The dancer’s feet are comparable to a concert pianist’s hands. Extensive training, often beginning before the age of 10, is common, especially among girls. Through the years, changing styles and great leaps have placed increased strain on the foot, resulting in the variety of dance injuries we must diagnose and treat today. In a follow-up to the last column (see “How To Identify And Treat Common Ballet Injuries,” pg. 70, April issue), let’s take a closer look at other common foot and ankle injuries that affect ballet dancers. The most common acute injury in theatrical dance is the ankle sprain. Most sprains usually involve the lateral ligamentous structures and result from forced inversion of the hind foot when landing from a jump. With the foot in plantarflexion, the talus is relatively unstable within the ankle mortise. In this position, the primary static restraint to inversion stress is the anterior talofibular ligament. Forced inversion results in stretch, partial or complete tear of this ligament with the immediate onset of pain and swelling within the sinus tarsi. Regardless of severity, ankle sprains are initially treated with rest, elevation, ice massage and a compressive dressing. However, there are different treatment protocols for different grades of sprains. How To Grade The Severity Of Ankle Sprains Grade I sprains are stable injuries that involve stretching or partial tearing of the anterior talofibular ligament. You can effectively treat these injuries with serial taping or the air cast. Patients should maintain icing, elevation and compression until all swelling has subsided. Emphasize to patients to continue with three-point crutch walking until they can walk with a normal gait. Grade II sprains usually involve a complete tear of the anterior talofibular ligament with varying degrees of injury to the calcanealfibular ligament. Patients with these injuries usually present with significant swelling. This often restricts initial treatment options to a compressive dressing and posterior splint. When swelling decreases, you may employ serial taping or the air cast. Grade III sprains involve complete or close to complete tears of both the anterior talofibular and calcanealfibular ligaments. Frequently, you can manage these injuries successfully via immobilization. However, the prognosis for a completely stable ankle following such treatment may be somewhat unpredictable. Dancers, like gymnasts, require absolute stability with the ankle in the plantarflexed position. If the torn lateral ligaments heal in a scarred, stretched position, this laxity can lead to chronic instability and may adversely affect performance. Operative management of grade III ankle sprains offers reliable restoration of ligament length and decreases the likelihood of long-term instability. Regardless of the method of treatment, adequate physical therapy and proper rehabilitation are necessary to restore normal use following injury. Key Pearls On Subluxing MPJs And Cuboids The collateral ligaments of the lesser metatarsophalangeal joints can be torn by a dorsiflexion sprain or, in an older dancer, can be stretched out, slowly leading to instability in the joint. When the dancer relevés onto the ball of the foot, the base of the phalanx subluxes onto the dorsum of the metatarsal head, forcing it downward (the dropped metatarsal), leading to metatarsalgia. When the dancer comes back down to the floor, the phalanx relocates and appears normal. The regular set of X-ray films will also be normal. To pick this condition up during the physical exam, you must do a Lachman test on the metatarsophalangeal joints. This test is similar to that which is done on the knee. When you test the joints in this manner, the affected toe will easily dislocate and then relocate, making the diagnosis apparent. Once the ligaments are loose, you cannot tighten them without surgical intervention. Sometimes flexion exercises and a toe retainer with padding under the metatarsal head will at least make the problem workable. The subluxing cuboid is a common but poorly recognized condition. It presents as lateral midfoot pain and an inability of the dancer to work through the foot, i.e., go smoothly from foot flat to relevé. This condition may present as an acute sprain or an insidious overuse injury. The dancer is unable to run, cut, jump or dance without a marked increase in discomfort or a feeling of weakness and lack of intrinsic support in the foot. Pressing on the plantar surface of the cuboid in a dorsal direction is painful. The normal dorsal-plantar joint play is reduced or absent when compared to the uninjured side. Severely subluxed cuboids leave a shallow but definite depression you will see on the dorsal aspect and a palpable fullness on the plantar aspect of the cuboid. Treatment usually involves a manual reduction called the cuboid whip. This reduction should be performed by a practitioner who is familiar with the condition. You may also need to repeat the maneuver. How To Address Metatarsal Stress Fractures Metatarsal stress fractures do affect ballet dancers, but the most common one you’ll see is at the base of the second metatarsal. As with many stress fractures, it is often difficult to see these injuries on the X-ray film, especially within a week or so of the onset of the symptoms. Persistent tenderness in the proximal first web space or around the base of the second metatarsal in a dancer usually indicates a stress fracture until proven otherwise. This condition is usually an indication for a bone scan. However, if the dancer is very young, you would simply instruct her or him to refrain from jumping and doing grand pliés until the pain and tenderness are gone. You usually don’t have to put this fracture in a plaster cast. Activity modification for six to eight weeks is usually sufficient for the fracture to heal providing the dancer has not been working on it for a prolonged period of time while it was hurting. If she or he has, it