Footcare: Advice from a Podiatrist

by Dr. Richard T. Braver, Sports Podiatrist
Englewood, New Jersey

The dancer's foot requires special attention. Redness, swelling or pain is a warning sign of impending danger and can be helped by icing the affected area for 10 minute periods several times a day. The following advice may help you avoid or care for dancer's injuries; however, if pain or problems persist, see your sports physician / podiatrist.

Ingrown Toenails

Ingrown toenails are regularly caused by the edge growing inward or piercing through the surrounding skin. This may first present with a red, pusy and painful nail border and can lead to infection. To avoid this problem, trim the nails straight across. However, if your nails appear to hook or excessively curve downward into the skin, then cut your nails at an angle to remove the offending portion of the nail, which is growing inward. Over the counter ingrown nail medications are not recommended.

Fungus Nails

Thickening of the nails may be due to chronic trauma to the nail root area. The nails may appear whitish or yellowish and be significantly thickened. Over the counter medication is available which may help to soften the nail plate, making cutting the nails more manageable, especially after bathing or soaking the feet. It is important to keep the nails cut short and to use an emery board to reduce nail thickness.

Toenail Blisters

Blood blisters form under or around the toenail usually as a result of an enlarged toenail pressing against the tip of the pointe shoe. This forces the toenail back up into the skin at the nail base. This can be avoided by trimming the nails shorter and ensuring a large enough pointe shoe. Some dancers have a longer second toe than their neighboring toes, causing the second toe to receive extra pressures. Pad the neighboring toes with a foam toecap or lamb's wool so they take their fare share of the pressure, thereby relieving the second toe of pressure.

Blisters

Blisters are caused by friction irritation, which causes the layers of skin to rub back and forth against each other, usually a result of sliding of the foot in the shoe or a prominent bone rubbing against the shoe. This should be treated like a burn so ice may be applied. Painful blisters may be drained with a sterile needle. The roof of the blister should be left intact for protective covering. Accommodative felt prefabricated or self-made donut or "U" shaped felt pad should be applied around this area to reduce pressure and to protect it from further irritation. The blister is then covered with a triple antibiotic ointment or petroleum jelly, which further helps to reduce friction.

Warts

If you note red dots within a rough appearing callous lesion and you have tried to accommodate this area with padding as discussed, but the lesion still persists and is growing in size, then a wart may be present. It may present as a singular lesion or as a cluster of lesions. A wart is a virus infection and can be treated with application of either a liquid or disc shaped pad containing acid medication after soaking and filing the lesion. A wart is a skin disease and may spread; it is not caused by blisters, pressures or bone deformities. Seek medical care if problematic.

Corns

Corns are hard skin lesions, which may develop on top or between the toes. If red, swollen and painful, then use ice. The corn should then be covered with an accommodative pad as described for blisters and covered with a piece of cloth athletic tape. The idea is to reduce pressure to the corn by transferring weight to the pad which surrounds this lesion. Felt pads are better than foam pads because they are less compressible.

Check the fit of the shoe for irritation ensuring proper width and toebox depth. Dance technique should also be examined to make sure the toes are not clawing or gripping inside the shoe during releve or pointe position. For a corn between the toes, wear a foam toe separator or felt donut pad between the toes.

Hammertoe, Mallet and Claw Toes

Appearing as knuckled or clawed toes. Either flexible or rigid, these create a bony prominence over the toe joints with resultant rubbing of this area against the top of the shoes. This irritation causes redness and an eventual corn (hard skin) formation. Because the toe now appears clawed, the tip of the toe often presses and rubs against the bottom of the shoe again resulting in pain and eventual hard skin.

Accommodative donut shaped padding as discussed in blisters should be applied for corns on top of the toes. If there is a callous at the tip of the toe, then a foam toecap or lamb's wool should be wrapped around the sore toe. Corns and callouses may be reduced in size after bathing or soaking in soapy water by use of a pumice stone or corn callous file. While this will give temporary relief, a true hammertoe bone deformity will not disappear and may require medical attention.

Morton's Toe

A second toe which is longer than the big toe causes increased pressure to the tip of this toe. This longer second toe may buckle causing it to claw with resultant irritation to the top of this toe. The dancer should accommodate for the longer second toe by placing lamb's wool in the toebox of the shoe to fill in the gap underneath the shorter toes, effectively lengthening them. There should be less or none of the lamb's wool at the tip of the longer second toe. This will help to better balance pressures to all the toes equally, thereby preventing abnormal pressure demands. Alternatively, the dancer may wrap the lamb's wool around the shorter toe or wear foam toecaps on the shorter toes.

Metatarsal Pain

Often this develops across the bottom of the foot to the bones just proximal to the toes (ball of the foot). Swelling, pain or a callous often develop. An underlying bone problem may e the culprit of this pain, i.e., the second toe and metatarsal may be longer than the large toe and its respective metatarsal.

When the dancer rises into releve, the longest metatarsal bone receives pressure first and in increased proportions. A similar single pressure spot occurs to a dropped metatarsal bone. Furthermore, many dancers have a high arched foot, angling one or more of the metatarsal bones more downward. All these inherent structural characteristics of the individual dancer's foot increases pressures to the ball of the foot, either in single or multiple spots, which is further aggravated by releve or jette movements.

If there is a singular callous present, then an accommodative "U" padding using 1/8" felt should be applied around this sore spot. If the callous is underneath the first metatarsal head just proximal to the large toe or underneath the first metatarsal head just proximal to the small toe, then an "L" shaped felt pad should be applied around these respective points. For a diffuse callous or pain across the ball of the foot, a metatarsal pad may be placed either on the foot or inside of the shoe to transfer pressure away from the metatarsal bones (ball of the foot) and back into the arch.

