Evaluation of the Correlation Between Flamenco Dance and Ankle and Foot Posture

ORIGINAL ARTICLES Evaluation of the Correlation Between Flamenco Dance and Ankle and Foot Posture Aurora Castro-Méndez, PhD* Desidero Mateos-Martínez, MPH† José M. Castillo-López, PhD* Alfonso Vargas-Macías, PhD‡ Background: The practice of flamenco dance involves great biomechanical demands, comparable with a high-performance sport. The technical movements of the footwork tap, the jumps, and the turns increase the prevalence of injuries and pathologic disorders of the foot and lower limb. Limited research has examined adaptation of the foot posture and dorsiflexion of the ankle in flamenco dancing. Therefore, the aim of this study was to evaluate whether the practice of flamenco dancing produces modifications in the ankle’s dorsiflexion range of motion, Foot Posture Index, or pronation. Methods: A cross-sectional observational study with intentional sampling was performed with 26 individuals (52 feet) in two groups: professional female flamenco dancers (n = 13) and nondancers (n = 13). The participants were assessed in a single session for ankle dorsiflexion, foot pronation (navicular drop test), and foot posture (Foot Posture Index). Results: Significant differences were found between the two groups for left foot Foot Posture Index (P= .007) and right foot navicular drop test (P= .006). Conclusions: The results of this study indicate that flamenco dancing can produce modifications in the Foot Posture Index and foot pronation versus nondancers. Further research is required. (J Am Podiatr Med Assoc 112(1): 000-000, 2022) Flamenco is a type of dance originating from the south of Spain, and it is one of the most representative symbols of its culture throughout the world. 1,2 It is characterized by a percussive dance and is performed in traditional high-heeled footwear. The main difference from other percussive dances, such as the Irish dance or tap dance, is that its footwork taps are done with a slight semiflexion of the knees 3,4 and without jumps before the impact. 5,6 Professional Flamenco requires high effort, comparable with any elite sports activity, and appropriate care and preparation is needed. 4,7 During a performance, dancers have to tap in sync to very demanding aesthetic and rhythmic patterns specific of flamenco music. 8,9 The impact zones in the footwork taps are the full sole of the foot, the forefoot, the heel, and the toes. The average frequency of footwork taps during a show is 4 per second; a maximum of 12 taps per second and a weekly load of 20,000 taps have been recorded. 4 This tap technique generates frequencies that, associated with the stress due to the repetition of the impact, trigger very specific injuries among the participants of this dance. 9 This is why the foot is one of the most prevalent zones for the occurrence of injuries, as are the ankle, knee, and spinal column. 3,4,7,10–14 There are diverse foot deformities as a consequence of practicing flamenco dancing: hallux abductus valgus, tailor’s bunion, hyperkeratosis, metatarsal pain, nail damage, 10,11,15–18 or ankle problems. 19 The importance of the correct biomechanics of the foot and ankle is paramount in activities of great physical demand to prevent the occurrence of injuries. In relation to analysis of the biomechanics of the foot and ankle, measurement of the range of motion of the ankle joint, 20 assessment of foot posture with the Foot Posture Index (FPI), 21 and quantification of the drop of the internal arch via the navicular *Podiatry Department, University of Seville, Seville, Spain. †Podiatric Clinic, E11406 Jerez de la Frontera, Ca ´diz, Spain. ‡Telethusa Centre for Flamenco Research, Ca ´diz, Spain. Corresponding author: Aurora Castro-Me ´ndez, PhD, Podiatry Department, University of Seville, Avicena Street, E-41009 – Seville, Spain. (E-mail: [email protected]) J_ID: JAPMAART NO: 10.7547/20-078Date: 4-February-22 Page: 1 Total Pages: 6 4/Color Figure(s) ARTTYPE="ResearchArticle" ID: rahul.baikarTime: 15:07I Path: //mumnasprod/cenpro/ApplicationFiles/Journals/APMA/JPMA/Vol11201/220009/Comp/APPFile/AM-JPMA220009 Journal of the American Podiatric Medical Association Vol 112 No 1 January/February 2022 1 drop (ND) test 22 are the tools normally used in clinical podiatric medical practice. The foot’s pronation has been the subject of several research studies into prevention of the risk of injures, mainly in sports activity. 22–25 Some studies have been reported in different types of dance. For example, in ballet, hyperpronation is related to the technical placing of the lower body associated with this dance. 26,27 Foot posture has also been linked to the perception of pain in Irish dancing, 28 contemporary dancing, 29 and western dancing 30 or to the consequences of using heels in jazz dancing. 