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CHAPTER 28 Foot and Ankle Injuries in Dancers William G. Hamilton • Phillip A. Bauman TOES Entrapment of the Lateral Plantar Nerve to Corns, Calluses, Blisters the Hallux Fractures and Dislocations Lesser Metatarsophalangeal Joints Chronically Unstable Fifth Proximal Freiberg’s Disease Interphalangeal Joint Acute Dislocation of the Lesser Mallet Toes Metatarsophalangeal Joints Proud Fourth Toe Metatarsophalangeal Instability Subungual Hematomas Idiopathic Synovitis Subungual Exostoses THE METATARSALS Painful Fifth Toenails Pseudotumor of the First Web Space INTERPHALANGEAL JOINT OF THE Metatarsal Stress Fractures HALLUX Base of the Second Metatarsal Subhallux Sesamoid Third and Fourth Metatarsals Dorsal Impingement in the Interphalangeal Fifth Metatarsal Hallucal Joint Fracture of the Proximal Tubercle of the METATARSOPHALANGEAL JOINT OF Fifth Metatarsal THE HALLUX BUNIONETTES Bunions MIDTARSAL AREA Lateral Instability of the First Painful Accessory Navicular Metatarsophalangeal Joint Stress Fracture of the Navicular Hallux Rigidus Lisfranc’s Sprain Grade I Plantar Flexion Sprain of the First Grade II Tarsometatarsal Joint Grade III Degeneration in the Tarsometatarsal Joints Sesamoid Injuries Sprains at the Base of the Fourth and Fifth Differential Diagnosis of Sesamoid Pain Metatarsals Removal of a Sesamoid THE MEDIAL ANKLE Sesamoid Bursitis Posterior Tibial Tendinitis Sesamoid Instability Posterior Tibial Tendon Dislocation Neural Entrapment around the Sesamoids Medial Sprains of the Ankle Joplin’s Neuroma Soleus Syndrome 1603 1604 PART VII Sports Medicine THE ANTERIOR ANKLE Accessory Soleus Muscle, the Pseudotumor Impingement Syndromes of the Calf Tendinitis HEEL PAIN THE LATERAL ANKLE Heel Spur Syndrome Classiﬁcation of Ankle Sprains Plantar Fasciitis Treatment Rupture of the Plantar Fascia Conservative Treatment Calcaneal Stress or Hairline Fracture Surgical Treatment Plantar Calcaneal Bursitis Sprained Ankle That Won’t Heal Entrapment of Baxter’s Nerve POSTERIOR ANKLE Bone Cysts and Tumors Posterior Impingement Syndrome LEG PAIN Treatment Stress Fractures of the Distal Isthmus of the Tendinitis of the Flexor Hallucis Longus Fibula Tendon Shin Splints Treatment Stress Fractures of the Tibia ACHILLES TENDON HIP PAIN Achilles Tendinitis ACKNOWLEDGMENT Achilles Tendon Rupture Treatment Dance, whether ballet, modern, Broadway, jazz, tap, skin needs to be tough in order to dance en pointe in folk, or ethnic, places unique stresses on the body. toe shoes. Indeed, this toughness of skin and bone is Dancers can have a variety of anatomic deﬁcits and necessary for its normal function, and blisters and weight problems, although dancers with severe deﬁcits metatarsal stress fractures occur when the necessary and problems rarely reach the professional level.10-12,19 toughness is not present. Of all the various dance forms, ballet places the Normally, a dancer’s foot is also quite strong and is most stringent requirements on its dancers. Female intrinsic plus. Intrinsic minus feet are characterized by dancers hover at the same weight criterion used by the splaying of the metatarsals and clawing of the toes,18 American Psychiatric Association to diagnose anorexia whereas the opposite, the intrinsic plus foot, has nar- nervosa (i.e., less than 15% below ideal weight for rowing of the metatarsals and straightening of the toes. height). Other dance techniques require women to The dancer’s foot may be unsightly because of callus weigh approximately 6% below their ideal weight, formation, but an intrinsic minus claw toe in a dancer whereas male dancers and those who pursue ethnic is very rare. dance can perform at a normal weight. For female In addition to strength, the dancer’s foot and ankle dancers, unrealistic weight requirements can lead to need to have an extreme range of motion.16,18,20 Most extreme dieting (and eating disorders) because dancers have 10 to 5 degrees of recurvatum at the knee, dancing alone is not aerobic. Over time, amenorrhea and for the ankle to be in a vertical position en pointe, can develop, contributing to a 4% loss of bone mass there should be 90 to 100 degrees of combined plantar annually over the following 3 to 4 years until bone loss ﬂexion in the foot–ankle complex. If the ankle and slows. Amenorrhea and weight problems must be con- metatarsals are vertical, the dancer also needs 90 to 100 sidered when addressing stress fractures in dancers.64 degrees of dorsiﬂexion in the ﬁrst metatarsophalangeal It is important for physicians who treat dancers to be (MTP) joint to relevé onto demi-pointe (Fig. 28–1). aware of the occupational stresses in the profession.8,10 Few people are born with this much motion, and to Dancers’ feet are the equivalent of musicians’ hands: get it, most female dancers begin training early, around they earn their living with them, and they are their age 8 years, so that the immature skeleton can be instruments. A dancer’s foot is a unique structure, the molded as it grows.19,21,23 result of years of endless training, classes, and barre Five foot types are found in dancers: Grecian, Egypt- exercises. It tends to be slightly cavus (at least the ian, simian, peasant’s, and model’s.63 dancer wishes it were, even if it is not) with a rounded The Grecian, or Morton’s, foot with foreshortening of arch. It has thickened metatarsals to support body the ﬁrst and ﬁfth rays is the most common. Difﬁcul- weight for dancing on the ball of the foot (demi- ties are sometimes encountered in the relatively long pointe), and calluses on appropriate areas where the second, third, and fourth rays, but problems found in CHAPTER 28 Foot and Ankle Injuries in Dancers 1605 Corns, Calluses, Blisters Corns and calluses are necessary for ballet dancers and allow them to bear weight on their toes in the toe shoe. When corns become hypertrophied, they might need to be trimmed, preferably with a pumice stone, but most dancers know all about these things because they deal with them every day. Ballet dancers usually use lamb’s wool or paper towels in their toe shoes to redis- tribute the forces within the toe box, and they become experts at it. If the toe box is made too tough, however, it takes away their proprioception and “feel of the ﬂoor,” and the professional cannot perform in it Figure 28–1 The 90 degrees of dorsiﬂexion needed in the because dancers cannot watch their feet when they dancer’s ﬁrst metatarsophalangeal joint. dance. Minor complications such as bleeding or infec- tion beneath the corn can occur. If an infection occurs, it may be best to drain or unroof the corn and pre- scribe antibiotics if necessary and Epsom salts soaks (1 heaping teaspoon of Epsom salts per quart of warm the general population, such as transfer metatarsalgia water twice daily for 20 to 30 minutes). Repeated infec- and loosening of the second MTP joint ligaments with tions may be a sign of undiagnosed early diabetes or instability, are surprisingly rare in dancers. other medical problems such as immune disorders, The Egyptian foot with its long hallux is the opposite and dancers with repeated infections should undergo of the Grecian foot and is predisposed to difﬁculties a thorough medical evaluation. (There was such a case with the ﬁrst MTP joint: degenerative joint disease, in the New York City Ballet.) osteophyte formation, hallux rigidus, and hallux Soft corns in the fourth web space are common in valgus. This is likely due to the increased lever arm of dancers with shortened ﬁfth metatarsals. Ideally, the the long hallux acting on the MTP joint through an proximal interphalangeal (PIP) joint of the ﬁfth toe extreme range of motion. should lie in the concavity of the diaphysis of the adja- The simian foot with metatarsus primus varus is the cent phalanx of the fourth toe. When the ﬁfth ray is bunion-prone foot. As the ﬁrst metatarsal migrates foreshortened, the ﬁfth PIP joint comes to rest against into varus, it becomes hypermobile and does not bear the lateral head of the fourth metatarsal and a soft corn weight well, leading to transfer metatarsalgia and forms. These can usually be managed (nonsurgically) pronation. Bunion surgery, however, should be by trimming the corn and placing lamb’s wool or a avoided in a professional dancer because it does not foam rubber spacer between the fourth and ﬁfth toes leave the dancer with the