of training. So if you think about this time of year in holiday shows, they rapidly increase their rehearsal schedule. So this may put them at risk. And then again, I think of the weekend warrior. So the athlete that doesn't train regularly. They go out to a family event. They play pickleball. They play volleyball. They may get injured because they're not training as consistently.

Host Amber Smith: So when you see an injury like this, do you typically see it in one leg, or would it ever show up in both legs at the same time?

Michelle Dolphin, DPT: I love this question because I'm surprised by the answer actually. I would suspect it's both legs, right? You would expect your Achilles. You're training both feet, both legs, whatever the case may be. But it actually seems to show up on one side, which we call unilateral. So it may be your dominant side, the side that you push off with more often. And when I've seen it in patients that have both legs are painful, one is usually worse. But I don't know the reason why that is, other than maybe speculating, they're loading that a little differently.

Host Amber Smith: Now with ballet dancers, did you see a difference or did you even look between whether they were in pointe shoes -- those slippers that have the kind of the toe box that's really stiff and firm -- or just the regular ballet slippers?

Michelle Dolphin, DPT: Yeah. What we found is exactly that the pointe shoe itself, not only because you're in the a toe box, a constructed toe box. If folks aren't familiar, you load all the way up onto your tippy toes, so not just the ball of your foot. Your entire body weight gets in a straight line over your toes. Then, based on the shape of your foot, the longest toes take the most load. We all have different foot arrangements. But the other unique part about the pointe shoe is the ties. The satin ties cross in an area over the Achilles, where normally the Achilles does not have a good blood flow in any of us. So you're taking two factors -- put them up on your tippy toes, and tie these satin ribbons around a place that has a compromised blood flow naturally. And we did see that that has a greater risk of injury than other types of dance, particularly dance footwear.

Host Amber Smith: Well, that's interesting. And there's no way, though, you have to have those satin ties. You can't really keep the shoe on without them, right?

Michelle Dolphin, DPT: That's correct. Plus, think about ballet being this classical or traditional dance. Like most people would object if we put them in a different type of shoe, like some modern way to take that pressure off. So the classical aesthetic demands are such.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. My guests are Dr. Michelle Dolphin, who is part of the physical therapy faculty in Upstate's College of Health Professions, and Nicole Harry, who is a student in the physical therapy program. We're talking about their research into Achilles tendon injuries in ballet dancers. Now, Ms. Harry, I'd like to hear about the research which was published in the Academy of Orthopedic Physical Therapy. Can you tell us why you investigated Achilles tendon injuries in dancers?

Nicole Harry: Absolutely. So I grew up dancing and still really enjoy being a part of the dance world. And I'm drawn to ballet, and specifically pointe because it's just so beautiful and really, truly an art form, how they can do this for hours on end. And so, you know, I thought they're using their bodies in a different way than the normal population is, just walking and exercising. So I figured it would be interesting to look into the difference.

Host Amber Smith: So how was your research done?

Nicole Harry: So our process was a literature review. We searched multiple databases using very specific search terms, and we found all the relevant articles on ballet dancers, specifically on Achilles tendon disorders that were published in the past 10 years. And so we screened these abstracts and full manuscripts and articles based on the author consensus.

Host Amber Smith: So what were your findings? I know you looked at a lot of things, but what are the most relevant findings?

Nicole Harry: We found so many things of interest. I'll touch on a couple here. The prevalence of Achilles pain in ballet dancers of the collegiate level is six times higher than contemporary Chinese dancers of the same level. And they also found that the prevalence of Achilles tendinopathy was very high as well, and it was ranked as the second most common overuse by one of the authors, Sabrina et al. So we also looked a little bit on risk factors in young female ballet dancers. Risk factors they found included maturation, hyper mobile joints and compensatory mechanisms. And so it was really interesting because compensatory mechanisms can occur at any joint. You know, the hip, the back, the knees. And it's just how the body's moving differently that can affect the joints above and below. And so that can beaffecting the ankle and the Achilles, achilles tendinopathy there.

Host Amber Smith: Dr. Dolphin, overuse injuries in athletes must be tricky to treat because the athlete, I know, wants to train and to get stronger or maintain strength, but not overdo it. So how would you counsel a dancer to avoid developing this injury?

Michelle Dolphin, DPT: Yeah, and Amber, it is such a unique thing. It's unique to every dancer, right? Or every athlete that you might counsel. So it's that gradual loading. We call it graded loading. So start with a little. When your body gets ready, do a little more, and so on and so on. That's important for specificity. So if I need to dance on my toes, I need to train by dancing on my toes. But when we think about someone who's maybe having a little setback or having injury, then we say, well, are you cross training? Have you been in a pool? Have you ridden a bicycle? Have you done other things, because your whole body needs to be strong, flexible, fit, et cetera. So it's a really challenging, balance act, particularly if somebody has a performance schedule, they have a deadline, or an athlete has a competition. So it can be a difficult conversation with adolescents, with families, with dance teachers, with coaches.

