My Feet Roll In - Do I Need Orthotics?

The term “rolling in” or overpronation refers to an alignment issue in the foot and ankle where the foot collapses towards the inside which tends to flatten the arch of the foot. Overpronation is a common issue in the general population but more prevalent in dancers by nature of the demand of the sport on the feet.

If left untreated, rolling in of the feet and ankle can cause secondary problems including:

• bunions (due to excessive pressure on the big toe)

• plantar fasciitis

• shin splints

• overuse injuries of muscles and tendons on the inside aspect of the foot and ankle

• pain on the inside aspect of the knee

An orthotic is a medical appliance that is inserted into the shoe and can help lift the inner aspect of the foot into proper alignment. Orthotics can be purchased over the counter or custom made by a pedorthist or podiatrist. Although a useful tool, they may not be necessary for all dancers experiencing rolling of the feet.

How do I know if I need orthotics or not?
My favourite answer… it depends.

For dancers, one of the biggest things to consider is whether the dancer’s foot rolls in when they are standing casually (or in parallel), or is it ONLY when they are standing in turnout. Let’s look at two different scenarios.

1. Rolling in ONLY when standing in turnout but NOT in parallel.

Rolling in at the feet ONLY when standing in a turned out position may be caused by excessive cranking at the knees and feet to achieve turnout. Dancers with poor strength and control of the turnout muscles in the hip will often overcompensate at the knee, ankle and foot, which puts a lot of pressure on the inner aspects of these joints. In this scenario, foot alignment can be corrected by training proper turnout at the hips. For these individuals, orthotics may not be necessary.

2. Rolling of the feet while standing in parallel AND in turnout.

Rolling of the feet with casual standing or standing in parallel may be indicative of other underlying issues such as weak intrinsic foot muscles, poor walking/running/jumping mechanics, ankle/foot instability, or other knee or hip issues causing compensation at the foot.

For these individuals, an orthotic in their everyday shoes may be needed to help realign the foot and provide symptom relief. However, orthotics must be accompanied with exercise to treat the underlying issue and strengthen muscles of the foot. The stronger the foot muscles are, the better the foot can support itself without the use of the orthotic.

NOTE: Currently, there are no over the counter orthotics that fit in dance shoes, which emphasizes the need to strengthen the muscles to support the foot while dancing.

In summary, rolling in or overpronation of the feet can often be corrected through appropriate strengthening and conditioning. Orthotics are a great tool for realigning the foot and providing symptoms relief but are not a replacement for exercise.

If you are a dancer experiencing rolling feet or want to learn more about addressing rolling in feet, book with Anh online or give us a call at (778) 630-8800. 

Are You Ready For Pointe?

When I was a young dancer, I remember wrapping ribbons around my ballet shoes and going on my highest tippy toes pretending I was in pointe shoes. I couldn’t wait to turn 13 so I can start dancing en pointe like all the big girl ballerinas.

Then came the day! I got my first pair of pointe shoes and had my first pointe class. Within a few minutes I remembered thinking, “ow this hurts”, followed by “this is much harder than it looks”. I spent the next 5 years struggling through pointe classes and performances, accompanied by lots of ankle sprains, painful blisters, bunions, and blackened toenails (that would occasionally fall off).

Looking back now, I wish someone would have told me that I was not ready to start pointe at 13.

There is a misconception that all ballet dancer’s are ready to start pointe by the age of 11-13 years of age because of sufficient bone maturation. This is false! Yes, bone maturation is important but is not the sole marker.

When it comes to pointe readiness, a strong ballet foundation, and adequate mobility, strength, and body control is imperative for a dancer to be successful en pointe.

“There’s no reason to get a young dancer on pointe if she cannot do anything once she is there.”

- George Balachine

The Pre-Pointe Assessment: What's The Pointe?

A pre-pointe assessment goes beyond just the dancer’s feet. We take a thorough look at the dancer as a whole. During the assessment, the physiotherapist will examine overall mobility, strength, balance, body alignment, trunk and core stability, and neuromuscular control. These components are all critical in pointe work. The purpose of a pre-pointe assessment is to identify deficits in each category and to provide corrective steps to address the problems to reduce risk of injuries once en pointe.

