Common in dancers, and usually tired, overloaded anklesStrong evidence
Dancing asks the ankle for more range, more often, than almost any other activity: relevé and pointe take it to the end of pointing, a deep plié to the end of bending up, and jumps, turns and heels load it at both ends. Across 29 studies of dancers, a review found "a high prevalence and incidence of lower extremity and back injuries, with soft tissue and overuse injuries predominating". In ballet, the foot and ankle accounted for 14% to 57% of injuries, and across 11 studies of 1,650 pre-professional and professional ballet dancers they were the most affected region in both sexes; ankle tendon pain (19%) was among ballet dancers' commonest problems in a meta-analysis of 19 studies.
Other styles show the same pattern. Almost 1 in 5 first-year contemporary dance students reported an ankle injury over a year. In Irish dancers the foot and ankle are the most affected areas (25% to 68% of injuries), and about half of Dutch ballroom and Latin dancers reported a foot, ankle or lower leg injury over their dancing lives. Street styles differ: in hip hop the knee leads, with the foot and ankle 15% of injuries at a London clinic, and breakers report wrist, spine, shoulder and ankle pain.
Injury is uncommon for the hours danced: under 5 injuries per 1,000 hours across recreational, student and professional dancers, about 1 per 1,000 hours in ballet, and in social salsa about 1.1 for women and 0.5 for men. Ordinary aches after a long class or a night out are far commoner than injuries that stop dancing. In children's emergency visits for dance injuries in the US, sprains and strains of the legs led, and 30.8% came from dancing at home or at parties rather than in class.
Sources 18, 1, 2, 49, 3, 50, 4, 5, 51, 19, 52, 6, 7, 53
Pointe, plié, jumps and heels: what loads the ankleEmerging evidence
Dancing on pointe and in relevé "requires extreme plantar flexion" of the ankle, pointing it as far as it goes, as a review of back-of-ankle pain in dancers puts it. In two professional ballet companies over 3 seasons (455 dancer-seasons), women had 1.20 foot and ankle injuries per dancer each season needing medical attention, and men 0.83. Ankle impingement and joint irritation (synovitis) were the commonest problems seen, and sprains cost the most dancing time; sprains came mostly from jumps, and impingement in women mostly from dancing on pointe. The authors call outer ankle sprains and impingement at the back "the 2 most burdensome injuries in professional ballet".
Heels add a sideways risk. In elite teenage ballroom and Latin dancers, who dance in heels, 49.5% had sprained an ankle and 45.1% had an ankle that kept giving way, with an average of 11.2 days missed per sprain (we read this study's abstract). In US women generally, emergency department injuries from high heels were mostly ankle and foot sprains and strains. No study has tested heel height in dancers.
Sources 16, 8, 9, 58
The back of the ankle: impingement and the big toe's tendonEmerging evidence
Pain deep at the back of the ankle on pointe or relevé is usually posterior ankle impingement: soft tissue, and sometimes a small extra bone behind the ankle (an os trigonum), pinched as the foot points fully. It was the commonest ankle problem professional ballet dancers saw the medical team for. The big toe's long flexor tendon (flexor hallucis longus) runs just behind it on the inner side and often hurts alongside it, sometimes with a big toe that catches.
A review says "The diagnosis of posterior ankle impingement requires an accurate history and specific examination". Dancers tend to put off seeking help for the tendon, and a review of ankle injuries in dancers says that a team approach with knowledgeable physical therapists "can obviate the need for surgical treatment".
Sources 21, 8, 46, 15
The front of the ankle: a pinch at the bottom of a pliéEmerging evidence
A pinch or block at the front of the ankle at the bottom of a deep demi-plié, a landing or a lunge is anterior ankle impingement: soft tissue or bone spurs at the front of the joint caught as the shin moves over the foot, often after old sprains. It is less common than impingement at the back in professional ballet. Bone spurs don't settle the question on their own: a review notes that "The presence of osteophytes does not always correlate with impingement suggesting that soft tissue changes must also be necessary".
Sources 23, 24, 8
Sprains, and ankles that keep giving wayEmerging evidence
A roll on a turn, a landing or in heels is the classic dance sprain. In the teenage ballroom and Latin dancers, 35.3% of sprains came back within a year (from the abstract), and in a review of dance studies a past outer ankle sprain went with a higher risk of the next. A dance review warns that because sprains are so common, "it may not receive the careful attention it deserves". The NHS says most sprains feel better after 2 weeks, and to avoid strenuous exercise for up to 8 weeks.
Sources 9, 20, 47, 48
A stress fracture: the one not to missEmerging evidence
One spot on a bone that hurts with jumps, and later at rest or at night, needs checking. In two US ballet companies, dancing more than 5 hours a day and longer spells without periods went with stress fractures, an association, and a review of fractures in dancers covers stress fractures of the outer leg bone (the fibula), the heel bone and the midfoot. The first X-ray can look normal: in 64 second metatarsal stress fractures in professional dancers, the first X-rays were negative in 42, so a scan may be needed.
