Foot care for pointe shoes.

Sprains, fractures, and tendinitis are foot injuries common to both ballet and modern dancers. But several injuries sustained by ballet dancers are peculiar to dancing on pointe; ironically, many modern dance foot injuries are caused by the lack of protection provided by shoes. Here we will discuss the most common pointe-related injuries; in a future issue we will discuss foot injuries in modern dancers.

Toenail Ailments

Of the twenty-five hundred professional ballerinas I have treated, I can't recall one who didn't have "abnormal" toenails. Pounding on the toe tip for up to six hours per day will cause adaptive thickening, which is desirable. When factors overpower this thickening, problems result. The most common causes of toenail problems in the ballerina are improper maintenance, fungus, and getting stepped on or dropped hard during partnering.

Good maintenance includes cutting nails close to the quick in the center, then straight across out to the edges. Nails cut short of the skin corners may become ingrown. If your corners are presently too short, round each one slightly with an emery board. Once your nail grows ever so slightly beyond the corner, maintain this length with an emery board two or three times a week. Another aspect of good maintenance is making sure that your pointe shoes fit properly.

Many pointe dancers suffer from nails that bruise, which can range from a temporary soreness all the way to an acute, bloody loosening of some or all of the nail plate. To reduce the chances of bruising from impact or jamming, keep the center of the nail trimmed close to the quick.

If your nail becomes loose, it may tear and get infected. To prevent tearing in a nail that has been loose for a while, cut all the loose nail away at the attachment site. First aid for freshly torn nails starts with gentle cleansing in soapy, warm water. Next, douse the site with a skin disinfectant such as Betadine or Povidone (unless you're allergic to iodine, which both of these products contain), and cover it with a Band-Aid (not too tightly), In most cases of nail tearing, however, you should probably see a podiatrist.

Some dancers live with a partially torn nail by avoiding pointe for a few days and thereafter taping the loose nail down with a Band-Aid (only the non-sticky part should touch the nail, please) until a new nail plate forms underneath, which often takes at least three months. Viscous lidocaine, a topical painkiller used by dentists and acquired by some dancers, masks pain in infected skin conditions. I have seen this result in blood poisoning, a medical emergency requiring hospitalization. (In fact, any painkiller used continuously for any condition is inadvisable.) If the pain is severe and unrelenting, or if your torn or ingrown nail is getting hot, swollen, fiery red, or odorous, see a professional as soon as possible.

If your nail is very yellow and brittle and a good bit at the end is loose, you may have a fungal infection. These are extremely common in dancers, because shoe trauma can initiate and perpetuate fungus growth. Because they recur, fungal infections are very difficult to treat. Topical anti-fungal medications usually yield unsatisfactory results. Intelligent hygiene will minimize the likelihood of contracting a fungal infection: Keep your feet dry and don't use someone else's nail clippers.

Corns

Like hair and nails, corns are a skin secretion composed of the protein keratin. They are produced at pressure-sensitive sites. Because corns are so pointy, and because they continue to build at pressure sites, they can become painful. In some cases, they actually perforate the base skin on which they rest, creating an ulcer that gets infected. An infected corn looks swollen and red and is usually hot and painful. An infected corn is especially dangerous if it is between the third and fourth toes, an area in which many dancers have a certain degree of numbness--nerves are susceptible to pinching at this site. Anything that looks like an infected pimple between the toes but, curiously, doesn't hurt warrants a professional visit. Regardless of location and regardless of how much it hurts, if your corn looks infected it should be treated by a professional.

If you don't have an infected corn but suffer from chronic discomfort at these hard-skin sites, here is some advice. First and foremost, check the fit of your pointe shoes. Inspect the underside of your old pointe shoes. If the did pattern at the back of your heel extends more than one inch beyond the end of the shank, your pointe shoes are probably too small. Experiment at the barre with a half-size larger shoe. Also, remember that feet get bigger over the years. It is not unusual for a ballerina to develop corns later in her career because her feet have grown and she's wearing the same size pointe shoes she wore at seventeen.

Shoes may also not fit properly if one of your feet is substantially larger than the other. You can check this by standing on a big piece of paper and having someone draw one line at the hindmost part of your heel and another at the tip of your longest toe. (Make sure that the person measuring keeps the pencil completely vertical.) If there is more than a half-inch difference, you need a different size shoe for each foot.

Lamb's wool or doughnut pads can be extremely helpful if your corns don't go away after properly fitting your shoes. Avoid the chemical pads or drops for corns available at the drugstore--they can burn away your good skin and cause infection. Removal of the corn is important it it gets too thick, but it will come back unless the pressure is removed. You may need to have your corns periodically trimmed by a professional. This may sound scary, but it shouldn't hurt at all. The young dancer must keep in mind that thick skin, knots, and non-painful corns or calluses are totally normal and part of the "toughening-up" process all dancers go through.

Blisters

Blisters are also pad of the toughening-up process. Like the other injuries we've discussed, blisters can be minimized it shoes fit properly. Nevertheless, almost everybody develops blisters when experimenting with an unfamiliar shoe. Blisters develop where a new area of the foot is getting rubbed all of a sudden--perhaps the back of the heel where the drawstring catches, or where the vamp hits the metatarsal heads of the toes (the knuckles over the ball joints), or any toe.

Blisters occur when the shoes and tights rub hard against the skin, especially if excess heat is generated. People most susceptible to blisters seem to be those whose outermost layer of skin is not so strongly attached to the skin layer directly underneath. In addition to care in fitting, ways to avoid getting blisters include applying a Band-Aid or tape to susceptible sites. Another preventive measure is applying the stickum "tincture of benzoin" (pronounced BEN-zoh-win), available at drugstores, to the skin before carefully pulling on your tights (avoiding wrinkles). The benzoin causes the tights to stick to the skin, and the shoe then rubs against the tights; some people also believe that benzoin thickens the skin. All of these "preventive" measures ultimately lengthen the time it takes the skin to toughen up. Some people's skin never toughens; for them, these are necessary measures.

Immediate care for blisters includes covering them with a Band-Aid. If a blister bursts, apply an antibacterial ointment. Under no circumstances should you completely unroof a blister, and non-painful blisters should not be punctured. Both of these actions predispose the injury to infection, which causes more pain, lengthens downtime, and is potentially quite serious. Most often, recurrent blister sites toughen benignly into calluses and that's the end of it. If a blister is painful, then puncturing should relieve the pain. Optimally, puncturing should be done by a professional; certainly it should not be attempted in cases of very deep or blood blisters. It is not really practical, however, to seek professional help for every sore blister, and there is a safe way to render them pain-free at home. Ask your foot-care professional to show you how this is done.