Specialising in Dance Podiatry

A Career Series in podiatry – Simon Costain
Specialist in dance podiatry, Simon Contain, describes how dancing problems relate to a weak foot link. For those interested in a career in podiatry, he provides advice on how to become engaged in this exciting sport.

Simon Costain is one of those timeless podiatrists who has worked in most fields of foot health. He specialised early in biomechanics during the 1970s and worked with well-known names in the podiatry profession. Although a capable podiatric surgeon, he saw the field of non-surgical podiatry as equally important and set up a national orthotic laboratory in Northampton during the early eighties. Simon’s family, mother, brother and sister were all podiatrists, no one can doubt their collective loyalty to the profession. Working at his prestigious Harley Street address in London since 1985, he has developed expertise in sports and dance. I joined him on Easter Monday, 2021, to discuss his career in the field of podiatry and what a podiatrist can offer the dancer. The subject drifted toward mechanics of the lower limb or, as podiatrists refer to the subject, biomechanics or musculoskeletal (MSK) Podiatry. This subject brings movement, muscles and joints into focus with medicine and the orthopaedic field of foot leg and spinal health.  

He launched into his view about where podiatry sits. “Often, podiatry is portrayed as dealing with very old people, but young people suffer foot and leg problems also. Generally speaking, sport and dance  magnify pre-existing foot and leg mechanical problems.”

The word “dance” he tells me, covers a large field. Most people think of dance injury as focusing on ballet, but there’s a vast range of dance activities. But, again, the one thing they all have in common is the need to use their feet. Footwear and dance play a crucial role; he continues to explain in more detail in his deep sonorous educated voice, expanding on the variety of concepts that podiatrists need to understand. Sometimes, feet are shod in a variety of dance footwear; varying from pointe, ballet slippers, tap, swing, tango heels, tap or Irish dance shoes. So there’s a variety of footwear to study that may be causing or exacerbating any foot or leg problem, but remember Simon says, “barefoot contemporary dancers also suffer.” Simon reminds us that most foot problems are not caused by footwear, but by a combination of foot weakness and poor foot and leg mechanics. Most astute podiatrists will analyse gait asymmetry which more likely than not, reveals the real cause of gradual onset foot or leg injury.

Any form of sport, whether it be walking, running, swimming, or dancing, makes for an exciting podiatric career because it is a vast field and brings the profession into contact with all ages of people who maintain their interest in their sport, one of which may be dance. From a podiatry viewpoint, it brings the podiatrist into contact with an assessment of full-body movement, and away from specifically dealing with foot and ankle problems alone, which was one of the main reasons, Simon reminded me of why he left the field of podiatric surgery.

Professional dancers usually start their dance careers often in the first decade of life. Dance and sports potential is to a large extent governed by a combination of the acquired and genetic foot structure. Genetically, some foot structures are more suited to certain types of dance than others. Mal-alignment of the length of the metatarsals especially the parabola of metatarsal heads can upset the load placed on the foot and in the event of a long 2nd metatarsal in a classical ballet dancer who will be on demi-pointe or pointe hundreds of thousands of times in a dance career, be a career breaker. Podiatrists advising dancers need to stress that repetitive overuse injuries in the professional dancer’s foot can compromise performance, and in those extreme circumstances, compromise their dance career.

Footwear

‘Tango shoes’, for example, are very thin-soled and high heeled and the individual’s foot geometry must be considered. It is essential to discuss footwear with the dancers and their parents if young, to avoid any threat to their career through poor selection. From years of experience, Simon suggests that it is important for podiatrists involved in musculoskeletal medicine to spend time analysing not just the foot function, but also ankle knee, hip and back movement whilst the dancer walks, runs and dances. Analysing injury in a dancer or sportsperson, he stresses with conviction, isn’t just looking at the injuries sustained during the performance. Podiatrists he states should be most concerned about the type of shoe dancers wear outside their dance hours, as he says candidly – they often buy rubbish footwear!

“Many dancers, walk around in terrible shoes out of dance hours! Therefore, one has to treat the dancer very holistically, not just on the stage, which is the icing on the cake, but spend time understanding what do and what footwear they wear at other times, and make sure treatment is aimed at those many “non-dancing hours” and target them with helpful orthoses where possible, reminding them that there is absolutely no evidence to confirm wearing orthoses weakens feet.”

The potential of losing their Corps de ballet/ Solo or Principal dance position within the dance company is something that is very close to a dancer’s heart, and a good podiatrist is essential in assisting them in this respect with regular check-ups and gait evaluation annually.

Podiatrists working within MSK medicine don’t just manage foot and ankle or lower limb problems, but we have a responsibility to assess competitive sportspeople and be open and honest with them even if on occasions being frank with them may jeopardise their career. Without optimum performance for the dance company, a career can end abruptly. Simon emphasises the point about responsibility, “it’s our job to try to reduce the extent of the injury and optimise their foot leg and spinal mechanics with the other health care team as much as we can to allow them to continue with their careers.”

Foot exercises

It is natural to ask what the most common injury in dancers is. Simon often presents to medical and podiatric conferences and makes the following points:

“One of the main causes of injury in dancers is weakness, caused by the fact that most humans walk around with their feet in leather coffins called shoes. Shoes are essential in and out of dance but restrict the movement and activity of muscles, so muscles in the feet become weaker (atrophy). As a result, most dance injuries are caused by weak feet so podiatrists must insist dancers perform exercises to enhance the intrinsic strength of the foot.”

Simple forefoot problems, which can be excruciating such as ingrowing toenails, interdigital corns or ulcerations are common. Barefoot or barefoot walking footwear walking Simon advises strongly against unless worn for short periods and the dancer is extremely fit, and young.”

