The Achilles Tendon: Dancer Injury and Prevention

Of body parts in the dance world, the Achilles tendon is perhaps one of the more infamous.
What’s in a name?

IMAGE Photograph of the statue of Death of Achilles. Taken in the Achillion Gardens, Corfu IMAGE

Achilles was a figure of Greek Mythology refuted as an infallible hero of the Trojan War – infallible, of course, except for the small injury to his heel that killed him.  Consequently, the term “Achilles Heel” is used to describe the greatest weakness of an individual, and the small tendon connecting the calf muscle (triceps surae) to the heel bone (calcaneus) is called the Achilles tendon.

Tendons are the fibrous, elastic  structures at the end of each skeletal muscle.

Their job is to connect muscles to bones, and to store elastic energy (that is then converted into mechanical forces acting on the bone, enabling movement to occur).

Tendonopathies

IMAGE Graphic of an inflamed Achilles tendon. IMAGEInjury to any tendon is universally referred to as tendonopathy.

The most commonly injured tendons in dancers are the Achilles tendon, peroneal tendons, posterior tibial tendons and Flexor hallucis longus (FHL).

Dancing places frequent stress on the Achilles tendon.  Achilles tendonitis occurs when the tendon becomes inflamed due to overuse, excessive pronation,  bowlegs, tight Achilles tendons, or abnormally shaped heel bones (Hodgkins, Kennedy & O’Loughlin, 2008).

The likelihood of developing Achilles tendonitis increases if you use 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).

How can I prevent tendonitis?

First and foremost, be diligent in your technique.  Dancers with improper technique are more likely to develop injuries, including Achilles tendonitis.  Be sure to press the heels down while jumping and use proper alignment of the foot in turnout and jump landings.

As I stated in my recent post on knee injuries, environmental factors can greatly contribute to your chance of sustaining an injury.  Hard, unsprung floors, raked stages, and cold temperatures are all risk factors for Achilles tendonitis.  Futhermore, shoes and/or ribbons that are too tight place unwanted stress on the tendon and can exacerbate tendonitis.

If I have Achilles tendonitis, does it go away?

Well, that’s kind of a trick question…

Tendonitis (tendinitis is also an accepted spelling) is an acute inflammation of the tendon, and it can go away with proper treatment (generally including rest, ice, strapping the tendon and anti-inflammatory drugs).  Tendonitis can and will go away if you take the proper steps to treat it, and prevent it from recurring.

As I mentioned above, some dancers will be predisposed to tendonitis because of their anatomy (e.g. short tendons, bowlegs, malformed calcaneous, etc.).  It is exceedingly important that these dancers take the proper steps to prevent flare-ups.

Repeated occurrences of tendonitis can lead to a chronic and more serious condition called tendonosis. Tendonosis can develop if acute bouts of tendonitis are not treated properly or the dancer does not take adequate time to rest.  If tendonitis progresses to tendonosis,  persistent inflammation leads to degeneration and the formation of nodules on the tendon and the dancer is at an increased risk of rupturing the tendon (You may recall dancer, Alex Wong’s injury in 2010, brought to the world’s attention via the televised So You Think You Can Dance).

Further tips for preventing Achilles tendonopathy:

  • Mind your technique. (Coming through, loud and clear?) Be diligent in pressing your heels down when landing from jumps, returning from grand plié.  Don’t force turnout or over-pronate.
  • Make sure your shoes fit properly and aren’t pinching the back of your heel
  • Sew elastic into pointe shoe ribbons at the point where they cross the back of the leg and tie shoes less tight, relieving pressure placed on the tendon (Kadel, 2006).  Bloch and Bunheads are now manufacturing “tendonitis ribbons” with elastic already sewn in.
  • Warm-up! Warm muscles and tendons are less likely to become inflammed and injured under repeated stress
  • Increase your flexibility by performing a calf stretch (when properly warmed-up or after class), or using an angled stretch box, and prevent shortening of the tendon by always rising to your highest relèvé.
Many dancers have struggled with Achilles tendonitis at some point during their careers (including me).

Do you have a story you can share?

References:

Beers, M. H. (2003). The merck manual of medical information, second home      edition. Pocket Books, 424-425.

Fernandez-Palazzi, F., Rivas, S. & Mujica, P. (1990). Achilles tendonitis in ballet dancers. Clin Orthop Relat Res 257, 257-261.

Hodgkins, C. W., Kennedy, J. G. & O’Loughlin, P. F. (2008). Tendon injuries in dance. Clin Sports Med 27, 278-288.

Kadel, N. J. (2006). Foot and ankle injuries in dance. Physical Medicine and Rehabilitation Clinics of America 17, 813-826.

Motta-Valencia, K. (2006). Dance-related injury. Physical Medicine and Rehabilitation Clinics of North America 17, 697-723.

Lauren Warnecke

Lauren Warnecke

Dance writer, educator at Art Intercepts
Lauren Warnecke is a dance writer based in Chicago, IL, and is a contributing author at 4dancers.org, danceadvantage.net, Windy City Times, and SeeChicagoDance.com. In 2009 Lauren created Art Intercepts, a blog for dance-based discourse that incorporates dance and movement research, editorial commentary, and critical reviews. She is a full-time faculty member at the University of Illinois at Chicago.
Lauren Warnecke
Lauren Warnecke
Lauren Warnecke

Comments

  1. Oh, thanks for this post! I have long-standing trouble with plantar fasciitis, heel pain, and achilles that gets so stiff when I stand up I sometimes can’t walk very well.