What should I expect at a pre-pointe assessment?

At the beginning of the session, the physiotherapist will ask a series of questions to better understand the dancer's background and medical history. After that, the dancer will be asked to perform a series of dance and non-dance specific tests and movements.

It is recommended that dancers dress in clothes they can dance in (ie bodysuit, tights, shorts, leggings, athletic wear) and dance shoes (for turning). After the assessment, the physiotherapist will debrief and provide recommendations and exercises based on the findings from the assessment.

What are the risks of starting pointe before a dancer is ready?

There are several risks with rushing to pointe work, including:

• Overuse injuries: inadequate strength of foot and ankle muscles will cause compensations up the chain including knee, hips and low back, as well as stress fracture in the foot

• Strains & sprains: dancers with inadequate ankle strength put themselves at risk for ankle sprains and chronic ankle instability

• Foot malalignment: poor pointe technique can put unnecessary stresses through foot joints which overtime can lead to irreversible deformities such as bunions and hammer toes

Successful pointe work requires a lot of patience, commitment, and a willingness to listen to and apply corrections. Having the right attitude and expectations going in lay the foundation for a successful transition to pointe.

If you’re considering starting pointe work, book an assessment with Anh at Ladner Village Physiotherapy online, by email or phone at (778) 630-8800.

Flexibility vs. Mobility - What’s The Difference?

People often use the terms “flexibility” and “mobility” interchangeably but there is a difference! In this blog, our dance physiotherapist Anh Duong explains the difference between the two as well as why one is more advantageous than the other.

As physiotherapists we throw around the terms “flexibility” and “mobility” a lot, but what do they actually mean?

Flexibility is the ability of muscles to move through range passively (in other words, pushing to the end of the joint’s range with assistance from your hands, the wall, a strap - you get the idea) where as mobility is the ability of a joint to move through range actively, using your muscle to do the movement without assistance.

Imagine a dancer who can do the full splits when she is stretching on the ground but cannot achieve the full splits when performing a grande jeté. This dancer would be demonstrating flexibility but lacking mobility.

Ultimately, dancers should be aiming for mobility over flexibility.

How do we improve mobility?

Strengthen while you lengthen! This is achieved by working the muscles while elongating them at the same time. Some ways you can do this include:

• opting for more dynamic stretches rather than static stretches

• using bands and weights for resistance

• performing resisted holds while in an elongated position

But doesn’t being flexible help my technique?

There is a misconception that hyperflexibility will improve dance technique when it can actually do the opposite.

Think of your muscles like hair elastics. If you use the same hair elastic and stretch it and stretch and stretch it, overtime it will become long and weak and no longer be able to hold up your hair. Similarly, an overstretched muscles becomes long and weak and loses its ability to produce force which is needed for all dance movements such as kicks and jumps.

But there’s more..

Overstretching is highly dangerous and
NOT recommended

In the short term, overstretching increases the dancer’s risk of muscles strains, muscle gripping due to weakness, and snapping/pinching hips.

In the long term, overstretching can lead to stretching of other tissues such as ligaments, cartilage and joint capsules which play an integral part in joint stability.

Micro-damage accumulates over time which may lead to long term problems such as early degeneration of the joint, and chronic instability and pain.

What does overstretching look like?

• “sitting” in extreme positions for long periods of time

• Having peers or teachers pushing limbs at end ranges

• using yoga blocks or furniture as a lever to get more range

• Stretching before warming up muscles

To recap:

Dancers should be aiming for mobility over flexibility which includes incorporating strengthening and avoid stretching joints into extremes.

In this day and age, with the influence of social media and growing popularity of incorporating gymnastics and acrobatics movements into dance technique, the demand on dancers’ bodies are higher than ever and it is important that we educate dancers, parents, teachers, about safe and effective training.

To book an appointment, call (778) 630-8800, email us or book online.

Low Back Pain in Dancers and Gymnasts

For dancers and gymnasts, low back pain can come in many forms and can involve the spine itself. Two of the most common spinal injuries are:

1. Spondylolysis - a stress fracture of the pars interarticularis, a thin area of the vertebra that is more vulnerable to injury.

2. Spondylolisthesis - occurs if stress fractures are on both sides of the vertabra and allow a slippage of one vertebrae over the other to occur.

