ONE TO ONE

Lord of the dance

The Royal Ballet’s principal podiatrist, Denzil Trebilcock, explains how the art of dance interacts with the hard science of biomechanics.

Interview Matt Lamy

When an audience sits rapt, watching the dancers of the Royal Ballet perform, the idea that these supreme athletes with perfect poise, form and balance could suffer from corns and ingrowing toenails is probably the furthest thing from the onlookers’ minds. But for the Royal Ballet and Royal Ballet School’s principal podiatrist, Denzil Trebilcock, the issues the dancers face – and the major effect that seemingly minor problems can have – are very familiar.

‘The range of complaints I see is fairly varied,’ Denzil says. ‘A lot of what I do is a combination of biomechanics and completely classical routine care: all the delights and horrors of soft corns, ingrowing toenails and the excruciating wounds that dancers get. But equally, the important thing to remember is that if a dancer gets something as innocuous as a soft corn, that will alter how they go into a position to try to avoid loading. Unless we deal with these small things, it can have a knock-on effect that causes impingements or restrictions, or overwork.’

Denzil’s reference to biomechanics is a clue to how he came to work with the Royal Ballet. He took a degree in physics at King’s College London, but after graduating and being underwhelmed by career options, someone suggested human mechanics might be of interest.

‘I ended up sitting in with a podiatrist and was introduced to this wonderful world of classical mechanics associated with how humans move – all the relevant forces, mass times acceleration, Young’s modulus in terms of how tendons work, and how much strain you can put them under. It all fi tted really perfectly with the areas that I had enjoyed while studying physics,’ he says.

Dancing return

After studying podiatric medicine at University College London and the London Foot Hospital, Denzil worked for the NHS at Lambeth Primary Care Trust (PCT) for fi ve years, becoming Lambeth PCT department lead for the musculoskeletal foot and ankle centre. At the same time, he also enjoyed working in private practice; it was through this that his connection – or more accurately a reconnection – with the Royal Ballet occurred.

‘I was working for a physiotherapy clinic and the lead physiotherapist was contacted in an emergency to see if she knew a podiatrist who could look after a ballerina’s feet. She called me, so I went in on my day off and I spent a really productive hour or two with Leanne Benjamin, who at the time was principal dancer at the Royal Ballet,’ Denzil says.

‘Afterwards, I thought it was fun but nothing more. However, Leanne went back to the Royal Opera House and must have said she’d been treated by me. The next day I was contacted by the Royal Ballet’s head of healthcare, who said they were in desperate need of a podiatrist, and could I go in for a chat. I graduated in 2005 and this was in 2009, so it was still all very new to me and I hadn’t specifi cally dealt with dancers at that time, so it was a bit nerve-racking.

‘Funnily enough, my grandmother used to be in charge of all the ballet shoes at the Royal Ballet from the 1960s to the 1980s. Weekends during my childhood were spent walking round this very old, strange place where all these dancers were leaping and jumping. So I suppose from a very early age I was primed and aware of what ballet was.’

A new focus

Although the world of ballet that Denzil re-entered was familiar, it was about to undergo an overhaul of its approach to dancers’ health and wellbeing.

Digital goals

During the pandemic, Denzil has been using his technological background to think about other ways he can help patients.

‘One of the things that I’ve always had at the back of my mind is the concept that, as a profession, we need to be face-to-face with people in order to do what we do,’ he says.

‘So I’ve been looking at ways to provide a distanced form of analysis that we can use to establish whether or not there is a need for further treatment. I’m learning the programming needed in order to design various apps for that.’

‘Ballet is an art form, but one where the dancers strain themselves physically to make it look beautiful. But it wasn’t seen in the same light as an elite sport in its treatment processes at that time – it was very much a case of patch them up, send them on their way, see what happens and then we’ll go onto the next phase – which invariably would be surgery and the like,’ Denzil says.

‘But in around 2013 or 2014, there was a complete change. The Royal Ballet brought in a top British Olympic medical director and he set up a full sports science-based modality programme. The doctors were all sports medicine doctors, the physios were all in tune with screening and monitoring, and that’s where I started to fi t in.

‘As the only podiatrist on the team, it can be challenging to say, “I can do that.” The physios look at me and wonder what I’m doing with my podiatry hocus-pocus, while I explain why my approach might have a better outcome. It’s a case of not treading on any toes but offering my help and making suggestions where I see opportunities. It’s really about providing another weapon in their arsenal, whereas before they were very much about icing, strapping and immobilising injuries.’

Long-term approach

While Denzil’s ballet caseload can involve almost any condition, the biomechanical and overwork issues have the potential to be the most serious.

‘I have a designated clinic once a month where the Royal Ballet sends me people who need looking at but who aren’t emergencies. They come to Harley Street and I treat them there rather than at the opera house because a lot of the biomechanical work that I do is easier in clinic, where we have treadmills and video capture technology,’ Denzil says.

‘As a result of those clinics, I’ll tell the physios what I’ll be doing. Most of the treatments involve biomechanical control – orthotics, taping, strapping, padding – it’s all of the things needed in order to offl oad and redistribute. ‘From a podiatry point of view, I can provide very temporary solutions while they’re dancing. But we’re still dealing with an art form, so the dancers don’t like to have anything that shows around the leg or the foot, and they don’t want it to change the shape of the foot. So I’m actually quite limited in terms of how I can make an immediate difference.’ Where Denzil does have a role, though, is in longerterm options. ‘It’s a case of ‘It’s all very well treating and asking not treading them to manage and stabilise themselves on any toes but off ering when they’re dancing, but that damage can still be done, or the my help and making suggestions healing pathways can still be disrupted if they have a biomechanical abnormality when they’re just standing have a biomechanical abnormality when they’re just standing ’ where I see opportunities’ or walking normally. I can help them when they just want to go for or walking normally. I can help them when they just want to go for a walk or a run without a walk or a run without irritating the area. That irritating the area. That is very much a case of orthotics and h a case of orthotics and bringing in processes to stabilise the processes to stabilise the feet themselves over the long term,’ lves over the long term,’ he says. ‘I’ve been very privileged to have very privileged to have worked with some amazing people h some amazing people through the Royal Ballet, but treating Royal Ballet, but treating dancers is actually much like treating ctually much like treating anybody else. I know it’s a cliché, but e. I know it’s a cliché, but just helping people is why we do this people is why we do this job. Podiatrists are really honoured in ists are really honoured in that we can do things where people do things where people immediately stand up and say, “Oh, that y stand up and say, “Oh, that feels so much better.” It makes me very ch better.” It makes me very happy to hear someone saying they feel ar someone saying they feel great as they walk out.’ y walk out.’ Or, in this case, perhaps – dance away. case, perhaps – dance away. For top tips tips on how to treat a on how to treat a patient with a dancing or sports with a dancing or sports injury, go to page 32. o to page 32.

Flat feet

‘The very nature of what a ballet dancer does is completely artificial for what the foot is designed to do,’ Denzil says.

‘The classic plié is a really forced situation – the idea of turning your feet out and then being able to bend the knees – you’re forcing that midtarsal joint into a completely compromised position, so it’s no wonder that the majority of ballet dancers are flat footed.’

New shoes?

One of Denzil’s own long-term goals isn’t just for dancers.

‘I’m fascinated by ballet footwear but also everyday footwear for non-dancers,’ he says.

‘There are very good shoes out there, but equally there are people who will need stabilising and support but who don’t want ugly or orthopaedic shoes. We haven’t really found a happy medium, so I’m very interested to see so I’m very interested to see how we can do that.’ how we can do that. ’