31 As mentioned previously herein, there is a lack of similar studies regarding pathologic disorders and adaptations of the foot related to flamenco dancing, despite the high number of foot deformities registered. Therefore, the main aim of this study was to determine whether the practice of flamenco produces modifications in the ankle’s dorsiflexion movement, foot posture, or pronation in relation to individuals who do not perform this dance or similar activities. Materials and Methods This cross-sectional observational clinical study was approved by the research ethics committee of the University of Seville (Seville, Spain). All of the participants were volunteers and provided informed consent, and the study was performed following the ethical principles of the Declaration of Helsinki. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guideline was followed. This study was registered with ClinicalTrials.gov (NCT04145206). Participants Twenty-six Spanish women participated in this study: an experimental group of 13 semiprofessional female flamenco dancers (median of 9.69 hours of flamenco dancing per week; mean 6SD age of 40.15 64.67 years, height of 161.38 61.61 mm, and weight of 58.74 62.62 kg) and a voluntary control group of 13 healthy women who did not practice any kind of dance (mean 6SD age of 38.92 65.17 years, height of 162.92 62.73 mm, and weight of 56.23 63.2 kg). Procedure and Sampling Technique From March to June 2019, intentional sampling was performed: an experimental group (female flamenco dancers) recruited from flamenco dance schools in Jerez de la Frontera (Andalusia, Spain) and a control group of voluntary women who came to Clinical Podiatry at Seville University on the date of the study. Inclusion and Exclusion Criteria The inclusion criterion for the experimental group was to have practiced flamenco dancing for a minimum of 6 years; the exclusion criteria were previous fracture or a current lower-body injury. For the control group the inclusion criterion was age older than 18 years and the exclusion criteria were the practice of any kind of semiprofessional or professional dancing, a previous fracture, or a current lower-limb injury. Variables Information was collected with respect to the sociodemographic variables of nationality, age, sex, height, and weight, as well as data about illnesses or conditions that would impede fulfilling the acceptance criteria for the study. Next, a biomechanical exploration of the participants was conducted in a single session, coinciding with the day of inclusion in the study. The following variables were evaluated for each of the feet for both groups of participants: Dorsiflexion of the Ankle The patient was in the supine position, knees extended, and at an initial position of 90˚ of ankle flexion with respect to the leg. Range of motion was measured with a two-branch goniometer. The goniometer’s center was placed in the center of the lateral edge of the heel, and a fixed branch was aligned with the longitudinal median line of the leg; the other branch of the goniometer was placed in the longitudinal bisection of the fifth metatarsal. To evaluate range of motion, dorsiflexion of the ankle was performed and the degree obtained from the initial position was quantified (a limitation of range of motion is considered when from the initial position a value less than one-tenth of the dorsiflexion movement was attained 20 ). ND Test With the participant initially in a sitting position, the tubercle of the navicular bone with the subastragaline articulation in neutral position was marked with a point. The distance from the navicular bone to the ground was measured with a millimeter ruler. J_ID: JAPMAART NO: 10.7547/20-078Date: 4-February-22 Page: 2 Total Pages: 6 4/Color Figure(s) ARTTYPE="ResearchArticle" ID: rahul.baikarTime: 15:07I Path: //mumnasprod/cenpro/ApplicationFiles/Journals/APMA/JPMA/Vol11201/220009/Comp/APPFile/AM-JPMA220009 2 January/February 2022 Vol 112 No 1 Journal of the American Podiatric Medical Association Later, with the patient standing with full weight, the second measurement was from this reference point to the floor. The difference between these two values is the result of the ND test. 22 A normal value is a maximum difference of 10 mm. This is the standard protocol to measure dorsiflexion of ankle range of motion in the Clinical Podiatry of Seville University. Foot Posture Index The FPI is a scientifically proven clinical tool. Foot posture is evaluated by six measurements of the foot: the palpation of the head of the astragalus bone, the supra curvature and lateral inframalleolar, the position of the calcaneus in the frontal plane, the prominence of the talonavicular region, the congruence of the internal longitudinal arc, and the abduction/adduction of the forefoot with respect to the rearfoot. Reference values are as follows: normal foot (0 to 15), pronated foot (16to19), highly pronated foot (110 to 112), supinated foot (–1 to –4), and highly supinated foot (–5 to –12). 