Dancers and gymnasts are at a higher risk of developing these spinal injuries due to repetitive hyperextension-type movements such as back-bending. These movements put significant load on the pars interarticularis, a thin part of the vertabra that connects the main part of the vertebra at the front with the bony bits at the back.

When you combine hyperextension with forceful dismounts and landings (gymnasts, we’re talking to you), it increases the risk of both spondylolysis and spondylolisthesis significantly. As more and more dancers are combining gymnastic skills into their routines, I expect to see more dancers with these conditions as well.

A slippage of less than 50% (a Grade 1 or 2 spondylolisthesis) is often treated with physiotherapy including hands on treatment techniques and exercise. A slippage of greater than 50% (a Grade 3 or 4 spondylolisthesis) is considered more serious and usually involves the care of a specialist.

Both spondylolysis and spondylolisthesis can happen at any spinal level. It most commonly occurs in the L5 vertebra, with L5 slipping forward over S1 (see the photo above). The second most common site is L4. 

What do spondylolysis and spondylolisthesis feel like?

Athletes will often complain of the following:

• Dull pain that can be sharp with movement

• pain with extension type movements including arabesque, bridges, back walkovers, back hand springs etc.

• Focal pain in the low back but may radiate into the buttock or down the legs

• Symptoms that are worse with activity and better with rest

How is it diagnosed?

Diagnosis starts with a thorough subjective history. If a spondylolysis or a spondylolisthesis is suspected, imaging via X-ray, CT or MRI will be ordered to confirm a diagnosis.

It is important that athletes with suspected spondylitic conditions be medically cleared before beginning an exercise program. This is crucial for the health and well being of the athlete as the wrong exercises can aggravate and worsen the injury.

How do we treat it?

Spondylitic conditions can cause instability of the low back. Spinal stabilization through core stability training is a key component in prevention and rehabilitation in these young athletes. Often, athletes focus on the large muscles and neglect the little guys that are responsible for stabilization. Core stability training targets the little muscles that directly support the spine including the transversus abdominis, multifidi, paraspinal, and internal and external obliques.

Appropriate flexibility is also important after a spinal injury. Tightness of certain hip muscles can increase the extension of the low back which can exacerbate symptoms.

If you’re suffering from back pain, give us a call at (778) 630-800, email us or book online. 

Are Your Nerves Limiting Your Mobility?

Our dance physiotherapist Anh is back! Here, she discusses neural mobility and tension - what it is, why it occurs and why dancers especially should know about its wide-ranging effects.

Hey dancers! Are you or do you know someone who stretches for hours a day, every day of the week and still can’t get into their splits? As dancers we often think about stretching our muscles to improve mobility. But what if it isn’t your muscles that are preventing you from touching your toes or achieving the splits? What if the problem is your nerves?

Your nerves are meant to move freely throughout your body. They connect our brains to our big toes and everything in between.

Neural tension occurs when a nerve’s ability to move has been impeded.

You can think of your nervous system as a tangle of ropes, extending from your brain to all areas of your body. Imagine one of these thick ropes starting at the top of your head, running down your spine, behind your glutes, down the back of your leg and all the way into the bottom of your foot and toes (this would be your sciatic nerve). If there is a restriction anywhere along the line of this rope, you won’t be able to move your leg the way you should.

Like rope, nerves do not like to be stretched or squeezed - both affect the ability of the nerve to do its job. In order to achieve full range of motion, nerves need to glide back and forth in the body. If a restriction is present and not removed, further stretching can cause irritation of the nerve over time.

So how do I know if it's neural tension that's preventing my mobility and not muscle?

1. If you are experiencing burning, tingling, numbness, or shooting pain that radiates past the muscle that is being stretched

2. If the sensation of stretching changes with different head and neck positioning

3. If the sensation of stretching changes with a change in position of a joint unrelated to the muscle being stretched (ie. stretching your hamstring feels better when your feet are pointed vs when your feet are flexed)

How do I get rid of neural tension?

First things first - if there’s neural tension, there’s a reason for it. As physiotherapists, we assess and identify the source of the tension. Is there something squeezing the nerve in the back? What about in the glutes or behind the knee? Finding the source of the problem is always the first step.

