Dancer's Heel: Posterior Ankle Impingement Syndrome, Causes, Symptoms, and Treatment

What is a Dancers Heel?

Dancer's heel, medically known as posterior ankle impingement syndrome, is a condition characterized by pain at the back of the ankle, often exacerbated by repetitive plantarflexion movements, common in activities like ballet, gymnastics, and running.

Understanding Dancer's Heel: A Scientific Perspective

Dancer's heel refers to a specific type of ankle pain resulting from the compression or "impingement" of soft tissues or bony structures at the posterior (rear) aspect of the ankle joint. While commonly associated with dancers due to the extreme plantarflexion required in their art form, it can affect any individual engaging in activities that involve repeated forced pointing of the foot.

Anatomical Basis: The ankle joint is formed primarily by the tibia, fibula, and talus. At the back of the ankle, several structures can become impinged:

• Os Trigonum: This is an accessory (extra) bone that develops from a secondary ossification center posterior to the talus. It is present in approximately 7-15% of the population. When the foot is pointed (plantarflexed), the os trigonum can be crushed between the posterior aspect of the tibia and the calcaneus (heel bone).
• Stieda's Process: Even without an os trigonum, some individuals may have an elongated posterior process of the talus, also known as Stieda's process, which can similarly cause impingement.
• Soft Tissues: The posterior capsule of the ankle joint, ligaments, scar tissue, or the flexor hallucis longus (FHL) tendon (which runs behind the ankle to the big toe) can also become inflamed and compressed.

Pathophysiology: The core mechanism involves the repetitive compression of these structures. During maximal plantarflexion, the space at the back of the ankle narrows significantly. If an os trigonum or an elongated Stieda's process is present, or if soft tissues are inflamed, they get "pinched," leading to pain, inflammation, and potential damage over time.

Causes and Risk Factors

Dancer's heel typically develops due to a combination of anatomical predispositions and biomechanical stresses.

• Repetitive Plantarflexion: This is the primary mechanical cause. Activities demanding extreme and repeated pointing of the foot, such as:
  • Ballet (especially en pointe work)
  • Gymnastics
  • Figure skating
  • Soccer (kicking motion)
  • Downhill running
• Anatomical Variations:
  • Presence of an Os Trigonum: Individuals with this accessory bone are significantly more prone to posterior impingement.
  • Elongated Stieda's Process: A naturally long posterior talar process can mimic the effects of an os trigonum.
• Training Errors:
  • Overtraining: Rapid increases in training volume or intensity without adequate recovery.
  • Inadequate Warm-up and Cool-down: Muscles and joints not properly prepared or recovered.
  • Poor Technique: Incorrect foot and ankle alignment during movements can increase stress.
• Footwear:
  • Pointe Shoes: While essential for ballet, these shoes put immense pressure on the ankle in extreme plantarflexion.
  • Improper Support: Footwear that doesn't adequately support the foot and ankle, or that forces the foot into an unnatural position.
• Previous Ankle Injuries: A history of ankle sprains can lead to scar tissue formation, which may contribute to impingement.

Signs and Symptoms

The presentation of dancer's heel is quite characteristic, though severity can vary.

• Pain Location: The hallmark symptom is pain localized to the posterior aspect of the ankle, deep within the joint.
• Characteristics of Pain:
  • Often described as a sharp, catching, or aching sensation.
  • Worsens significantly with activities involving forced plantarflexion (e.g., rising onto toes, jumping, kicking).
  • May be present at rest in more severe or chronic cases.
• Tenderness: The back of the ankle may be tender to the touch, particularly when pressing deeply just above the heel bone.
• Swelling: Localized swelling at the posterior ankle can occur due to inflammation.
• Decreased Range of Motion: While plantarflexion might be painful, dorsiflexion (lifting the foot upwards) is usually unaffected unless other issues are present.
• Clicking or Popping Sensation: Some individuals may report a clicking or popping sound or sensation with ankle movement, especially during plantarflexion.
• Stiffness: The ankle may feel stiff, particularly after periods of rest.

Diagnosis

Diagnosing dancer's heel involves a thorough clinical evaluation and often imaging studies to confirm the diagnosis and rule out other conditions.

• Clinical Examination:
  • History Taking: The physician will inquire about the onset of pain, aggravating and alleviating factors, type of activities performed, and previous injuries.
  • Physical Assessment: This involves palpating the posterior ankle for tenderness and swelling. The physician will assess active and passive range of motion, specifically noting pain during forced plantarflexion. A "posterior impingement test" (forced passive plantarflexion) often reproduces the pain.
• Imaging Studies:
  • X-rays: Standard ankle X-rays (lateral and oblique views) are crucial for identifying the presence of an os trigonum or an elongated Stieda's process. They can also reveal any degenerative changes or bone spurs.
  • Magnetic Resonance Imaging (MRI): An MRI provides detailed images of soft tissues, allowing for the assessment of inflammation, scar tissue, tenosynovitis (inflammation of the tendon sheath, particularly the FHL), and cartilage damage. It can also confirm the presence and size of an os trigonum or Stieda's process.
  • Computed Tomography (CT) Scan: A CT scan offers excellent bony detail and can be useful in surgical planning, especially for precisely mapping the os trigonum or bony impingement.