necessary 90 degrees of dor- to hold them apart. Dancers might need to be siﬂexion in the ﬁrst MTP joint. instructed in management and hygiene because these The peasant’s foot is a broad square foot with uniform soft corns can develop into local infections that can metatarsal length. It provides stability and an equal create a deep sinus tract into the fourth web space. distribution of forces among the metatarsals. Though When surgery for intractable soft corns is necessary, it is wide, it is the ideal foot for the dancer and athlete. there are several choices. In Europe, surgeons excise the The model’s foot is often seen in redheads. It is narrow skin and “web” the fourth and ﬁfth toes together. (This and pleasing to look at but has an exaggerated taper is not popular in North America.) Usually, it is neces- in metatarsal length from the ﬁrst to the ﬁfth rays. sary excise the medial condyle, or all of the distal Unfortunately, it bears weight unevenly on demi- portion of the proximal ﬁfth phalanx, or the lateral pointe and tends to be hypersensitive. It is a poor foot portion of the fourth metatarsal head, or both. (See for a dancer. the section on soft corn surgery in Chapter 7.) An x- ray taken with a radiopaque marker on the soft corn helps determine which resections are necessary. Often TOES there is a painful corn with a small osteophyte beneath it on the lateral condyle of the PIP joint of the ﬁfth Dancers have a remarkable ability to tolerate pain in toe. In this situation the distal portion of the proximal the feet and toes. They often develop elaborate systems phalanx should be removed with both the medial and to control discomfort so that they can continue lateral condyles. Care should be taken when making dancing. incisions on the ﬁfth toe because postoperative numb- 1606 PART VII Sports Medicine ness, incisional neuromas, or hypertrophic scars can need to be substantially modiﬁed to ﬁt into a charac- develop and lead to signiﬁcant problems when the ter shoe. foot is in a toe shoe or tightly ﬁtting character shoe. Blisters are part of the everyday life of the dancer. Calluses, like corns, are essential because they They are a necessary part of the toughening process for toughen the dancer’s feet. The dancer usually develops the skin before corns and calluses form that allow areas on the ball of the foot that resemble intractable weight bearing on the toes. Most dancers know how plantar keratoses. Usually, they are not true keratoses to manage them. For example, they might unroof a because they are not painful; they are simply areas of blister and use benzocaine (Benzodent) as a local concentrated weight bearing. Occasionally they need anesthetic so that they can continue dancing with less to be trimmed, but most dancers know how to do this. pain. The cold red laser used by some dance physical Painful callosities may be a sign of another problem, therapists can heal blisters remarkably fast. Occasion- usually a plantar wart or an invaginated callus (seed ally, a blister can form under a corn. This blister can corn). A plantar wart usually is not found on a weight- contain blood and might need to be drained or bearing surface of the sole of the foot, and black unroofed. The blister can contain blood and might spicules and capillary bleeding are encountered when need to be drained or unroofed, as previously the wart is pared down. Treatment consists of remov- described. These blisters may also be accompanied by ing the excess callus with a pumice stone and apply- local cellulitis requiring oral antibiotics and Epsom ing one of the salicylic acid products such as salts soaks (1 heaping teaspoon of Epsom salts per “Wart-Off.” Surgical excision is rarely, if ever, indicated quart of warm water twice daily for 20 to 30 minutes). because the condition is self-limited. Warts almost always resolve with symptomatic treatment, and exci- sion risks a painful scar on the plantar aspect of the Fractures and Dislocations foot, a condition far worse than a wart. Dancers wear any of four kinds of shoes when per- When a seed corn is present, trimming reveals a forming: toe shoes, ballet slippers, character shoes, or white nidus. It sometimes penetrates deeply into the jazz shoes. callus. This nidus must be entirely removed, even if Toe shoes are worn by female ballet dancers when multiple trimming sessions are required. Dramatic dancing on full pointe (tips of the toes). The toe shoe relief of pain usually follows removal. Care should be contains a hardened cardboard toebox in which the taken not to cause bleeding, and sterility of the instru- toes are rosebudded. The forces are dissipated both ments used in these trimming procedures is essential axially and circumferentially within this box. Toe to prevent possible contamination or spread of infec- shoes date from the early 19th century and separate tious diseases. ballet from all other forms of dance. Modern dancers need very thick calluses to dance Ballet slippers are soft, glovelike shoes with a small barefoot. Calluses occasionally become hypertrophic sole worn by male dancers and by female dancers and need to be trimmed. Hygiene is difﬁcult when a when they are dancing on demi-pointe (ball of the person dances barefoot all day in a dirty studio. foot) only. Toe shoes and ballet slippers are made on Modern dancers occasionally develop massive calluses a straight last. There is no right “or” left shoe. The shoe under the entire ball of the foot, and this callus can is held onto the foot by ribbons and elastics, which the tear at its margins, leaving little crevices that contain dancer sews onto the shoe according to individual breaks in the skin. These raw creases can become preference. infected, and can lead to a local cellulitis that can be Character shoes are special shoes or boots worn for a managed with proper hygiene, soaks, oral and local speciﬁc role in a ballet and in many other types of antibiotics. On occasion, a local cellulitis that is dance such as jazz, modern, Spanish, and musical ignored can become a major infection requiring hos- theater. Character shoes may be ﬂat or may have a heel. pitalization, appropriate intravenous antibiotics, and Jazz shoes are soft, laced shoes with a sole and small open drainage via marginal incisions off the weight- heel. Some newer versions have a split sole consisting bearing surface of the foot. (A thorough medical eval- of two separate parts for the forefoot and for the hind- uation should also be performed.) foot. These are often used by jazz and Broadway Orthoses are often prescribed for dancers. Certainly dancers. Older ballet dancers often wear jazz shoes orthoses can be worn in street shoes and sometimes in when teaching class. their rehearsal shoes, but they cannot be worn in many Most of these shoes protect the toes to some degree. types of dance including ballet and modern. Orthoses It is nearly impossible to fracture a toe while wearing may be helpful for some Broadway or musical theater a toe shoe. In the ballet slipper that male dancers wear, dancers, if the shoes and the choreography permit, but the toes are less protected, so toe injuries can occur an orthosis may also affect proprioception and may when the dancer wears this shoe or when dancers are CHAPTER 28 Foot and Ankle Injuries in Dancers 1607 what is wrong with the toe, only that it hurts or dislo- cates. Standard x-ray ﬁlms are normal. It is easy to diag- nose on physical examination. A valgus force causes the toe to dislocate, and the patient usually says, “That’s what happens when it hurts” (Fig. 28–3). If surgery is necessary, a PIP resection and insertion of a Kirschner wire corrects the problem nicely by remov- ing the fulcrum on which the distal phalanx dislocates and allowing the joint to scar down, restoring stabil- ity. The Kirschner wire may then be removed in the ofﬁce in 2 to 3 weeks and the toes taped together for another several weeks. Mallet Toes Mallet toes usually do not need treatment. If surgery is needed, a DIP resection with an intramedullary toe Figure 28–2 An acute dislocation of the second proximal wire corrects the problem. It usually is not necessary interphalangeal joint (arrow). to tenotomize the long ﬂexor tendon. (See the section on mallet toes in Chapter 7.) barefoot. PIP dislocations can occur when dancers in Proud Fourth Toe ballet slippers exit the stage and accidentally kick one of