21 Statistical Analysis Statistical analysis was performed with IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp, Armonk, New York). The variables are shown using the mean, the standard deviation at a confidence interval of 95%, the median, and the interquartile range. A P#.05 was considered statistically significant. In the initial exploratory analysis, comparisons were made between the two groups of participants to evaluate their homogeneity as to age (via the Student ttest for independent samples), body mass index (through the Mann-Whitney Utest), sex (via the Pearson x 2 gender test), and FPI and ND test results (through the Mann-Whitney Utest). Nonparametric tests were used. Results The mean 6SD and ranges of the variables in relation to the range of motion of dorsiflexion of the ankle, the ND test, and the FPI (scale from –12 to 112) in the total sample and for each group are shown in Table 1 T1. With respect to the inferential analysis, significant differences were obtained when comparing the two groups regarding the FPI of the left foot and the pronation (ND test) of the right foot (Table 1). Discussion The aim of this study was to compare dorsiflexion range of motion of the ankle, foot posture, and pronation (ND test) in a group of female flamenco dancers compared with individuals who do not practice any kind of dance. According these research results, it has been observed that dorsiflexion of ankle range of motion has not been modified by the practice of flamenco; the only significant differences have been obtained with respect to the ND test of the right foot and the FPI of the left foot comparing the two groups. Despite flamenco dancing being performed in footwear with a heel, the sample does not show a shortening of the posterior muscles. These data coincide with the work of Vargas, 3 who did not record shortenings in a sample of 11 professional female flamenco dancers. This result could be justified by the fact that muscular stretching is performed in flamenco and that the footwork tap at the level of the heel is performed in front of the sagittal plane and in maximum dorsiflexion of the ankle. These data differ from those recorded by Pedersen, 6 who indicated shortenings in the range of motion of the right dorsiflexion with statistically significant differences with respect to the left foot (mean 6SD, 6.57˚ 611.69˚). These findings could Table 1. Segregated Description of the Dorsiflexion Values of the Ankle, the Navicular Drop Test, the Foot Posture Index, and the Previous Drawer Test for the Study Groups Variable Right Foot Left Foot Control Group (n = 13) Experimental Group (n = 13) P Value Control Group (n = 13) Experimental Group (n = 13) P Value Range of motion (mean 6SD [°]) 11.77 60.42 11.92 60.38 .325 11.15 60.15 12.00 60.43 .183 Navicular drop test (mean 6SD [mm]) 5.6 67.2 3.9 64.1 .006 a 5.0 65.7 4.3 67.0 .204 Foot Posture Index (mean 6SD) 3.77 60.77 4.54 60.83 .311 3.69 60.41 4.85 60.77 .007 a Drawer test 0 0 0 2 a Statistically significant (P,.05). J_ID: JAPMAART NO: 10.7547/20-078Date: 4-February-22 Page: 3 Total Pages: 6 4/Color Figure(s) ARTTYPE="ResearchArticle" ID: rahul.baikarTime: 15:07I Path: //mumnasprod/cenpro/ApplicationFiles/Journals/APMA/JPMA/Vol11201/220009/Comp/APPFile/AM-JPMA220009 Journal of the American Podiatric Medical Association Vol 112 No 1 January/February 2022 3 be due to the sample being of adult students and not of professional dancers. The range-of-motion data obtained in this sample are slightly lower than those recorded in another percussive dance, Irish dancing (mean 6SD, 14.70˚ 64.02˚), 28 perhaps as a consequence of the footwork tapping in flamenco not having jumps or springs and, therefore, submitting the structure of the foot to greater overload compared with Irish dancing. Likewise, the height of the average heel in flamenco dancing is 4.0 to 7.5 cm, 16 whereas in Irish dancing it is 3 to 4 cm. 32 With respect to nonpercussive dances, the results recorded in ballet or contemporary dance are much greater due mainly to the high requirements of flexibility needed in these modalities, which are not required in flamenco. 33 Continuing with the discussion of the results, in relation to the ND test, it has been described previously that this clinical tool quantifies the excessive pronation of the foot and is used frequently in studies, mainly in sports, in relation to the occurrence of injuries. 22,34–36 In this study, the ND test showed normal values for both groups. However, a statistically significant difference was recorded with respect to the right foot. Due to the asymmetry in flamenco of the footwork tapping movement of both feet, according to studies 4 it is estimated that there is a greater number of footwork taps in female flamenco dancers in the right foot than in the left foot. This can reach 600 footwork taps per week, which can predispose to greater strengthening of the anterior and posterior tibia muscles of the leg and so may justify the difference with the contralateral foot. 37,38 In this sense, greater flattening of the footprint of the right foot after practicing flamenco dancing was recorded. 