We then use a combination of techniques including manual therapy, soft tissue massage and specific exercises designed to help settle the tissue down and not reaggravate it.

Without a doubt, nerve flossing comes into play. Nerve flossing is a dynamic stretching technique that mobilizes the nerve. Think of a piece of dental floss: when you are flossing your teeth, you pull on one side of the floss and allow the other side to slacken, then reverse directions. Nerve flossing is the exact same idea - it is performed by tensioning one end of the nerve while slacking the other end.

Nerves control your muscles. If a nerve feels unsafe (like when going from sedentary to being over stretched) it will send signals to the muscle to contract and stiffen. This puts the dancer at risk of muscle strain. It is important to incorporate nerve flossing techniques and movements into your warm and stretch routine. 

For more information on neural tension and its effect on mobility, book online or give us a call at (778) 630-8800.

Ballerinas & Bunions

Anh Duong grew up in Prince Rupert and was a competitive dancer for years, training in ballet, jazz, tap, contemporary, modern, hip hop and acrobatics. She is a member of the Dance Health Alliance in Canada and she now works with dancers at all levels. Whether it’s dealing with an injury, preparing the feet for pointe or improving performance, Anh has the experience and expertise to help you reach your goal. Read Anh’s latest blog on bunions in dancers.

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Bunions are one of the most common foot injuries in dancers. They can be incredibly painful, making it nearly impossible to go on demi-pointe, land a sauté, or perform a pirouette.

Hallux valgus, more commonly known as bunions, is a deformity of the 1st metatarsophalangeal (aka MTP) joint causing the big toe to deviate towards the other toes. It can often lead to swelling, inflammation and bony growth on the inside of the big toe.

There are certain risk factors for developing bunions that are out of our control. These include being female, older age, genetic predispositions, and having a longer 1st metatarsal bone.

Luckily, there are certain risk factors that we can control:

• Practicing proper turnout technique: Insufficient turnout at the hip can cause hyper-pronation or ‘rolling in’ at the feet. This places more pressure on the inside of the big toe, pushing the big toe towards the other toes and leading to bunion development.

• Avoid wearing ill-fitting shoes: Constrictive shoes can contribute to development of bunions. While this goes for all shoes, wearing worn out or ‘dead’ pointe shoes also increases the risk as the shoe may no longer provide adequate support. Dancers should get their shoes properly fitted by their local dance shoe expert to avoid problems with bunions down the road.

• Strengthen foot arches: Fallen arches are often the result of weak intrinsic foot muscles and can increase the stress to the inside of the foot including the big toe.

• Avoid leaning on the big toe: Although a winged foot is a desirable look, be careful to avoid bearing weight and putting significant pressure through the big toe, especially in classical position or positions in derriere.

How Do We Treat Bunions?

When it comes to treating bunions, research suggests that a multifaceted approach is best. When treating conservatively, this includes:

1. Correction of improper technique and alignment with the focus on proper turnout technique at the hip and proper weight distribution over the foot

2. Use of toe spacers can assist with big toe alignment and help reduce pain

3. Joint mobilization of the foot, ankle, knee and hip, depending on specific joint restrictions

4. Strengthening of the big toe muscles as well as the little muscles in the foot to help manage symptoms and slow progression of bunion formation

Surgical management is an option but should be the last resort and delayed as close to retirement as possible, generally speaking. The flexibility and mobility of the big toe can be impaired and difficult to regain fully after bunion removal. 

If you are a dancer experiencing bunions or want to learn more about preventing bunions, book with Anh online or give us a call at (778) 630-8800. 

Hip Pain in Dancers

Anh Duong grew up in Prince Rupert and was a competitive dancer for years, training in ballet, jazz, tap, contemporary, modern, hip hop and acrobatics. She is a member of the Dance Health Alliance in Canada and she now works with dancers at all levels. Whether it’s dealing with an injury, preparing the feet for pointe or improving performance, Anh has the experience and expertise to help you reach your goal. Read Anh’s latest blog on hip pain and overstretched hip flexors.

Dancers, do you really have tight hip flexors?

For years, I suffered from hip pain, especially with movements involving kicks (i.e. grand battement, developé, rond de jambe en l’aire, etc). I always thought it was because I had tight hip flexors. So naturally, I would get down into a deep lunge and stretch and stretch and stretch... but nothing changed.