the lead weights used to hold down the scenery In some dancers the fourth toe is too long in relation (Fig. 28–2). These dislocations may be complex to the adjacent third and ﬁfth toes. The toe reacts by (i.e., the plantar plate is subluxed into the joint, pre- curling under the third toe, by forming a mallet toe, or venting closed reduction). Open release of the col- by forming a hammer toe (see the section on hammer lateral ligaments under a digital block usually allows toes in Chapter 7.) If surgery is necessary, the toe an easy reduction. An intramedullary Kirschner wire should be shortened at the site of the deformity, so may be inserted across the PIP joint (but not across that the tip of the resected fourth toe lines up with the the MTP joint) for 2 to 3 weeks and then removed in base of the nail of the adjacent third toe. The patient the ofﬁce. Phalangeal fractures and dislocations are should be warned that the toe will be “fat” for at least more common in modern dancers, who dance bare- 3 to 4 months after the operation. foot and unprotected, than in other dancers who wear shoes. Subungual Hematomas Toe fractures in dancers are common but usually occur, like many injuries, at home in the middle of the Subungual hematomas are seen usually in the ﬁrst or night when the dancer is barefoot. These fractures second toenails. In the acute phase, especially with usually occur in the diaphysis of the phalanx and rarely involve the joint. They can be treated by buddy taping the broken toe to the adjacent toe for 3 to 4 weeks. Open reduction of an acute phalangeal fracture is rarely indicated. If they cause trouble later, a PIP or distal interphalangeal (DIP) resection can be per- formed as a salvage procedure with a high degree of success. Chronically Unstable Fifth Proximal Interphalangeal Joint The chronically unstable ﬁfth PIP joint can be a problem. It usually follows an untreated lateral dislo- cation of the ﬁfth PIP joint with complete rupture of the medial collateral ligament. Often, it is difﬁcult to Figure 28–3 Recurrent dislocation of the ﬁfth proximal inter- recognize because the patient does not know exactly phalangeal joint (arrow). 1608 PART VII Sports Medicine uncomfortable and may warrant permanent removal of the nails. For this situation, the Thompson– Terwilliger operation is the preferred treatment (see Chapter 14). In this procedure, the nail, nail bed, and terminal portion of the distal phalanx are removed, allowing a Syme primary closure of the wound. The dancer should be warned that she will need at least 2 months to recover, will need perhaps 3 months to get into a pair of toe shoes, and will not be entirely free of pain for 6 to 9 months. Care should be taken when performing this simple operation because incisional neuromas or incomplete removal of the nail bed can cause problems later. INTERPHALANGEAL JOINT OF THE HALLUX As in the ﬁrst MTP joint, a remarkable variation in anatomy can be found in the interphalangeal (IP) joint of the hallux. Increased dorsiﬂexion at the IP joint often compensates for lack of motion in the MTP joint, especially if the ﬁrst ray is foreshortened (the Grecian foot). One female dancer presented with a congenital ankylosis of both ﬁrst MTP joints and no Figure 28–4 Subungual hematoma. Note the drainage hole. dorsiﬂexion in these joints at all. She also had fore- shortened ﬁrst metatarsals but was able to dance without difﬁculty because she developed 90 degrees of dorsiﬂexion in the IP joints of both great toes. large hematomas, symptoms may warrant drilling a hole in the nail to relieve pressure and pain (Fig. 28–4). Later, it is best to tell the dancer to keep the old toenail on as long as possible to protect the sensitive new nail and the nailbed beneath it. As the new nail grows out, the old nail will loosen, and it may be nec- essary to temporarily tape the old nail over the new nail when dancing. Subungual Exostoses Subungual exostoses are uncommon and at times may be large. In dancers, the cause may be related to pres- sure from the toe shoe irritating the periosteum of the distal phalanx, giving rise to this tumor like growth (Fig. 28–5). They do not appear to be any more common in dancers than in nondancers. Removal is usually curative. (See the section on subungual exos- toses in Chapter 14.) Painful Fifth Toenails Some female dancers have ﬁfth toes that are rotated outward so that in the toe shoe they bear weight Figure 28–5 Subungual exostosis growing out through the directly on the ﬁfth toenails. This condition can be very skin. CHAPTER 28 Foot and Ankle Injuries in Dancers 1609 Subhallux Sesamoid Anything (such as bunion surgery) that takes away that motion adversely affects the dancer’s career. Hobby A subhallux sesamoid can occasionally be found dancers or dance teachers may be able to function after under the IP joint of the hallux. This sesamoid is on bunion surgery if the bunions are moderate and if the the plantar aspect of the joint and causes a fullness or surgery is performed carefully. Obviously, they should thickening that is palpable on the plantar surface. This be warned in advance that they will lose motion in the sesamoid is not in the insertion of the ﬂexor hallucis joint and will in all likelihood have to sickle (invert) longus (FHL) tendon; it is like all sesamoids of the foot when they relevé. Unfortunately, we have seen several and located in the plantar plate, deep to the FHL. The young dancers who claim that their budding careers in prominence caused by the sesamoid is best left alone. dancing were ended by well-meaning bunion sur- If symptoms warrant, a small pad can be worn beneath geons. Even severe bunions can usually be managed the proximal phalanx to ﬂex the IP joint slightly. This conservatively with toe spacers (Fig. 28–6), wide usually alleviates the discomfort and callus that forms shoes, and horseshoe pads to relieve the pressure over under the joint. the medial eminence. All bunion surgery in serious dancers should be deferred until their professional Dorsal Impingement in the careers are over. Interphalangeal Hallucal joint If the ﬁrst MTP joint motion is poor, either from an Lateral Instability of the First early hallux rigidus or from congenital stiffness, the IP Metatarsophalangeal Joint joint will be forced into dorsiﬂexion to compensate for Several cases of acute traumatic rupture of the medial the lack of motion in the other joint. Osteophytes, ligament of the ﬁrst MTP joint have been seen. These degenerative joint disease, injuries to the insertion of ruptures were unrecognized at the time of the injury, the extensor hallucis longus (EHL) tendon, and even and all caused difﬁculties later as the hallux drifted some mild dorsal and lateral instability can occur sec- into valgus. Based on personal experience, when this ondary to these forces. On several occasions a dorsal injury occurs, it is best to open the medial ligament cleanout, similar to that of the ﬁrst MTP joint, for complex and repair the torn ligaments (analogous to dorsal osteophyte formation or loose ossicles has been turf toes and third-degree ankle sprains). Late repair successful. The surgeon should keep in mind, however, using local tissues has been successful in three that this is a forgiving joint and decisions regarding surgery must be based on the patient’s symptoms and disability and not on the x-ray. One of us (WGH) has seen some very shoddy IP joints that were barely symptomatic. METATARSOPHALANGEAL JOINT OF THE HALLUX Bunions There is a general belief that dancing causes bunions. This is not true. Bunions are no more common in dancers than in any other group of female patients, a fact conﬁrmed in a Swedish study.4 Dancers, like every- one else, are born with bunion-proof or bunion-prone feet that are familial. If a bunion-prone foot is placed in a toe shoe, it will form a bunion, but it is the foot type (simian) that causes the bunion, and not the dancing or the toe shoe that causes the bunion. The bunion-proof foot forms calluses over the bunion area without any hallux valgus, but like other calluses, they are a necessary part of dancing. The dancer needs 90 to 100 degrees of dorsiﬂexion in the ﬁrst MTP joint for proper dance technique.20 Figure 28–6 Spacers in the ﬁrst web space. 