Plantar Fascial Strain: A Common Cause of  Pain  in Indian Classical Dancers

by Pranamya Suri, MD (Resident physician at University of California, Irvine) 

Reference Video

Indian classical dance forms have very unique biomechanical demands. They have intricate and stylistic footwork and aesthetics. Notably, of the six pada bhedas (foot movements), the first five may cause excess strain on the feet.  The six-foot movements are described below. Of note, dorsiflexion refers to the extension or flexion of the foot at the ankle, as depicted in Figure G.  The plantar aspect of the foot refers to the bottom of the foot, and the dorsum of the foot refers to the top of the foot.

1. Udghattita –Dorsiflexion of the ankle (Figure A)
2. Suchi Pada – Plantarflexion of the foot at the ankle (Figure B)
3. Kunchita – Plantarflexion of the foot the ankle and dorsiflexion of the toes (Figure C)
4. Agratalasanchara- Plantarflexion of the foot and ankle and dorsiflexion of the toes (Figure D)
5. Anchita – dorsiflexion of the foot at the ankle (Figure E)
6. Sama Pada- feet flat and together (Figure F)

Four muscles of the foot originate from the calcaneus (heel). Overload of these muscles due to the Anchitam (dorsiflexion of the ankle), in particular,  can cause strain on the plantar aponeurosis when done in excessive repetition, especially without proper support. The plantar aponeurosis a strong tissue (also known as fascia) that extends from the heel to the toes.  It is a source of heel pain for many Indian classical dancers since it may be strained, partially torn, or simply inflamed (inflammation causes plantar fasciitis, of inflammation of the plantar fascia). Usually, injury has a slow, insidious onset, due to overuse from increased training from workshops, practice for an upcoming performance, or change in the type of flooring. Lack of appropriate rest and treatment at symptom onset will lead to the progression of symptoms.

Additionally, according to Wanke et al, dance floors play a significant role in the occurrence of acute injuries, even in experienced dancers. The majority of Indian classical dancers in the United States and in India practice on a tiled, cement or wooden floor without support, putting the plantar aspect foot at risk injury. The greater the ground reaction force that is sustained to the plantar aponeurosis, the greater the risk of inflammation and injury. Additionally, according to the kinetic chain theory, improper body mechanics and loading stress on the plantar surface of the feet can affect the biomechanics of the knee, hip, and low back.  Thus, proper plantar arch support is essential for dancers.

Dancers with plantar fasciitis will present with pain with their first few steps in the morning, tenderness over the middle of the heel. Pain worse with dorsiflexion (due to increased stretching of the fascia) and weight-bearing. Pain is decreased with plantar flexion of the toes. There is no bruising or swelling noted.

Indian classical dancers are often regarded only as artists and not as athletes, despite requiring equivalent coordination, physical strength, stamina, and psychological control. Thus, they are prone to some of the similar injuries as other athletes and extra precaution must be taken to prolong the time a dancer is able to safely practice and perform. Treatment is initially conservative and consists of rest, avoiding exacerbating activities, icing the heel, calf and plantar arch stretches. 

Unfortunately, students and performers often continue practice and performance despite preexisting injury and pain. Instead, they should be encouraged to rest when symptoms are present. Taping the arch for dance, for plantar arch support, until symptoms improve also provides relief. A local corticosteroid injection may sometimes be given to reduce inflammation, but it can increase the risk of rupture of the fascia. A night splint for sleeping is also helpful in reducing pain.

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This post discusses a common cause of heel pain in Indian classical dancers and is not medical advice.

References

Wanke, E. M., Mill, H., Wanke, A., Davenport, J., Koch, F., & Groneberg, D. A. (2012). Dance floors as injury risk: analysis and evaluation of acute injuries caused by dance floors in professional dance with regard to preventative aspects. Medical problems of performing artists, 27(3), 137-142.

 Shah S, Weiss D, Burchette R. Injuries in professional modern dancers; inci- dence, risk factors, management. J Dance Med Sci 2012;16(1):17–25.