Simon informs parents of children who want to become professional dancers, that foot anatomy is very similar to hand anatomy, but we use hands more, so the muscles in hands are stronger as a result. There are foot artists who hold paintbrushes with their feet and have managed to create foot movement similar to the movement of the hand. Simon advises parents of aspiring dancers that “their children must make their feet so strong that they work like a hand, so it withstands the forces of dance, whether shod or unshod. To do this, they must enhance the foot intrinsic muscle strength (lumbricals and interossei) by exercising those muscles up to an hour a day to increase the strength of the foot. The aim is to follow the adaptable and flexible strength seen in a primate’s foot. He tells parents that their children will not maintain enough power in the foot to withstand the dangers of recurring foot injury in sport and dance, without this approach”.

Intrinsic muscles

Muscles within the foot are known as intrinsic, while those arising from the leg around the ankle joint are extrinsic muscles. In hands, we can move our fingers out like the character Spock from Star Trek. The movement uses tiny muscles that in feet are seldom used. It is possible to find people able to move the big toe sideways. Again, intrinsic muscles are used. Painting with feet can illustrate the control from these intrinsic muscles which rely on shorter digits in feet than in hands. In later development, the toes buckle or hammer up as shown in the picture of the young girl.

Controlled painting but not through necessity but with less controlled toe function than in the picture below.

Developing toe control with a flexible foot – born without hands this development was through the necessity for painting.

Specific problems

the MTP joint is where the breakpoint or toes bend and the second MTP joint is often the focus of foot pain

Second metatarsophalangeal joint (MTP) toe joint inflammation is not uncommon between the toe and metatarsal. Conditions such as capsulitis or synovitis arise if the lesser toes become weak. The big toe, often known by the public as the bunion joint, can in some cases drift across underneath if the smaller toe strength is weak. If you want to maintain your interest in dance and a dance career, you must exercise the foot intrinsic muscles until your foot is extremely strong and then maintain it by continuing to do this for a few minutes each day. The bones of the feet will strengthen and enlarge (hypertrophy) in response to this extra workload by building bone density and size. Simon reinforces this advice with an example.

Having worked with many dancers from a number of elite dance companies in London and the UK, Simon has experience in treating all ages and levels of dancers from beginners to the most elite principals.

“I looked after the late Gillian Lynne, (Cats and Hot Gossip choreographer and iconic ballet dancer), X Rays confirmed the circumference of her lesser metatarsals had increased to the same diameter and density of her 1st (big toe) metatarsal to compensate for the repetitive stress that she’d put it through her forefoot all through her career until she was still teaching in her late 80s.”

Simon pointed out that Nureyev and Baryshnikov believed in the importance of supreme foot strength. For those interested, he suggests, “watch the biopic film White Nights” to see how Mikhail Baryshnikov could support his whole body weight on the dorsum of his extended lesser toes.

Advice on how to specialise?

As with many parts of professional life, the recently qualified student must have a good grounding in their subject, which means knowledge of functional anatomy, medicine, physiology, and orthopaedic conditions. Most people who wish to enter the sports field understand human movement, with many taking post-graduate courses in sports science. While undergraduate university schools teach the essentials and framework of this science; those who wish to do well must go the extra mile. Having a degree or diploma alone does not always give you access to the real action, so I wanted to ask Simon how someone could get into this area of specialism early and what guidance he could offer.

“I advise all podiatrists interested in MSK Podiatry to firstly identify the best practitioners in their field, then work with several experienced MSK podiatrists. Junior podiatric surgeons work with more experienced surgeons who offer a surgical “apprenticeship, and I did this before qualifying as a podiatric surgeon many years ago, by working with David Bell, and two others of the best podiatric surgeons at the time, so MSK Podiatry is the same. Learn from the most experienced practitioners. MSK podiatrists with experience in treating many different dancers are thin on the ground, but research who they are and work with them.

In the early days, I used to offer my service to the dance schools, the Central School of Ballet, Rambert, Royal Ballet, White Lodge (Royal ballet junior school), the English National Ballet and then the London Contemporary Dance Theatre. This gave me a good insight into the world of professional dancers, to learn about how they think, what their goals and podiatric problems are, before identifying what podiatric services they required. In those early days, I offered my time and services with minimal financial reward as dancing is often poorly funded and some of the best dancers come from poor backgrounds, so some professional philanthropy is necessary. Spend a day a week to help the dancers with simple foot problems, using your unique skill set.”

Simon recommends asking permission to visit local dance schools to offer a research study about let’s say, foot injury incidence in one form of dance compared with other dance styles and watch some dance classes. Once you are familiar with the scene and have chatted to dancers about MSK problems affecting feet and legs, you can then identify how to to assist. Be prepared to extend your interest beyond the feet as many dancers suffer from ankle, lower leg, knee and hip knee injuries rather than just foot pain. Knowing your foot, ankle, leg, hip and spinal anatomy is important.

Simon watched the dancers perform in many central London shows several times to identify mechanisms of injury, and he confirms that you need to be prepared to discuss the moves with the choreographers if you believe the injury could be reduced by adjusting the choreography, or certain dance movement and substantiate it with a full explanation.

Simon advises podiatrists “to watch what experienced podiatrists do. Observe and spend time with them like an apprentice. Remember until you have been out in the wide world for a time and are trained, your training will only include the basics until you have experience in the field. The skill sets that you’re going to develop extends way beyond your university degree. While teachers of podiatry try to encapsulate a wide field, they can only give you basic skills to be able to develop yourself fully, once qualified.”

If this area of podiatry interests you please feel free to contact Simon Costain at clinic@gaitandposture.com and he will be more than keen to offer you further guidance. Look out for the Irish Dance Podiatrist in this career series released this month or you can read Jenny Murray’s story as a professional dancer.


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Thanks for reading “Dancing and the weak foot link” with Simon Costain

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