1610 PART VII Sports Medicine patients. Two were associated with recurrent lateral dislocation of the sesamoid mechanism into the ﬁrst 3. The head of the metatarsal is exposed and web space. (See the discussion of sesamoid injuries, inspected. Usually damage to the articular later.) cartilage is on the dorsal or dorsolateral portion of the head, but it can involve other areas of the joint including the sesamoid Hallux Rigidus articulation. Hallux rigidus can be a major disability in the dancer. 4. Initially, the dorsal osteophytes are removed As previously noted, loss of the 90 degrees of dorsi- to restore the original anatomy. Then the ﬂexion normally present in this joint prevents a proper dorsal one fourth to one third of the relevé onto demi-pointe and forces the dancer to roll metatarsal head is removed with an onto the lateral rays of the foot (sickling). Hallux osteotome or thin oscillating saw. Ideally, rigidus is a spectrum occurring in three types or grades: most of the degenerated articular surface is I, II, and III (mild, moderate, and severe). removed when the dorsal surface of the metatarsal head is excised. At least 90 to 100 Grade I degrees of dorsiﬂexion of the MTP joint rel- In grade I hallux rigidus, the joint is essentially normal ative to the metatarsal shaft should be but osteophytes on the dorsum of the joint limit dor- obtained in the operating room. There is siﬂexion. This is the simplest type of hallux rigidus to often a tendency not to remove enough of treat, because a generous removal of the spurs restores the metatarsal head. The surgeon can expect motion and relieves pain. Still, the recovery can be that the dancer will ultimately achieve about slow and the dancer should be warned that it could 50% of the motion measured at the time of take 3 to 4 months to return to dance. Early range of the surgery after excision, so every effort motion and physical therapy is necessary for a good should be made to achieve as much motion result. This type of hallux rigidus is uncommon. as possible. 5. If insufﬁcient motion is present intraopera- Grade II tively, a dorsal closing wedge osteotomy of In grade II hallux rigidus, there is both osteophyte for- the proximal phalanx (the Moberg proce- mation and some degree of degeneration within the dure) can be added to increase dorsiﬂexion joint, usually the dorsal part of the metatarsal head. (see Chapter 16). This osteotomy can only be Some early narrowing of the cartilage space is seen on done if the ﬁrst MTP joint has adequate the x-ray ﬁlm. This type is amenable to a generous plantar ﬂexion preoperatively; otherwise the cheilectomy,36 but the dancer should be warned of the toe will not reach the ﬂoor after the surgery following: and the dancer will not be able to point the hallux. • The result will not be perfect, only better. Postoperative Care • Even though the procedure is relatively simple, it often takes a long time (at least 3 to 6 months) to The patient is encouraged to place weight on recover. the limb as soon as possible after surgery, and • The underlying degeneration can progress to early active and passive motion is begun as soon osteoarthritis in spite of the surgery, and further as the wound is healed. Aggressive rehabilita- surgery may be needed later if this occurs. tion may be necessary to obtain motion before scar tissue sets in. Occasionally, early manipula- tion with anesthesia or even lysis of adhesions CHEILECTOMY FOR HALLUX RIGIDUS is needed to obtain full motion. Surgical Technique Results 1. This procedure may be performed under Mann36 reported good results in 90% of his ankle block. Either a midline dorsal or a mid- cheilectomies. One of us (WGH) had results that medial incision can be made. were not as good until the Moberg procedure 2. The deep tissues are mobilized, and care is was added to the cheilectomy in grade II cases. taken to avoid damage to the adjacent The added dorsiﬂexion is gained at the expense digital nerves and the ﬂexor and extensor of plantar ﬂexion, and the dancer should be tendons. forewarned. CHAPTER 28 Foot and Ankle Injuries in Dancers 1611 Grade III Sesamoid Injuries In grade III hallux rigidus, the dorsal osteophytes are In view of the forces placed on the sesamoids by the secondary to obvious degenerative joint disease. This dancer, it is a wonder that there are not more sesamoid presents a dilemma for the surgeon and the dancer. problems in dancers. Over the 35 years that one of us There is no good answer for this problem. Fortunately, (WGH) has been treating professional dancers, he has grade III hallux rigidus is usually seen in older dancers developed great respect for the sesamoids’ ability to and athletes in the twilight of their careers. The results heal. On many occasions in older dancers, the with cheilectomy are not reliable, although a radical sesamoids appeared as if they had been smashed with cheilectomy with a Moberg procedure sometimes a hammer. During questioning, the dancers invariably results in some improvement in MTP motion. Joint stated that they had experienced pain in the area for a replacement will not hold up, arthroplasty destroys the year or more, but it eventually went away. Most of the windlass mechanism, leaving the toe weak, and ﬁrst time, they had been unaware of the nature of the MTP fusion eliminates all joint motion, which is problem and just continued dancing with the pain. incompatible with dancing. The sesamoids eventually healed by asymptomatic If the ﬁrst and second metatarsals are relatively the ﬁbrous union. same length and the patient needs to preserve MTP A careful physical examination and an accurate diag- motion, then a capsular arthroplasty25 can be tried as nosis are essential because pain around the plantar a last resort, but the limitations and poor prognosis aspect of the ﬁrst MTP joint does not always come should be carefully considered, especially in the from the sesamoids. female ballet dancer. The patient needs to be warned that this might not work and that if it does, it might Differential Diagnosis of Sesamoid Pain not hold up over time. If it fails, an MTP fusion can be The differential diagnosis includes: done as salvage, but this is incompatible with a career in dance. • Stress or hairline fracture (a technetium bone scan Capsular arthroplasty is similar to a resection arthro- will be positive) plasty, but the thick dorsal capsule of the joint is • Sprain or avulsion fracture, usually of the proxi- placed between the metatarsal head and the resected mal or distal pole base of the proximal phalanx and sutured to the • Sprain of a bipartite sesamoid in which x-ray ﬁlms stumps of the ﬂexor brevi, distal to the sesamoids. The show widening of the space between the two surgeon must be careful not to remove too much of fragments the proximal phalanx (25% to 30% at the most). If the • Sprain of the distal pole, an injury that usually EHL tendon is tight, it should be lengthened to prevent accompanies a strong acute dorsiﬂexion force, the hallux from riding upward. A tenotomy of the similar to turf toe in football extensor hallucis brevis (EHB) tendon is performed proximal to its insertion in the capsule so that the • Osteonecrosis (avascular necrosis [AVN]) that is whole dorsal sleeve of the MTP joint, including EHB not yet apparent on the x-ray ﬁlms (The symp- insertion, can be pulled down into the gap between toms can precede the changes on the x-ray ﬁlm by the bones. as long as 6 months. A bone scan and magnetic Mixed results have been obtained with this pro- resonance imaging [MRI] are indicated when the cedure in dancers. If the ﬁrst ray is foreshortened, diagnosis is not clear.) this operation will not work because the patient • Degenerative joint disease in the sesamoid–ﬁrst will develop a transfer lesion beneath the second metatarsal articulation metatarsal head. Of course, the windlass mechanism • Chronic bursitis beneath the sesamoids is destroyed, and weakness in plantar ﬂexing the great • Neural entrapment around the sesamoids toe will be present, but it might make the best of a bad situation. This procedure is only indicated to save a Removal of a Sesamoid dance career when all else has failed. Silastic or metal implants have been abandoned in Persistently painful sesamoids in a dancer can be athletes by almost all reputable foot surgeons because removed surgically if the operation is done carefully. the long-term results have been so poor. They simply Our preferred technique for removal of either cannot hold up under the