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.