A review lists low energy availability (eating too little for your training), low bone density and sudden rises in training among the factors, and the fracture review says treatment should address any problems around the fracture, such as eating, hormones and training. These are reasons to see a GP about bone health, not to stop dancing.
Sources 39, 40, 55, 41, 42
When a scan helps, and when it misleadsEmerging evidence
Most ankle pain after dancing needs no scan. After a twist or a fall, clinicians use the Ottawa ankle rules to decide who needs an X-ray (see the warning signs), and the NHS ankle pain page says to contact NHS 111 if you think it may be broken. For pain at the back of the ankle that doesn't settle, an ultrasound-guided injection of local anaesthetic and steroid can help find and ease the problem: a review calls such injections "useful interventions to locate the symptomatic lesions and reduce symptoms and occasionally prove curative".
Scans need care in dancers. In 31 professional ballet dancers without pain, 82% of feet and ankles showed swelling inside a bone (bone marrow oedema) on magnetic resonance imaging (MRI); the authors write that "Positive MRI findings are commonplace" in such dancers and "The majority do not result in the development of symptoms requiring medical attention within 12 months". At the front, bone spurs on an X-ray don't always cause pain. A suspected stress fracture is the main reason for an MRI, because early X-rays miss many.
Sources 54, 21, 14, 24, 40, 55
How it usually goesEmerging evidence
Aches settle in days. In a UK ballet company, the average injury cost 7 days of dancing (4 in women, 9 in men); in two professional companies, ankle injuries that stopped dancing cost a median of 23 days in women and 41 in men; and sprains in teenage ballroom and Latin dancers cost an average of 11.2 days. The NHS says most sprains feel better after 2 weeks.
Most back-of-ankle pain is treated without surgery first, though a review found only six reports of non-surgical treatment, in 28 dancers, "which does not allow for any evidence-based recommendations". When surgery is needed, the results are good: across 376 ankles in dancers, the outcome was good to excellent in 89%, with return to dance at an average of 11 weeks; after open removal of an os trigonum in 38 young dancers, the average return to dance was 7.9 weeks and to pain-free dance 17.7 weeks; after keyhole removal in 12 professional dancers, 8.7 weeks; after keyhole surgery at the front, nine dancers were back at full dance at an average of 7 weeks; and after a tendon release in 13 ballet dancers, all returned within an average of five months. In an older series of 37 dancers, results were good or excellent for 28 of 34 professional dancers' ankles against 2 of 6 amateurs'.
These are case series of the hardest cases, and professional dancers may have more support to rehabilitate. No one can promise a date.
Sources 56, 8, 9, 48, 16, 27, 28, 25, 29, 22
When it isn't dancing: the causes the warning signs cover
Some ankle pain has causes dancing didn't create, and the warning signs follow the pages behind them. The NHS broken ankle page asks for help from NHS 111 if an injured ankle hurts to put weight on or comes with a very high temperature, and the Ottawa ankle rules, tested in emergency departments and in a review of 27 studies, pick out who needs an X-ray. A tendon slipping over the outer ankle bone needs a specialist review, an international consensus says, and a review calls peroneal tendon problems an under-appreciated cause of pain on the outer side that can be hard to tell from a ligament injury. A snap at the back of the heel can be an Achilles tendon rupture, as an NHS hospital's leaflet describes. A sudden hot, red, swollen joint can be gout or a joint infection, which the NHS septic arthritis page says needs urgent treatment. A foot that is suddenly cold and pale without an injury is a vascular emergency, unlike the gradual leg pain of narrowed arteries the NHS peripheral arterial disease page describes, and a throbbing, swollen calf after an injury or a boot can be a blood clot, as the NHS DVT page explains. With diabetes, the National Institute for Health and Care Excellence (NICE) asks for a new foot problem to reach a specialist foot service within 1 working day.
One spot on a bone that hurts with every step, and later at night, can be a stress fracture, as Health New Zealand and the American Academy of Orthopaedic Surgeons (AAOS) describe. The inner ankle bone and the talus are high-risk sites that heal less well, two reviews of high-risk stress fractures say; in 8 people with a stress fracture of the inner ankle bone, the first X-ray showed it in only 3; and in a review of 76 studies, more than 90% of athletes returned to sport, the longest returns coming after high-risk sites such as the navicular. Expert guidance on bone stress injuries and an NHS trust's leaflet set the bone rule below. More than one stress fracture, periods that stop, or eating too little for your training needs a GP: the International Olympic Committee calls this relative energy deficiency in sport (REDs), and an Endocrine Society guideline covers periods that stop. Bone pain that is constant or worse at night needs checking, the NHS bone cancer page says, though that is rare. After a sprain, an NHS hospital leaflet says the exercises should not increase your pain, and a trial found gentle exercise from the first week safe; the moving-on rule for the back of the ankle comes from a programme in adult footballers.
Sources 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88