demands of active dancers sesamoid is to perform the operation from inside the and athletes. capsule of the MTP joint, shelling out the bone from within the joint. A medial capsule incision is used for excising the medial sesamoid. A dorsal incision in the ﬁrst web space is used for the lateral sesamoid. The 1612 PART VII Sports Medicine insertion of the conjoined tendon of the abductor Neural Entrapment around hallucis into the base of the proximal phalanx is left the Sesamoids intact to prevent a hallux varus deformity later. This technique has been uniformly successful in more than Joplin’s Neuroma 15 professional dancers, who all returned to their Joplin’s neuroma is caused by entrapment of the careers. medial plantar nerve to the hallux adjacent to the medial sesamoid. This condition produces a positive Tinel sign, whereas sesamoiditis does not. Dancers Sesamoid Bursitis who pronate are prone to this problem. Dancers with The bursa beneath the sesamoids can become swollen chronic cases might need surgical neurolysis and trans- and inﬂamed. This sesamoid bursitis is often misdiag- position of the nerve away from the adjacent sesamoid nosed as sesamoiditis. It can be recognized on physi- or resection of the nerve similar to Morton’s neuroma cal examination by palpation and swelling. The surgery. diagnosis can be conﬁrmed by injecting a local anes- thetic into the bursa. Treatment consists of a small Entrapment of the Lateral Plantar Nerve amount of corticosteroid injected into the bursa and a to the Hallux pad to unweight the area so that the inﬂammation can Entrapment of the lateral plantar nerve to the hallux subside. Unfortunately, the condition heals slowly, is difﬁcult to diagnose. It manifests as neuralgic pain and it can leave bands of ﬁbrous tissue within the radiating into the hallux from the plantar lateral side, bursa that can be painful later, especially if these bands analogous to Joplin’s neuroma on the medial side of lie directly under the sesamoid where they are rolled the joint. It is rarely possible to elicit Tinel’s sign upon when the dancer relevés. If the condition fails to because of the location of the nerve. The diagnosis heal, a bursectomy via a plantar medial incision can must be conﬁrmed by injection of a small amount of be performed, similar to excision of an olecranon local anesthetic into the area of the nerve just as it exits bursa for chronic bursitis. The plantar nerve in this from beneath the deep transverse ligament insertion area must be identiﬁed and protected. into the lateral sesamoid. The symptoms are not usually disabling enough to warrant surgery. When they are, the deep transverse ligament can be divided, Sesamoid Instability releasing the trapped nerve, similar to the median On rare occasions, rupture of the medial collateral lig- nerve release for the carpal tunnel syndrome. The nerve ament of the tibial sesamoid can lead to sesamoid lies directly beneath the ligament and is usually ﬂat- instability and recurrent dislocation. We have seen tened by the pressure. four cases of recurrent lateral dislocation of the sesamoid mechanism into the ﬁrst web space. The Lesser Metatarsophalangeal Joints complaint is that the great toe “dislocates” in relevé. When the dancer is examined barefoot, the disloca- Freiberg’s Disease tion is dramatic. A sudden clunk occurs when the Freiberg’s disease,63 though common in young sesamoids slip laterally. It is analogous to recurrent women, is no more common in dancers than in the dislocation of the patella. general population. It may be symptomatic for as long This condition requires surgery to correct the insta- as 6 months before it appears on x-ray ﬁlms. A bone bility. On these occasions a lateral sesamoid release scan or MRI study, or both, is usually positive early on. and reconstruction of the medial ligament of the tibial There are four variations of Freiberg’s infraction.63 sesamoid using local tissues has been successful. One In type I, the head of the metatarsal dies and then must keep in mind the anatomy of the medial liga- heals by creeping substitution. It heals completely, ment structures so that the reconstruction can be per- with little or no collapse, leaving the articular surface formed at the isometric center of motion, with a intact and almost as good as it was before the event. pull-through stitch through the ﬁrst metatarsal head In type II, the dorsal portion of the metatarsal head anchoring the reconstructed ligament down to raw collapses during revascularization, but the articular bone, maintaining the all-important MTP joint surface remains intact. Osteophytes form along the motion. On all occasions the operation has success- dorsal margin of the joint, limiting dorsiﬂexion. This fully prevented recurrent dislocation and preserved type is amenable to a dorsal cleanout, which should motion of the MTP joint. Rehabilitation should leave the joint intact and restore dorsiﬂexion. The include early motion to the MTP joint and a toe spacer surgeon should remember to remove more bone than to protect the repair. is considered necessary. CHAPTER 28 Foot and Ankle Injuries in Dancers 1613 after surgery, so if a pin is placed across the joint at the time of surgery, it should be removed earlier than usual (no later than 2 weeks) to allow early motion. (Despite early pin removal, joint motion will occasionally be limited and may require a manipulation in the ofﬁce using a local anesthetic block.) An alternative to a DuVries arthroplasty is a capsu- lar arthroplasty.62 If this is done, the surgeon should be careful not to remove more than one fourth of the proximal phalanx. This arthroplasty should be per- formed with a partial syndactyly to the adjacent toe and excision of the plantar condyles of the metatarsal head. Partial syndactyly and a plantar condylectomy are usually necessary to prevent laxity in the joint and Figure 28–7 Freiberg’s disease in multiple heads (arrows). metatarsalgia. Metatarsophalangeal Instability Metatarsalgia is not common in the young healthy In type III, the head collapses and the articular population of dancers. When it is encountered, the cli- surface loosens and falls into the joint, destroying the nician should suspect either early Freiberg’s disease or dorsal articular portion of the joint. Characteristically, MTP instability. This subtle problem often goes unrec- the plantar articular surface is spared. Simply remov- ognized because the x-ray ﬁlms appear normal. The ing the osteophytes does not sufﬁce, so a capsular dancer presents with isolated metatarsalgia. There is arthroplasty is required.62,63 All necrotic bone must be plantar tenderness under the metatarsal head. Dorsal excised from the metatarsal head, and all the dorsal tenderness and pain occur as the patient relevés osteophytes must be removed. Usually the plantar because the phalanx subluxes dorsally on top of the portion of the head is spared from the disease and is head. The dorsally subluxing phalanx pushes the head maintained after debridement. Again, the surgeon of the metatarsal downward, producing metatarsalgia. should excise a generous amount of bone so that the This condition is easily recognized on physical dancer has full dorsiﬂexion later. If necessary, the base examination. The base of the proximal phalanx is of the phalanx can be removed, but in this case the grasped in the ﬁngers, and dorsal–plantar stress is second toe must be partially syndactylized to the adja- applied. The instability is easily recognized when the cent third toe. phalanx subluxes or dislocates dorsally on the In type IV, multiple heads are involved in the process metatarsal head (Fig. 28–8), resulting in a positive (Fig. 28–7). This type is very rare. Each metatarsal head must be evaluated and treated individually. Acute Dislocation of the Lesser Metatarsophalangeal Joints In ballet, acute dislocation of the lesser MTP joints is more common in the male than the female patient because the male dancer’s feet are less protected by the shoes he wears when dancing. Sometimes, this condi- tion often goes unrecognized, perhaps because of the swelling that accompanies the injury in the metatarsal region. The dislocation must be reduced and stabilized so that it can heal. If the joint has been dislocated for a long time (a month or more), it might not be possible to reduce it and maintain stability and vascularity in the toe. In this case, it is usually necessary to perform a DuVries arthroplasty to allow a decompressive reduction without stretching of the neurovascular bundles. If this Figure 28–8 Unstable fourth metatarsophalangeal joint is done, the dancer will need excessive dorsiﬂexion (arrow). 