In theater, “break a leg” is a phrase used to wish a performer luck. But for ballet dancers, it isn’t simply an expression but an occupational reality. The intense physical demands of ballet put dancers at high risk for foot and ankle injuries, from blisters and bunions to stress fractures and tendonitis.
“I think ballerinas are probably some of the toughest athletes, in terms of the physicality of what they have to endure, along with their commitment,” said Dr. Arianna Gianakos, an orthopaedic surgeon and assistant professor of orthopaedics and rehabilitation at Yale School of Medicine (YSM), who specializes in sports-related injuries.
Arianna Gianakos and dancer Taylor McClure ’25
Ballet dancers often push their bodies to the limit: They support all their weight on the tips of their toes when rising to what is known as en pointe. They soar through the air in gravity-defying jetés. They spin their bodies by whipping around their legs when performing a fouetté. The stress these motions place on the body — especially if done to overexertion or without proper technique — may cause serious pain and injury.
Like many orthopaedic surgeons, Gianakos was drawn to the field by her own experience as an athlete. She’s been in her patients’ shoes — as a dancer, a basketball player, and a track and field athlete. Indeed, as a college athlete, she had her own share of injuries, including tearing her anterior cruciate ligament (ACL) and sustaining ankle ligament instability, both requiring surgical intervention.
“As an athlete, all you want to do is get back to the sport you love,” she said. “When you can’t get back to it — not because you don’t have the grit and determination, but because you’re physically unable to do it — it can be detrimental to an athlete’s overall well-being.”
In an interview, Gianakos explains the mechanics of being en pointe, the most common injuries experienced by ballet dancers, and how she centers her patients in her work as a surgeon.
The interview has been edited for length and clarity.
What happens to the foot and ankle when a ballet dancer goes en pointe? Walk us through the mechanics of how they make it look so effortless.
Arianna Gianakos: Even though they make it look effortless, it isn’t effortless. It takes a lot of skill, training, and hard work.
It’s complex biomechanically because it requires the dancer to have appropriate strength, flexibility, and overall alignment. When a dancer is going en pointe, they have to rise up to the tips of their toes. They’re using these specially designed pointe shoes that distribute the weight through both the toes and the metatarsals, which are the small bones in the foot and the forefoot. That ballerina pose allows the heel to line up on top of the toes. Those tiny muscles, along with a big tendon called the tibialis posterior, help control the arch of the foot and allow the foot to progress into this hyper flexible position for these dancers. In addition, calf muscles help lift the leg up to keep the dancer elevated.
We also can’t forget that, in addition to foot and ankle mechanics, the dancer needs to have good core hip stabilizers. This allows them to maintain an upright position and control their posture. Quadriceps and hamstrings also need to be trained for movements like the plié [a knee bend] and the relevé [in which they rise en pointe from flat feet] so that everything is done in a smooth and controlled motion.
What are the demands of being en pointe, especially for the feet and ankles?
Gianakos: It’s all about excessive range of motion for these individuals. They’re going into a hyper plantarflexion [in which the foot is forcefully bent downwards] and a hyper dorsiflexion state [in which the foot is bent upward toward the shin] at the ankle joint. They also need to have extra range of motion in the forefoot, midfoot, and all of their toes when they’re going on to their tippy toes and when they’re jumping. Two to three times their body weight is going through those feet. That’s an excessive amount of load that the feet must be able to take, which is why good form and technique are important when they’re en pointe.
That’s also a lot of motion through the ankle, the knee, the hips, and the foot itself, which can lead to some overuse injuries. In addition, the ballet dancer must do all this through somewhat of a rigid shoe. The pointe shoe itself is very hard and rigid, so the foot must adapt to that type of shoe wear, which becomes a bit restrictive. That’s why sometimes when they’re in these somewhat unnatural positions, they can have skin breakdown, blisters, nail trauma, and other injuries.
What are some of the most common injuries for dancers? Are there certain positions or moves that are especially risky for lower extremities?
Gianakos: Ballet dancers experience either overuse injuries or traumatic injuries. Because this sport requires a lot of athleticism, we see stress fractures, particularly in the metatarsals, which are the bones in the forefoot, as well as underneath the sesamoid, which is under the great toe, and the navicular [in the midfoot]. Those injuries can be exacerbated in patients who might have some nutritional imbalances or deficiencies or who aren’t as well trained and haven’t been practicing those moves as much.
Posterior ankle impingement is a very common injury for dancer athletes. This is essentially compression in the back of the ankle. If you’re in a pointed position repetitively, you get pinching in the back of the ankle joint. That can cause a lot of inflammation and scar tissue. It’s one of the injuries I often treat in ballet dancers, gymnasts, and soccer players.
What does treatment typically look like for dance-related injuries?
Gianakos: In general, we need to make sure they get enough rest, eat healthy, and stay hydrated, as well as pay attention to their mental health. If there is an injury, we need to make sure that the athlete knows it’s okay to take a little time off so that they are properly diagnosed. If there is an injury and it’s something that sidelines them for a period of time, they not only need an appropriate physical therapy protocol but a sport-specific therapy program, too. You can’t just have them sit on a bike and expect them to be able to return to an elite level of dance. They also need to speak with someone on the mental health side of things. Mental health is important not only to return to dance but also so they’re not fearful about re-injury.
Foot and ankle injuries can have a major impact on a dancer’s quality of life. How do you approach treatment? Does recovery look different depending on the individual patient?
Gianakos: The biggest thing is developing a really good rapport with my patient. I want them to be able to trust me as their physician and as their surgeon. I want them to be able to be open and honest about what they’re feeling both physically and mentally, so that I can better understand their injury entirely.
I also want to understand the individual’s goals. So, in a ballet dancer’s situation, their goal is to get back to doing things that require excessive range of motion, strength, balance, all these things. Depending on the injury, they might need some time where they are immobilized. But I try not to immobilize people in general with foot and ankle injuries. If someone is immobilized for too long, particularly a ballet dancer, they are not going to get the range of motion back because of all the scar tissue that will build up there. I usually want them at least doing some range of motion exercises early on.
Another thing that I try with my practice is, if it’s feasible, minimally invasive approaches to help expedite recovery and reduce risk of wound complications. I also do regular check-ins with the athlete to see how they’re progressing, including having direct communication with their therapist or trainer to understand if they’re meeting recovery milestones.
What are some of the ways dancers can minimize serious injury? What should people keep in mind before starting en pointe?
Gianakos: Knowing your body and listening to your body is important. That’s a good first step. Seeing a physician is also important. There are a lot of athletes who play through pain. If do you that, you can put yourself at increased risk for damage down the road, including a more severe injury.
Dance is a great sport, but it’s something that takes time and dedication. Start off with basics and really focus on technique, so that you can then progress to some of these more extravagant moves that require a little bit more strength and stability. You also need to stay on top of nutrition, like eating healthy and staying hydrated, and having social support is important.