    I want to mention that achilles pain is often soleus-muscle related. Trigger points in the soleus can mimic tendonitis (that’s what happened to me) and cause achilles and heel pain. As long as I remember to massage my soleus muscle – using my right knee to massage my left calf, etc., or using a tennis ball, I don’t have any troubles. If I neglect the massage, the pain comes back.

    It took care of my pain the first time I tried it – I was skeptical but now I’m a believer. Might want to pass that along. :) Thanks for the article!
    Jen

    • Thanks, Jen!

      The Achilles is the ending point of the triceps surae – which is the name for the combined gastrocnemius and soleus. Both muscles come together at the achilles, so it makes sense that you might be having trouble with both. I’m glad to hear that you are managing your injury well and good luck with everything! Lauren

  2. Susan Cushing says:

    great article about a dreaded subject….. thanks!

  3. Thanks for the concise summary of dancers’ Achilles tendon problems. Do dancers’ commonly fail to plant their heel when landing from a jump? I suppose in a fast petite allegro it might seem to be an advantage.

    I also help dancers focus on the balance of use between the flexor digitorum longus (which curls in the toes) vs. the flexor digitorum brevis (which keeps the toes long as you point them. It’s my observation that proper use of these toe flexors helps deceloerate the landing from a jump, thus taking stress off the Achilles tendon. Any thoughts on that connection?

  4. Epernay says:

    Thank you for the insight. After doing ballet as a serious amateur for 40 years now, I just started with a new teacher who does a bouncy 1st position pseudo-warmup where we go up a few inches into releve (not full releve) and then bounce down 3 times, and then reverse, go a few inches into releve and then bounce up. I now have tendon pain and soreness in the morning. Will sit this exercise out now.

  5. Ron and Epernay, thanks for your comments, and Ron, I apologize for not seeing yours sooner.

    I don’t think I know enough on the biomechanics of the foot and ankle to comment on how a focus on flexor digitorum could influence jump landings, but it’s an interesting question that I’d like to bring to a few of my colleagues.

    My feeling is that an active effort to press the heels down and complete a full plie is the best way to balance the strain on the achilles that comes from jumping. Obviously this is not always possible, especially if the dancer has an extremely tight tendon or the combination is very fast. In these cases extra time and energy put into stretching and legnthening the tendon would be beneficial.

    In reference to your comment, Epernay, I wouldn’t say that this bouncing exercise is necessarily “bad” if it is balanced with an opposing activity. This sort of exercise is used to help warm-up for jumps and strengthen the calves. But perhaps 3 bounces followed by a deep plie, which is good practice for a proper landing. Regardless, you’re wise to sit this one out for awhile if you’re experiencing pain.

    Thanks again for all your thoughtful words!

    • Epernay says:

      Lauren,

      Your point is well taken that including a move that complements another is critical. So many exercises don’t have that and teachers don’t seem knowledgeable about this. It’s the case of “I had pain, normal if you dance, deal with it…”

      In my “old” age, I actually add stuff to exercises when I feel the teacher isn’t addressing the body properly, but it’s a bad example for the youngsters in the class…(I have not become the oldest student in all clases :-)) you are supposed to follow the teacher instructions as part of the discipline. But if you’re hurting…
      Politically loaded.

  6. Lauren,

    Your article has very good information. But one thing I caught is you kept saying when you land from jumps to land on your heels. Well I don’t do ballet, I do Irish dancing. And in Irish dancing I always have to land up on my tippy toes. I already have Achilles tendonitis, so do have any easy tips on how to heal my tendons so I can keep dancing ? Please ?

    - M

  7. Hi Meghan,

    Thanks for reading the article and taking the time to comment! Let me clarify if I may: I didn’t say to land on your heels, but rather to roll through the foot and press the heels into the ground. Jumps should land through the toes and then the heels come down as the Achilles tendon stretches. For a ballet dancer, failure to put the heels down is a technical error that is very common and can contribute to developing tendonitis. I’m not especially familiar with Irish dancing, but I do know a bit about tap and imagine them to be similar in that a lot of time is spent jumping and traveling with the heels off the ground. This may be part of the technique that you can’t change, but I would be especially diligent about stretching the calves and Achilles at the end of class, and noticing any signs of inflammation.

  8. I injured my left Achilles tendon Octoberof last year. I had to go to physical therapy where they did massages, ultrasound, ice, and various stretches on my tendon. It helped heal it, but I’ve noticed that I cannot go en pointe on my left foot as easily, and it is also harder to stay en pointe on the left. Also, my releve is noticeably worse on my left foot. I used to have a really good releve, and now it looks like my heel is barely off of the ground even when I am trying so hard. It is true that the tendon becomes stiffer. Has anyone else had this problem?

    • Hi Isabelle,

      I’m sorry that I neglected to see this comment until now! I’m actually preparing a follow up article on tendons and came across it. It’s possible that you may have some scar tissue or residual inflammation that is keeping you from being able to rise as high in releve. Without being a doctor or seeing you it’s hard to say for sure, but tendon injuries can be very stubborn and take a long time to heal, and/or can recur. If you’re feeling any pain it’s important to step back the amount of stress you’re placing on the tendon and continue the therapies that have worked for you in the past!

      • Hi,
        I just found this and have done some pretty severe damage to my Achilles. I’ve been off it for 6 or so weeks now, was on crutches for 4… I still can’t stand on it yet (only on the balls of my feet). Curious to see if you think I’m likely to ever do pointe again (after physio)? I know it varies from person to person but I’m starting to get worried.

        • Kate, the best thing you can do is not rush and let the tendon heal completely. Follow the advice of your doctors and definitely get in touch with a good physical therapist! Keep us posted!

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