1614 PART VII Sports Medicine Idiopathic Synovitis Idiopathic synovitis64 is characterized by MTP swelling, or sausage toe. Its cause is controversial; it is usually not associated with systemic inﬂammatory diseases such as Reiter’s syndrome, but of course, these condi- tions need to be ruled out. The joint is usually lax and the MTP unstable. It is not known whether the laxity irritates the joint and leads to chronic synovitis, or vice versa, but we feel that this condition is most likely caused by laxity, which then leads to joint damage. In several cases, eventual surgical exploration of the joint revealed chondral fractures and joint damage. Conser- vative therapy should include reduced activities and anti-inﬂammatories. If symptoms persist, one or two (at most) intraarticular injections of steroids may be helpful. In recalcitrant situations, exploration and appropriate surgical treatment are indicated (see pre- vious section). Figure 28–9 Taping to stabilize an unstable second metatar- sophalangeal joint. THE METATARSALS Hamilton–Thompson sign (or Lachman test of the Pseudotumor of the First Web Space MTP joint).62 A slowly enlarging mass in the ﬁrst web space of the Conservative treatment consists of padding the area foot that cannot be aspirated or drained (i.e., is not a around the metatarsal head to unweight the painful ganglion) is usually muscle ﬁbers of the EHB. In these metatarsal head. Taping, or wearing a toe retainer, can cases, the muscle ﬁbers extend down the tendon, help to control the instability (Fig. 28–9). It often is a almost to the MTP joint, and can resemble a tumor. frustrating situation for dancers because they do not No treatment is necessary. want surgery, but once the ligaments and plantar plate are stretched, the condition becomes chronic and can only be corrected by surgery. Metatarsal Stress Fractures The surgical options for this problem in a dancer are An x-ray ﬁlm of a dancer’s foot shows a characteristic tricky. The usual operations, such as the Girdle- thickening of the lateral cortex of the ﬁrst metatarsal stone–Taylor, often result in a joint that is either too and the shafts of the second and third metatarsals (Fig. loose or too tight—an unacceptable solution. Better 28–10). This hypertrophy is an example of Wolff’s law: results have been obtained through a plantar condylec- Bone responds to the stresses placed upon it. In addi- tomy—removal of the plantar condyles of the tion, ballet dancers are selected for a mildly cavus foot, metatarsal head. The resection works in two ways: It which is rigid and absorbs energy poorly. Normally, by relieves the metatarsalgia by redistributing pressure on starting dancing early, there is time for the metatarsals the plantar surface of the metatarsal head, and it to hypertrophy as body weight increases so that the allows healing and scarring of the plantar plate, which loads placed on the foot as an adult do not fracture helps stabilize the MTP joint. Resection arthroplasty the bones. Metatarsal stress fractures do occur, espe- and partial webbing to the adjacent toe is another cially at the base of the second metatarsal in dancers.45 alternative. The surgeon should remove the plantar Predisposing factors include a rigid cavus foot, condyles of the metatarsal head, use a toe wire, remove common to dancers; a long second metatarsal (the the wire early (2 weeks). The surgeon should not Grecian or Morton’s foot); beginning dancing late and remove too much of the proximal phalanx (one fourth trying to catch up with their peers before they have to one third at most). Recently, we have had limited developed the necessary cortical hypertrophy in their successes treating MTP instability by injecting scleros- metatarsals (Wolff’s law); amenorrhea (the female ing agents into the lax ligaments (prolotherapy). This athlete’s triad10-12,64); and hard ﬂoors (good dance sur- treatment has also been successful in treating other faces should be sprung to absorb shock). types of orthopaedic conditions such as low back Eating disorders such as anorexia nervosa and pain.57 bulimia can occur in dancers, just as in other female CHAPTER 28 Foot and Ankle Injuries in Dancers 1615 arch. The middle cuneiform is the keystone in this arch and is recessed to accept the base of the second metatarsal, adding rigidity to the second ray. The ﬁxed proximal end of the second metatarsal creates a stress riser at the proximal metaphysis, and it is at this loca- tion that the metatarsal tends to fracture. These factors result in a characteristic stress fracture that dancers suffer at the base of the second metatarsal.45 Pain and tenderness at the base of the ﬁrst web space or on the proximal portion of the second metatarsal in a dancer is a stress fracture until proven otherwise. This is by far the most common location of a stress fracture in the dancer’s foot (Fig. 28–11). Whether or not it is seen on the x-ray ﬁlm depends on how long it has been present. A bone scan conﬁrms the diagnosis if neces- sary; however, the physical ﬁndings are so characteris- tic that often a bone scan can be avoided. The march fracture of the diaphysis of the second metatarsal com- monly seen in athletes and army recruits is rare in dancers. Figure 28–10 Metatarsal thickening. Note the fracture of the On occasion, the fracture occurs at the very base of tibial sesamoid. this bone, or by impingement of the base of the ﬁrst metatarsal against the second. These fractures can enter athletes. Secondary amenorrhea (the absence of at the cuneiform–metatarsal joint. This fracture usually least three menstrual cycles), along with extreme heals by bony or asymptomatic ﬁbrous union. weight loss and an intense fear of becoming over- weight,10-12 is one of the cardinal signs of anorexia nervosa. Younger dancers may also develop primary amenorrhea and delayed menarche (no onset of menses). The orthopedist should be aware that it is normal for dancers to exhibit delayed menarche (average age, 14 years) from intense exercise and low weight. However, adolescents who develop eating problems might forgo menstruation entirely. One 21- year-old anorexic ballet dancer with primary amenor- rhea presented to us with hip pain. Her work-up revealed severe loss of bone mass and Perthe’s disease of the hip with open femoral epiphyses. Typically, amenorrheic dancers are more likely to develop stress fractures. In a sample of 75 professional ballet dancers, 45% developed stress fractures, and the incidence rose with increasing menarcheal age.64 Sec- ondary amenorrhea in this group was also twice as high and of longer duration than in dancers without stress fractures. Amenorrheic dancers should be referred to an endocrinologist for a thorough evalua- tion and appropriate treatment. Dancers with eating problems also require psychological counseling as well as nutritional interventions. Some 46% of professional ballet dancers have disordered eating.8,12 Base of the Second Metatarsal The medial, middle, and lateral cuneiforms are wedge Figure 28–11 Stress fracture at the base of the second shaped and ﬁt together like the stones of a Roman metatarsal, the typical location. 