Treatment and Management Strategies

Treatment for dancer's heel typically begins with conservative measures, with surgical intervention reserved for cases that fail to respond.

Conservative Management

The goal is to reduce pain and inflammation, and restore normal ankle function.

• Rest and Activity Modification: Temporarily reducing or completely stopping activities that aggravate the pain is critical. This allows the inflamed tissues to heal.
• RICE Protocol:
  • Rest: Avoid painful activities.
  • Ice: Apply ice packs to the posterior ankle for 15-20 minutes several times a day to reduce inflammation.
  • Compression: Use an elastic bandage to minimize swelling.
  • Elevation: Keep the foot elevated above heart level when resting.
• Anti-inflammatory Medication: Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help manage pain and inflammation. Prescription NSAIDs may be used for more severe cases.
• Physical Therapy: A structured physical therapy program is vital. It may include:
  • Pain Modalities: Ultrasound, electrical stimulation.
  • Stretching: Gentle stretches to improve ankle dorsiflexion and overall flexibility.
  • Strengthening Exercises: Targeting ankle stabilizers, calf muscles, and intrinsic foot muscles to improve support and control.
  • Proprioceptive Training: Balance and coordination exercises to enhance ankle stability.
  • Manual Therapy: Joint mobilizations or soft tissue massage to address stiffness and muscle tightness.
  • Activity-Specific Rehabilitation: Gradual return to activity with technique modification.
• Footwear Modifications: Ensuring supportive footwear for daily activities and considering orthotics if foot biomechanics contribute to the issue.
• Corticosteroid Injections: In some cases, a corticosteroid injection into the posterior ankle joint space can provide temporary pain relief by reducing inflammation. This is often done under ultrasound guidance.

Surgical Intervention

If conservative treatments fail to provide adequate relief after several months, surgery may be considered, especially if a clear anatomical impingement (os trigonum or elongated Stieda's process) is identified.

• Posterior Ankle Arthroscopy: This minimally invasive procedure is the preferred surgical approach. Small incisions are made at the back of the ankle, and a camera and specialized instruments are used to remove the os trigonum, excise the elongated Stieda's process, or debride inflamed soft tissues/scar tissue.
• Open Surgery: In some complex cases, a traditional open incision may be necessary, though it is less common due to longer recovery times.

Recovery from surgery typically involves a period of immobilization, followed by a comprehensive physical therapy program to restore strength, flexibility, and function, with a gradual return to activity.

Prevention: Strategies for Dancers and Athletes

Preventing dancer's heel focuses on optimizing biomechanics, training practices, and listening to the body.

• Proper Training Progression: Gradually increase the intensity, duration, and frequency of training. Avoid sudden jumps in activity level, especially when introducing new techniques or movements requiring extreme plantarflexion.
• Technique Refinement: Work with experienced instructors or coaches to ensure proper technique and alignment, particularly in pointe work or other high-risk movements. Correcting form can significantly reduce stress on the ankle.
• Strength and Conditioning:
  • Calf Muscles: Strengthen the gastrocnemius and soleus for powerful and controlled plantarflexion.
  • Ankle Stabilizers: Strengthen the muscles around the ankle (e.g., peroneals, tibialis anterior) to enhance stability.
  • Intrinsic Foot Muscles: Improve foot arch support and control.
  • Core Strength: A strong core provides a stable base for all movements, including those involving the lower extremities.
• Flexibility and Mobility: Maintain good ankle dorsiflexion and overall lower limb flexibility. Tight calf muscles can indirectly increase stress on the posterior ankle.
• Appropriate Footwear: Wear supportive shoes for daily activities. For dancers, ensure pointe shoes are properly fitted and broken in. Replace worn-out athletic footwear regularly.
• Listen to Your Body: Pay attention to early signs of pain or discomfort. Promptly address any symptoms with rest and appropriate care to prevent acute inflammation from becoming chronic.
• Cross-Training: Incorporate diverse activities that promote overall fitness without constantly stressing the posterior ankle joint.

Conclusion

Dancer's heel, or posterior ankle impingement syndrome, is a common and often debilitating condition for individuals involved in activities requiring repetitive forced plantarflexion. Understanding its anatomical basis, causes, and symptoms is crucial for early diagnosis and effective management. With a comprehensive approach involving conservative treatments like rest, physical therapy, and activity modification, most individuals can achieve significant relief. For persistent cases, surgical intervention offers a reliable solution. Prevention through proper training, technique, and conditioning remains paramount for maintaining ankle health and longevity in sport and dance.