In fact, a removable orthotic device has been developed, which is worm on the foot inside in the ballet slipper or pointe shoe to reduce painful pressure spots and better support the arch. It is called the Braver Ballet device and is available from your sports podiatrist.

Bunions

This is seen as an enlargement of the inner side of the big toe joint. Occurring more commonly in feet that excessively collapse (pronate), it is often due to an inherent flat foot or low arch structure or due to improper dance technique, which causes the foot to roll inward. These foot faults eventually cause the big toe to shift toward it's neighboring toes. The bunion (first metatarsal bone) shifts the opposite way making it prominent and susceptible to pressure irritation against the shoe.

There are silicone gels and felt pads which will help to cushion this area and reduce such irritation. Icing helps to reduce swelling and pain. Wearing arch support helps prevent collapsing of the foot. However, proper dance technique and correcting for improper foot structure must be addressed to prevent progression of this problem.

Arch Pain

Arch pain usually results from a strain of the ligaments or tendons that provide support of the foot. The arch may also be strained if proper flexibility is not present. One may roll their foot over a golf ball or soup can to increase flexibility. Also helpful are repetitive strengthening exercises such as doming the arch, picking up a towel with your toes and point and flex exercises. Tension type rubber bands may be used to strengthen the arch and surrounding ankle and leg musculature. Proper dance technique is critical, as collapsing or rolling in of the arch will cause pain to this area. The use of felt or synthetic arch supports inside the ballet shoe is often helpful. For recurrent problems, use of the Braver Ballet orthotic device may be indicated.

Heel Pain

Heel pain may be caused by bruising from repetitive jumps of from a constant pulling of ligaments and tendons which attach to the bottom and the back of the heel. Prop0er flexibility of the arch as previously described is essential, as is calf flexibility.

Stretching of the calves may be performed by standing at the barre and extending one leg backward. The back leg foot is firmly on the ground and directed straight ahead. Gently lean forward to stretch the calf. Another exercise, the flex and point exercise, also stretches the calf, especially when the knee is locked and the flexion (toes toward nose) is held for 30 to 60 seconds.

There are silicone gel heel pads available to reduce shock if there is pain on landing. However, it is more common to find a mechanical fault including too much collapsing of the arch or sickling of the foot outward, which causes a teeter-totter at the bottom or at the back of the heel which causes irritation of soft tissue attachments on the heel bone. This may be addressed by various taping methods or paddings, which help to immobilize or raise or protect the heel, ankle and foot. Heat before activity and ice after activity is often helpful. Should problems persist a visit to your sports physician/podiatrist is recommended.

Tendinitis

Pain to the top of the foot or ankle may be attributed to the many tendonous structures which cross over these joints. Proper fit of the shoe is imperative, i.e., the vamp should not be too tight to cause irritation against the skin.

Minor tendon problems respond well to a few days of rest or alternative activity. This is followed by 10 - 20 minutes of heat treatment prior to activity, i.e., with a heating pad, placing the foot under the warm running water of the bathtub faucet or by use of a skier's heat pack. If pains resolve during activity, then a soft tissue injury is likely. Activity must then be followed by 10 - 20 minutes of ice. Strengthening the soft tissues with rubber tension bands or other exercises as instructed by your dance teacher are necessary after the initial onset of pain is reduced. However, if the pains persist for more than a few days, then professional care should be sought.

Hidden Factors

Often strains that do not resolve for after a few days are related to faulty technique or structural abnormalities. Technique factors should be analyzed by the dance instructor. Structural analysis includes bony alignment as well as proper balance between muscle strength and flexibility.

A screening exam by the parent may note that while the child is standing barefoot with the feet pointed straight ahead, the kneecaps should face straight over the feet. Ideally, the center of the kneecaps should be aligned over the second toe as if dropping a plumb line from this area. In the semi-plie position, the front edge of the knees should again remain over the feet and the plumb line should not fall between or in front of the feet. Ideally, in the first position the knees again should be pointed straight over the second toe.

If these parameters are not met, the dancer may have an inherent foot structure weakness or leg alignment problem. Knock-knees are more prominent in those with wider hips. They are often seen in relation to those dancers with display low arches or flat feet. For these problems, correct shoe selection from your Capezio dealer is a must. For those with a weak foot, then a higher amp shoe with a more rigid shank is recommended. On the other end of the spectrum, for those with a high arched stiff foot, then a lower vamp with a more flexible shank is generally recommended.

Improper knee position noted during hip turn out as in the first position is often related to an inadequate range of external hip rotation. In an attempt to externally rotate the hips, the knees buckle inward and are seen inwardly rotated or knock-kneed. The feet and arches also collapse making these joints more flexible so that the toes may point more outward. Unfortunately, these compensations cause unwanted stressed and strains on the joints leading to eventual injury. Adequate hip flexibility is essential to prevent injury and it should be noted that as striving for internal (turn in) hip motion should be stressed as much as external (turn out) hip motion.

If the dance instructor notices that the child's muscles are not strong enough to stabilize the joints of the feet and legs, then strengthening exercises will be given, many of them have been previously discussed. Together with proper shoe and fit for the individual dancer's foot structure, augmentative padding, if necessary, proper technique as well as balance of muscle strength and flexibility as well as proper technique, the dancer should enjoy a healthy activity level.