1616 PART VII Sports Medicine motion in the lateral tarsometatarsal joints than at the second metatarsal articulation. Pain and tenderness in these bones can be caused by an osteoid osteoma or occasionally by a stress reaction (an early reaction of the bone to forces that can lead eventually to a stress fracture if unchecked). Hallux rigidus, sesamoid pain, or other painful conditions of the ﬁrst ray can cause the dancer to roll onto the lateral rays of the foot and lead to pain or stress reactions in these metatarsals when moving on to demi-pointe. The treatment for stress reactions is similar to the treatment for stress fractures, but stress reactions usually heal and symp- toms resolve in a shorter period of time. Fifth Metatarsal The ﬁfth metatarsal fractures in four different places. Three of the four are innocuous. One is very serious: the Jones fracture. A spiral fracture of the distal shaft of the ﬁfth metatarsal is a common acute fracture in the dancer. It is called the dancer’s fracture (Fig. 28–13).20,46 It Figure 28–12 Minimally symptomatic nonunion in a world- class male dancer (arrow). An extreme example of the professional dancer’s ability to work through physical problems is seen in Figure 28–12. This male dancer had an unrecognized and untreated (stress) fracture of his second metatarsal when in ballet school. He is now a world-class ballet dancer who only has occasional mild discomfort in his foot, despite the nonunion. If the fracture is acute, immobilization in a remov- able walking boot for 4 to 6 weeks with the use of a bone stimulator is the best treatment. (This allows the dancer to remove the boot for sleeping and swimming so that he or she can maintain conditioning.) The healing time is 4 to 6 weeks, or if the dancer has been ignoring the pain and dancing with it, 6 to 8 weeks. Healing is usually judged by the disappearance of pain and tenderness rather than by the x-ray. Third and Fourth Metatarsals Injuries and stress fractures in the third and fourth Figure 28–13 “Dancer’s fracture” of the ﬁfth metatarsal metatarsals are uncommon, because there is greater (arrow). CHAPTER 28 Foot and Ankle Injuries in Dancers 1617 usually happens when they lose their balance while outset. Most nonunions we have seen were initially dancing on demi-pointe and roll over on the outer treated in weight-bearing casts, or else the serious border of the foot. Although there may be separation nature of the injury was not initially recognized and of the fragments, this fracture usually heals without the fracture was mistaken for the more benign fractures surgery. Nonunion of this common fracture is that occur at either end of this bone. Primary extremely rare. Treatment in a walking cast or remov- intramedullary ﬁxation with a large intramedullary able boot sufﬁces. noncannulated screw is preferred in serious ballet On the other hand, the Jones fracture is dangerous students and in professional dancers. We use the if not recognized. It can occur in an acute or chronic cannulated screw set to make the drill hole but form, or an acute fracture can occur through a stress an uncannulated screw for ﬁxation. In established fracture. Fortunately, it is an uncommon fracture in all nonunions, the fracture should be internally ﬁxed and dancers but is more common in Broadway and bone grafted. (See Chapter 27.) modern dancers who dance plantigrade than in ballet dancers who dance mostly on demi-pointe. It occurs Fracture of the Proximal Tubercle in a portion of the bone that has a diminished blood of the Fifth Metatarsal supply, so it often heals poorly and has a propensity to go to nonunion (Fig. 28–14). This fracture should Fracture of the proximal tubercle of the ﬁfth be treated in a non–weight-bearing, short-leg cast until it metatarsal, a common, benign fracture, is a planti- heals, and this can be 6 to 12 weeks, or longer. grade injury, so it usually happens on the way to the We have never had one of these fractures go to theater, rather than when the dancer is performing. It nonunion when it is treated in this manner from the is occasionally associated with inversion sprains of the ankle. It is really an avulsion fracture of the insertion of the peroneus brevis and a lateral slip of the plantar fascia. It is usually safe to treat this injury in a loose shoe or removable boot. A great deal of displacement can be accepted. Surgery rarely needs to be performed because ﬁbrous unions at this location are usually free of pain, even in high-level dancers. It is very important to recognize the difference between this fracture and the Jones fracture of the proximal diaphysis (see earlier discussion).20 BUNIONETTES Bunionettes frequently accompany bunions. They can be removed if they are symptomatic, however, the dancer should be warned that it may take an extraor- dinarily long time for the tenderness and swelling to subside after these procedures. For this reason, this surgery in professionals is usually postponed until retirement. MIDTARSAL AREA Painful Accessory Navicular Fortunately, the painful accessory navicular is uncom- mon in young dancers. It can become symptomatic following a contusion or sprain. We have seen one case of a fracture of an accessory navicular and one case of a partial avulsion personally. When the symptoms warrant, excision of the bone and reattachment of the posterior tibial tendon to a raw bony surface with a Figure 28–14 Jones fracture of the ﬁfth metatarsal (arrow). suture anchor are indicated. Cast immobilization is 1618 PART VII Sports Medicine very important. The recovery period is often much Lisfranc’s Sprain longer than expected. Occasionally, contusions of the medial prominence Lisfranc’s sprains are rare in dancers; however, it is of the tarsal navicular cause persistent pain. Contu- extremely important not to miss them. In these sions can occur when one foot is brought forward past patients, sprains are usually caused by a pure valgus the other and, as it passes the navicular, strikes the injury with disruption of the medial ligaments of the medial malleolus of the other ankle. These sympto- ﬁrst and second cuneiform–metatarsal joints (rather matic contusions usually heal with treatment, includ- than by splitting apart the ﬁrst web space with separa- ing padding and restricted activities. Rarely a fracture tion of the ﬁrst and second metatarsals as is so often of the medial tubercle or injury to the synchondrosis seen in trauma). This injury can be very subtle in between the accessory and true navicular can occur. If dancers, so a high index of suspicion is necessary. A the symptoms warrant, these conditions should be careful physical examination, x-ray ﬁlms (including treated in a short-leg walking cast or ankle–foot ortho- both a standing anteroposterior (AP) weight-bearing sis for 4 to 6 weeks to prevent the injury from becom- ﬁlm of both feet and a valgus forefoot stress ﬁlm, ing chronic. If surgery is necessary and the fragment under anesthetic if necessary), and bone and com- is large, it can be fused to the navicular with screw puted tomographic scans are advisable. ﬁxation. Lisfranc’s injury in dancers, as in anyone else, demands an anatomic reduction, usually by open means, with rigid internal ﬁxation and prolonged Stress Fracture of the Navicular non–weight-bearing immobilization (12 to 16 weeks). Even though dancers are continuously running and This is a bad injury to miss because the late deformi- jumping, stress fractures of the tarsal navicular are rare ties and weakness in the forefoot can be quite dis- despite a higher incidence of cavus feet in these abling and difﬁcult to treat (see section on Lisfranc’s patients. It should be suspected when chronic midfoot injuries in Chapter 41). pain and tenderness are present. The most reliable way to diagnose this condition is to obtain a bone scan, because x-rays (including the navicular view in 15 to Plantar Flexion Sprain of the First 20 degrees of supination) usually do not show the frac- Tarsometatarsal Joint ture in the early stages. If the scan is positive, then a This injury occurs when the dancer falls “over the top” computed tomographic (CT) scan or MRI, or both, while on pointe. It is a variation of a Lisfranc’s sprain. should be performed. A plantar ﬂexion stress ﬁlm shows opening of the joint The fracture can be acute or chronic. It can be compared to the uninjured side. If this injury is diag- medial, midline, or lateral and usually begins as a nosed at the time of the injury, immobilization in a partial fracture at the dorsum of the bone. If unrecog- short-leg weight-bearing cast for 6 to 8 weeks usually nized, it can progress to nonunion and even separa- restores stability (Fig. 28–15). tion of the fragments, so it is important not to miss it. It usually occurs in line with the base of the ﬁrst web space, but in a cavovarus foot, the navicular can lie medial on the talar head and the fracture can occur through the junction of the medial two thirds and lateral one third of the bone. Treatment options include non–weight bearing in a short-leg cast and a bone stimulator until the bone is healed, and this can be a long time—8 to 12 weeks or more. This is an option for the acute fracture, but not for the chronic fracture or nonunion. They require internal ﬁxation with a screw (or screws, if the navic- ular is large) or with a bone graft for