Treating A Dancer With Posterior ‘Impingement’ Pain

Lisa M. Schoene, DPM, ATC

   The use of diagnostic ultrasound revealed the following findings.
* A mild increase in caliber to the Achilles tendon, watershed area and distally posterior to the calcaneus
* A small focal deficit (4 mm x 4 mm x 2 mm) to the anterior fibers of the Achilles at the posterior superior corner of the calcaneus
* A prominent posterior superior border of the calcaneus with some impingement of the anterior fibers of the Achilles with dynamic evaluation.
* Hypertrophy of the retrocalcaneal bursa with increased fluid
* A slight extension of the peroneus brevis muscle belly distal to the inferior aspect of the lateral malleolus with significantly hypertrophy

   I discussed the findings of the Achilles tendon injury and bursa with the patient. We agreed to treat her conservatively with a series of prolotherapy type injections utilizing Traumeel. We started bimonthly injections in combination with deep tissue work, ultrasound, heat, heeled shoes and modified dancing with some form of heel padding. In addition to performing continued strengthening exercises, the patient also ensured proper warm up and cool down periods. Although this dancer has a “posterior” condition, she felt best with some slight heel height in her street shoes but excessive relevé and plié positions were uncomfortable.

What You Should Know About Treating Posterior ‘Impingement’ Ankle Pain

Posterior “impingement” ankle pain is common in dancers. The continual relevé and en pointe positions will continually stress the tissues behind the ankle due to the constant pinching in the region. When it comes to the diagnosis of ankle "impingement," there are many differentials to consider and rule out. These differential diagnoses include:

* Os trigonum syndrome
* Flexor hallucis longus tendonitis or interstitial tear
* Posterior capsule injury to ankle or posterior subtalar joint
* Achilles injury or tear
* Retrocalaneal bursitis
* Peroneal retinaculum injury
* Osteochrondral injury

   Conservative care is common when treating dancers so the practitioner must be creative and have many tools in the toolbox. Due to the fact that the calcaneus has been slightly irregular for probably some time with this patient, it was not appropriate to do any surgery on this professional dancer. I focused on repairing the Achilles tendon and reducing inflammation of the bursa via conservative needling or “prolotherapy” treatments.

Can Prolotherapy And Traumeel Have An Impact?

Prolotherapy has been present in the osteopathic literature for quite some time. It is a series of injections that one introduces into damaged tissues to stimulate the inflammatory cascade to induce reorganization of the disorganized collagen type III into proper type I collagen, creating the best linear mechanical strength for the tendon. The typical prolotherapy solution is a Dextrose solution. One can perform needling injections with other medications or solutions as well.

   Traumeel is listed in the Physicians Desk Reference and is a Food and Drug Administration (FDA) approved homeopathic medication. I have been utilizing this medication for approximately 20 years with great success for many foot and ankle conditions. Traumeel can induce the growth factors (TGF-beta) necessary for the regeneration of tissue.

   The typical technique is a bimonthly injection into the damaged tissues. One would complement this with other modalities and treatments as I discussed above. The bimonthly injection of Traumeel creates stability while still allowing mobility of the tendon, which is paramount to proper regeneration. These injections encourage the continual recruitment of fibroblasts to allow the tissues to go through more controlled inflammatory, proliferative and remodeling stages. Although these patients should ideally emphasize relative rest for the duration of the treatment protocol, this would be difficult for a professional dancer. This regimen affords the best outcomes with little to no downtime for the dancer's schedule with only minor compromises and alterations.

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