14 It can, therefore, be noted that because this musculature is considered fundamental for maintaining the arch and is strengthened in this foot, it may justify this finding, coinciding with the results of other authors. 28 This situation would represent an adaptation of the foot to the practice of flamenco. In this research, this variable is collected in a baseline situation, that is, when the musculature is not fatigued, before a performance. The present average results are similar to those of another study relating to ballet dancers. 38 The similarity could be due to the technical movement of “relever,” which requires an important musculature effort response of the internal arch maintained in the raised toes support position. Linking to the aforementioned discussion, and with respect to the FPI, the evidence shows that female flamenco dancers have a slightly more pronated foot posture than the control group, and despite both groups being within normal foot posture values, there are significant differences only for the left foot (P,.05). It seems to be connected with the different biomechanics performed by each foot during flamenco dancing. 4 The left foot performs a greater pivoting function than the right foot and, therefore, receives a higher load and, consequently, a greater internal arch drop. This movement could modify the foot posture with a tendency toward pronation. The functionality of the foot is influenced by the specific biomechanical requirements in each activity, allowing an adaptation according to each case; due to Flamenco being a high-performance activity requiring much absorption, this situation could justify the results. Compared with other dance techniques, the results obtained in the flamenco sample are similar to those recorded in contemporary Western dances such as hip-hop, popping, or tap dance. 30,33 On the other hand, pronation in ballet has been abundantly studied and compared with the present sample records a less pronated foot. 30,33 According to specialized literature, this hyperpronation is a consequence of the basic technical movement in ballet of turnout or external rotation of the coxofemoral articulation. 26,27,39 However, although flamenco dancing uses this technical movement, its frequency and the musculoskeletal requirement are not as high as in ballet, so the pronation results are lower. 40 According to the results of this study, we suggest that the practice of flamenco dance could produce modifications in the foot relating to its function. We recommend the use of sole supports to prevent long-term injuries. Limitations of this study include difficulties in obtaining the sample population, which led to using a purposive sampling technique. It would have been more pertinent to evaluate the variables before and after the study to accurately evaluate how the activity affects the foot. Also, there are difficulties in performing longitudinal studies to obtain more robust conclusions as to the postural positions or deformities developed in the foot in relation to the professional practice of flamenco dancing that are limitations. Future studies are necessary to supplement the results obtained. Conclusions In this study we found that the practice of flamenco dancing significantly changes the posture of the J_ID: JAPMAART NO: 10.7547/20-078Date: 4-February-22 Page: 4 Total Pages: 6 4/Color Figure(s) ARTTYPE="ResearchArticle" ID: rahul.baikarTime: 15:07I Path: //mumnasprod/cenpro/ApplicationFiles/Journals/APMA/JPMA/Vol11201/220009/Comp/APPFile/AM-JPMA220009 4 January/February 2022 Vol 112 No 1 Journal of the American Podiatric Medical Association foot and its pronation compared with the control group of nondancers. This research stresses the fact that the practice of flamenco might influence the foot’s pronation and posture. Consequently, this can be a factor in the occurrence of injuries, and, therefore, we need to emphasize the importance of regular checks of the feet to prevent and/or treat possible injuries. Financial Disclosure: None reported. Conflict of Interest: None reported. References 1. MACHIN-AUTENRIETH M: Flamenco >Algo Nuestro? 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FORCZEK W, BAENA-CHICON I, VARGAS-MACI ´AS A: Movement concepts approach in studies on flamenco dancing: A systematic review. Eur J of Sport Sc 17: 9, 1161, 2017. J_ID: JAPMAART NO: 10.7547/20-078Date: 4-February-22 Page: 6 Total Pages: 6 4/Color Figure(s) ARTTYPE="ResearchArticle" ID: rahul.baikarTime: 15:07I Path: //mumnasprod/cenpro/ApplicationFiles/Journals/APMA/JPMA/Vol11201/220009/Comp/APPFile/AM-JPMA220009 6 January/February 2022 Vol 112 No 1 Journal of the American Podiatric Medical Association