Host Amber Smith: For a dancer who suspects they may have a problem with their Achilles tendon, can you describe or walk us through what the diagnosis and treatment might entail?

Michelle Dolphin, DPT: Yeah, absolutely. So first of all, in New York State you can see a physical therapist directly without a referral for 30 days, up to 30 days or 10 visits. So PTs are very well trained to do medical screening, if additional imaging or anything else would be warranted. The diagnosis is based on history and clinical exams. So the patient tells you the story of their problem and then you observe specific movements -- walking, sitting, standing, balancing. And then go to a very specific look at the ankle -- range of motion, strength, tenderness. And the exam is really very easy to make in a clinical exam, by a therapist.

Host Amber Smith: So I'm assuming physical therapy is part of the treatment.

Michelle Dolphin, DPT: Absolutely. I would recommend if someone's having problem with this, go see your movement specialist. And the movement specialist is a therapist, physical therapist. Here at Upstate, we have a specialty service group called a performing arts service group, so we see patients throughout our outpatient offices, and a group led by Chris Rieger. We've been going out to local dance schools and doing some screening of young dancers. So definitely it's an area of interest and expertise here at Upstate.

Host Amber Smith: Are there ways that dancers can stay strong while they're recovering from an Achilles injury?

Michelle Dolphin, DPT: Yeah, we will teach them a variety of exercises. Some may be done in sitting. Some may be done with elastic bands and various exercise equipment.

Host Amber Smith: Let me ask, Ms. Harry, in your training so far, have you learned about ways to keep the tendons healthy?

Nicole Harry: Yeah, absolutely. I would emphasize proper training is really the most important factor. So a dancer and their dance teachers really should be aware of the most effective training. In terms of our research, the opportunities we found were linked to volume of training and then endurance and strength of the Achilles. So choreography might entail a limited number of jumps or releve's, which we said before was just going on your toes. But a dancer really should be as fit and as strong as they can be to perform the choreography. Dr. Dolphin previously mentioned changes in training demands. Such as increased dance at a summer camp or no dance while students are on break. And so that could affect the dancer's ability to really fully participate and perform and load their Achilles.

Host Amber Smith: Dr. Dolphin, is there any way to predict whether someone has a vulnerable tendon? Can you sort of anticipate that a certain person might have, might develop problems? I know that ballet dancers in general are at higher risk, but can you get down to individual level?

Michelle Dolphin, DPT: Yeah. I think Amber, it's not just based on a physical presentation. You know, there are requirements in terms of, you have to be able to fully point your foot, like get the top of your foot in a straight line with the front of your shin. It has to be completely vertical. So there is one physical capacity component to get into a toe box, which is to be up on pointe. Let's say you've met that physical criteria. The rest comes down to training. There's nothing I can look at, "oh, this one's too lean, or this one's too that" to decide what is a risk factor. It's about the training, which is actually pretty exciting because that's something we can change and influence.

Host Amber Smith: What about other types of injuries for ballet dancers? Aside from the Achilles tendon, are there other injuries that you see commonly among ballet dancers?

Michelle Dolphin, DPT: Yeah, it's primarily lower extremity and low back. So legs, hips, knees, ankles. And while I have this quick moment, I want to thank our co-author, Liz Janowitz, another student PT who helped us on this paper. And we have another paper in review right now looking at anterior knee pain in dancers as well, because that is very common in dancers.

Host Amber Smith: Well, dancers are not unique to sort of a rigorous training schedule. All athletes, I mean, you think about football players, soccer players, karate. So I don't, I don't know if there's any general advice. I mean, hopefully you have a good coach who's attentive and isn't going to ask you to do things that'll injure you.

Michelle Dolphin, DPT: Yeah.

Host Amber Smith: But how does the, how does an athlete learn their limits?

Michelle Dolphin, DPT: You know this. This is another really great point, and this was not from our research, but from being a clinician and being an educator. We talk about external load, which is how you work out. Are you sleeping? What's going on? And internal load, your stress, your emotional health, your mental health. We can show when people are under increased mental stress, they're more likely to have an injury. So that athlete that's having a really bad day, had a poor exam, had a fight with a parent, that actually increases their risk. So for our coaches and parents and loved ones to recognize, it's not just about the workouts, it's how are we sending ourselves or our family members out to do these activities? Is it? Is it good time? Should we pull back a little bit to protect them from that injury risk? So external and internal factors are at play for all of us.

Host Amber Smith: So being attuned to that maybe would help reduce the risk too.

Michelle Dolphin, DPT: Absolutely. Absolutely.

Host Amber Smith: Well that's really good to know, and I appreciate both of you making time for this interview.

Nicole Harry: Thank you so much.

Michelle Dolphin, DPT: It's been a pleasure. Thank you.

Host Amber Smith: My guests have been doctor of physical therapy, Michelle Dolphin from Upstate's College of Health Professions and physical therapy student, Nicole Harry. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.