will probably take longer to heal. The most common acute fracture you’ll see among dancers is the spiral fracture of the distal one-third of the fifth metatarsal, also known as the “dancer’s fracture.” Dancers sustain this fracture when they lose their balance while on demi-pointe and roll over the outer border of the foot. If it’s a displaced fracture, it may be necessary to put the dancer in a walking cast for four to six weeks while it heals. (One can accept a considerable amount of displacement with this fracture.) In fractures that are minimally displaced, it is often sufficient to emphasize a comfortable running shoe and restricted activities until the fracture heals. This approach will allow dancers to swim and stay in shape while they are waiting to dance again. Occasionally, you may see a markedly displaced and comminuted fracture. In this case, performing reduction and internal fixation will be necessary. A Guide To Anterior Ankle Impingement And Os Trigonum Syndromes The extreme dorsiflexion required by the demiplié position in ballet can lead to impingement of the anterior lip of the tibia on the talar neck. Anterior ankle impingement results from osteophytes occurring on the anterior tibia and talar neck. The dancer’s first recognition of the syndrome is lack of depth in the plié, which is often associated with poorly localized ankle pain. With time, the dancer may experience more localized symptoms to the anterior aspect of the ankle. These symptoms often include mild swelling. You can attain symptomatic improvement by encouraging the use of a 1/4-inch to 3/8-inch heel lift in street shoes, antiinflammatories and having the dancer discontinue forced plié. Definitive treatment consists of excising the offending osteophytes, either arthroscopically or through an anterior arthrotomy. Keep in mind that you’ll often see secondary inflammatory changes involving the capsule, the fat pad and local synovium. An exostectomy merely extends the dancer’s career. Repeated impingement will invariably lead to recurrent exostoses, usually within three to four years. Repeat excision may therefore be required in some cases. While it is rare in the general population, posterior impingement of the os trigonum is common in dancers. In extreme plantarflexion, an os trigonum, a large posterior tubercle or less commonly, a large dorsal process of the os calcis, is compressed intermittently for periods of up to six hours a day from the dancer standing in the demi-pointe position. The dancer with symptomatic posterior impingement presents with posterior ankle pain aggravated by relevé and relieved somewhat by plantar grade stance. The differential diagnosis includes Achilles, peroneal and flexor hallucis tendinitis. However, for these conditions, the symptoms are rarely aggravated by plantarflexion. You can reproduce the pain of posterior impingement via forced plantarflexion. When it comes to treatment, you should emphasize a flexibility program, with attention to stretching, and an antiinflammatory medication. If symptoms become disabling, surgical excision of the bony mass is indicated. Top Treatment Tips For Tendinitis Although tendinitis can be an acute condition, the frequency of recurrence and the nature of dance tend to make chronic tendinitis a common occurrence in dancers. You will frequently see Achilles tendon problems that are associated with muscle weakness of the feet, lower leg and thigh musculature. Tight-fitting pointe shoes or shoe ribbons that cut into the tendon may also cause Achilles tendon problems. When the gastrocnemius and soleus muscles are tight, dancers have difficulty with plié and often have poor weight distribution, resulting in faulty technique. Treatment includes contrast baths and NSAID medication. During the initial acute phase, employing a small heel lift in street shoes can be effective. However, the cornerstone of rehabilitation and prevention of re-injury is a structured stretching program the dancer or patient performs in conjunction with eccentric and concentric progressive resistant exercises. Flexor hallucis longus (FHL) tendinitis may manifest as posterior medial ankle pain, arch pain or great toe discomfort. The dancer typically experiences posteromedial ankle pain with a “clicking” or locking sensation of the great toe when he or she points the foot or when going from the fully pointed position to a more dorsiflexed position. Sometimes, an audible pop occurs with this maneuver. During the physical examination, you will note tenderness over the posteromedial aspect of the ankle in the zone between the retomalleolar region and the sustentaculum. Passive motion of the great toe and ankle may induce symptoms of tendinitis when palpating along the FHL. Be advised, however, that this does not often induce the popping unless the patient actively contracts the FHL tendon with the foot pointed and the toes plantarflexed. Distinguishing between a posterior impingement and the FHL tendinitis is challenging because the two structures are in close proximity and these conditions may co-exist (see “Detecting Posterior Pain Syndromes Of The Ankle In Dancers” above). When conservative treatment is indicated for these patients, emphasize relative rest and avoidance of the offending positions. A course of NSAIDs and physical therapy with phonophoresis or iontophoresis is warranted. For resistant cases, you may employ a boot brace or a steroid injection. On some occasions, FHL tendinitis may be recurrent and disabling. In these cases, operative tenolysis may be indicated, but one should only consider this option after at least a year of conservative therapy in the young dancer or six months in a professional. Dr. Caselli (pictured) is Vice President of the greater New York Regional Chapter of the American College of Sports Medicine and is a professor in the Dept. of Orthopedic Sciences at the New York College of Podiatric Medicine.
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