Little did I know that it wasn’t a hip tightness issue. The opposite, actually - my hip flexors were long and weak likely from years of being overstretched.

Think of that hair elastic that you have been using for 3 months, the one that has kind of lost its shape, doesn’t really hold your bun up. Similarly, my hip flexor muscle was overstretched and was not strong enough to hold my leg up.

The hip flexors are a group of muscles that are responsible for lifting your hip and leg up in front of you. They also play a role in bringing your trunk towards your legs (i.e. doing a full sit up). When these muscles are long and weak, they often have to work harder and strain to do their job resulting in that pinching or gripping feeling in the front of the hip. When this happens your body will often recruit different muscles to compensate for the weak hip flexors, often causing even more problems.

For many dancers with hip pain, the solution is often not stretching but strengthening the hip flexors through the whole range of the muscle. 

So what do you do?

1. Settle it down and avoid painful movements. This may include marking exercises for a period of time. 

2. Strengthen the hip flexors. Start with small ranges and slowly work towards larger ranges. Do floor exercises and floor barre before progressing to standing. Use weights and therabands to further build strength.

3. Core core core! Avoiding compensation movements through the pelvis and spine is key to long term success with overstretched hip flexors. A strong core is the best way to achieve this goal.

Should you stop stretching your hip flexors?

No! Flexible hips are required for many dance movements BUT you need to ensure that you are doing the proper stretches and combining stretching with strengthening. The goal is a strong muscle at any range!

Overstretched hip flexors are one of the many causes for hip pain but certainly not the only cause. Make sure you are assessed by a professional before getting back into the studio. Treating any injury correctly the first time saves you a lot of time and pain in the long run.

If you are a dancer experiencing hip pain, book with Anh online or give us a call at (778) 630-8800. You can either visit us at our Ladner location or book a virtual appointment.

Meet Anh!

Hailing from the Northern coast of British Columbia, Anh Duong brings a wealth of dance expertise to our clinic. Learn all about what makes Anh tick and why we are so excited for her to join us!

What is something totally random that people won’t know about you?

I did not learn how to ride a bike until I was 23 years old. Our family was never the outdoorsy type and my parents just never saw the need for me to learn. Luckily I have awesome, and very patient friends.  

When did you decide you wanted to be a physio?

Growing up as a dancer I’ve always had an interest in how the body moves. I also grew up in a family that values health and wellness. During my first year at university, I took an anatomy course and fell in love. I thought to myself, “how do I combine my values around health and well-being, my passion for dance, and my newfound love for anatomy all into one?” and physiotherapy was the answer. 

Which sports are you into?

Dance! I’ve trained in ballet, jazz, tap, contemporary, modern, hip hop, and acrobatics. I also recently started playing tennis but I’m just happy if I can get the ball over the net.

Where did you grow up?

Prince Rupert BC, the rainiest city in Canada.

What is your favourite orthopaedic condition to treat?

Hips, ankles and feet, all of which I, myself, have had problems with in the past.

What makes you happiest?

I am happiest in the dance studio. But may also be caught smiling when eating delicious food with family and friends.

LIGHTNING ROUND!!!!!

Cats or dogs? Dogs

Favourite food? Sushi

Favourite dessert: Crumbled apple pie, the crumble is a must!

Favourite Junk food: Nachos

Beach or mountains: Beach

Favourite colour: Rose gold

Favourite music: R&B

Favorite day of the week? Saturday

Nickname? Just Anh

Would you rather be able to speak every language in the world or be able to talk to animals? Speak every language

Favorite holiday? Lunar New Year

How long does it take you to get ready? 30 mins

Invisibility or super strength? Invisibility

Is it wrong for a vegetarian to eat animal crackers? nope

Dawn or dusk? Dawn

Do you snore? Don’t think so

Place you most want to travel? Japan, South America, Rome   

Last Halloween costume? A basketball player.

Favorite number? 9

Have you ever worn socks with sandals? This should be a crime

Would you rather cuddle with a baby panda or a baby penguin? Panda

Would you want to live forever? Nope

What's for dinner tonight? Butter Chicken