Treating A Dancer With Posterior ‘Impingement’ Pain

Lisa M. Schoene, DPM, ATC

This author details the treatment of a dancer who had a combination of right plantar heel pain and posterior heel pain deep in the right Achilles tendon.

A professional dancer presented with pain in the right plantar heel that she had for two weeks and right posterior heel pain deep in the Achilles tendon area that she had experienced for approximately four weeks.

   The plantar and posterior heel areas were both sore and achy in nature, and aggravated by increased activities and dancing in the morning and after prolonged sitting. The Achilles had been sore for a longer timeframe and at times the ankle felt “jammed” and “stiff with full relevé and plié positions.” The patient denied any ecchymosis, warmth or neurological type pain or symptoms. There was no swelling plantarly but slight fullness in the posterior heel area along the anterior border of the Achilles tendon.

   The patient was dancing everyday, typically in ballet slippers or barefoot, which aggravates both areas of pain. There was some previous and current lateral leg muscular soreness along both muscle bellies. She noted she had some relief of these issues with massages and strengthening exercises. A physical therapist had treated the patient at the dance studio with ultrasound, massage and various taping methods.

   The physical exam revealed pain with palpation at the medial plantar heel with no swelling, color or warmth. She had minimal pain with palpation along the distal course of the plantar fascia and along the abductor hallucis muscle belly. She had pain with palpation of the anterior border of the Achilles tendon, mainly distal to the watershed area. The patient also had pain with deep palpation along the superior lateral corner of the calcaneus and into the retrocalcaneal bursa area. She had minimal pain at the insertion of the Achilles. There was slight soreness along both peroneal muscle bellies but no pain along either tendon or at the peroneal tubercle. Muscle testing for extrinsic and intrinsic foot muscles revealed no crepitus, pain or weakness (eccentric or concentric), with an emphasis on flexor hallucis longus testing in three positions.

   X-rays revealed a slight irregularity to the superior corner of the calcaneus and os trigonum syndrome.

   The patient’s initial treatment was a corticosteroid injection into plantar heel. In order to address both pain locations, we employed a combination of strapping with a dancer’s pad, the use of heel cups with heeled shoes, stretching, ice, physical therapy modalities and massage to the lateral and medial extrinsic foot musculature. In regard to dance modification, we had the patient limit jumping and had her wear jazz shoes or dance gym shoes with padding/heel cups and/or tape.

How The Patient Had Progressed At The Follow-Up Visit

Due to the patient's work travel and performance schedule, the first follow-up was at 12 weeks. The patient had full plantar heel pain resolution due to exceptional adherence. The posterior heel/Achilles area was still painful to palpation with persistent minimal swelling in the retrocalcaneal bursa area. She felt much better in heeled shoes and any flat shoes or barefoot dancing were painful as the posterior heel pain was re-aggravated, even with various persistent treatments. In addition to repeating the aforementioned treatments, I gave the patient a Traumeel injection (Heel, Inc.) into the posterior heel/bursa/Achilles area.

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