a nonunion. If the fracture is medial or midline, the screw can be placed from the medial side, but if the fracture is in the lateral portion of the bone, the screw should be placed from the lateral side. We prefer the cannulated screw set to place the drill holes, but we perform ﬁxa- tion with uncannulated screws and prefer to internally Figure 28–15 Plantar-ﬂexion sprain of the ﬁrst tar- ﬁx virtually all of these fractures. sometatarsal joint. Note opening in the left image. CHAPTER 28 Foot and Ankle Injuries in Dancers 1619 Degeneration in the Tarsometatarsal with the New York City Ballet we had seen very few of Joints these injuries until recently, and all healed unevent- fully. Then within one year, we had three cases that did Older female ballet dancers routinely develop degen- not heal with rest and immobilization. Work-up eration of the ﬁrst and second tarsometatarsal joints. included MRI scans that revealed tendinosis. At explo- The appearance of these joints on the x-ray ﬁlm can be ration all three required surgical debridement and quite dramatic. It is amazing how few symptoms repair of the tendon. Postoperative management has dancers have from this problem. Decisions regarding included non–weight-bearing immobilization fol- debridement or tarsometatarsal fusions must be care- lowed by a gradual increase in physical activity and fully made on the basis of the clinical disability rather supervised therapy. The dancer must be warned about than the x-ray appearance. the prolonged recovery and guarded outcome. Although the early results have been promising, it is Sprains at the Base of the Fourth premature to report outcomes. and Fifth Metatarsals At the base of the fourth and ﬁfth metatarsals, the Posterior Tibial Tendon Dislocation plantar tarsometatarsal ligaments are thick, and the Posterior tibial tendon dislocation, a rare injury, can dorsal tarsometatarsal capsules are thin. If the dancer occur in dancers. One of us (WGH) has seen three falls over the dorsolateral foot into plantar ﬂexion, the cases. All involved female dancers. This injury is equiv- tarsometatarsal joints that are normally subjected only alent to acute peroneal tendon dislocation, and the to a dorsal force are forced into extreme plantar principles are the same: open reduction and anatomic ﬂexion. This often tears the dorsal capsules on the repair of the retinaculum with deepening of the groove dorsum of the fourth and ﬁfth tarsometatarsal joints. if it is shallow. The recovery is prolonged (6 months Occasionally the torn capsules are trapped in the to 1 year).32 sprained joints, producing symptoms. On two occa- sions, one of us (WGH) has had to explore these joints for intractable pain. At surgery the invaginated tissue Medial Sprains of the Ankle was removed from the joint, and the symptoms were Medial sprains of the ankle are very rare in dancers relieved. because the medial structures are strong and rigid com- pared to the lateral ones. Persistent symptoms on the medial side may be caused by a localized posterome- THE MEDIAL ANKLE dial ﬁbrous tarsal coalition. Medial sprains of the ankle do occur, usually from landing off balance with sudden pronation. The sprain usually affects the Posterior Tibial Tendinitis portion of the ligament under tension when the force Posterior tibial tendinitis, commonly seen in athletes, was applied: the anterior deltoid if the foot was in is rare in dancers. This is an example of altered kine- equinus, the middle (deep) deltoid if the foot was siology producing changes in the normal patterns of plantigrade, and the posterior portion if the foot was injury. Instead, ballet dancers, who work primarily in in dorsiﬂexion (very rare). the equinus position, develop stresses (and tendinitis) Isolated sprain of the anterior portion of the deltoid on the FHL tendon, (the Achilles tendon of the foot) ligament can leave a painful trigger point in this area, as it passes through its pulley behind the medial malle- resembling chronic infrapatellar tendinitis (jumper’s olus. In an equinus position, the posterior tibial knee). It can be a nagging injury. If a corticosteroid tendon is relatively shortened, and the subtalar joint injection does not cure the problem, the area can be is in inversion. In addition, dancers often have cavus curetted or drilled, or both. feet, and these seem less prone to posterior tibial ten- If a signiﬁcant injury to the deltoid ligament is dinitis. Indeed, more often than not, a dancer with a found, the clinician must always look for damage to diagnosis of posterior tibial tendinitis will be found on the lateral structures as well, especially the syndesmo- careful examination to have FHL tendinitis (dancer’s sis and proximal ﬁbula. An accessory bone, the os sub- tendinitis) instead.13,14,17,20-22 tibiale, may be present in the deep layer of the deltoid When it does occur, posterior tibial tendinitis (see section on accessory bones of the foot in Chapter should be managed the same way as in athletes. The 10), and this bone can be involved in the sprain, injury usually heals if treated properly, namely, rest becoming symptomatic when it had not been before. until it quiets down and then a slow return to activi- An x-ray study should be performed to rule out bone, ties with physical therapy. In 35 years of experience syndesmosis, or epiphyseal injury. As previously 1620 PART VII Sports Medicine noted, a trigger point can form in the deltoid, usually Soleus Syndrome around a chip fracture or accessory ossicle. This problem can require a corticosteroid injection if it Another cause of medial pain just above the medial does not respond to conservative therapy. Nodules can malleolus is the soleus syndrome.40 This manifests as form on the ﬂexor digitorum longus (FDL) or poste- chronic pain resembling a shin splint but is too far rior tibial tendon after medial strains, but these usually distal on the posteromedial tibial metaphysis to be a are not symptomatic. true shin splint. It is caused by an abnormal slip in the Attenuation of the deltoid is very rare in this group. origin of the soleus muscle (usually 3 to 6 cm) above If it is suspected, an AP standing x-ray or eversion stress the medial malleolus. Normally, the tibial origin of the ﬁlms (or both) of both ankles should be taken. soleus ends at the junction of the middle and distal In the differential diagnosis of medial ankle pain, thirds of the tibia. In this syndrome, the origin the clinician must also keep in mind the possibility of continues down the tibia to just above the medial osteochondritis dissecans of the talus. This condition malleolus. This condition, similar to exertional usually occurs in the posterior portion of the medial compartment syndrome, is more common in athletes talar dome and the anterior portion of the lateral who engage in sustained muscle activity than in dome. It can cause vague pains that are hard to local- dancers, whose efforts are usually intermittent. It ize, and symptoms can be present before the lesion usually responds to conservative therapy and injec- appears on regular x-ray ﬁlms. If it is suspected, a bone tions. On rare occasions, subcutaneous release of the scan, CT scan, or MRI may be indicated. tight band is necessary. In ballet dancers, another common cause of pain around the medial malleolus comes from “rolling in” (pronating) to obtain proper turnout (Fig. 28–16). THE ANTERIOR ANKLE This produces a chronic strain of the deltoid ligament of the ankle and the medial structures of the knee and Impingement Syndromes patella. It is one of many overuse syndromes seen in dancers that is exacerbated by poor technique. Ballet dancers are selected for an extreme range of Additional causes of medial ankle pain include motion in their joints and for cavus feet to give them a symptomatic accessory navicular (see above). maximum plantar ﬂexion. They constantly take the Management can be difﬁcult and recovery from joints of the lower extremity beyond the limits of surgery is prolonged (see Chapter 26). Sprains of the normal motion. The cavus foot has increased plantar spring ligament, the middle portion of the plantar ﬂexion but decreased dorsiﬂexion. For this reason, fascia, or both structures can be mistaken for medial impingement syndromes of the ankle are very ankle pain; however, a careful physical examination common. Bone impingement occurs anterior medially should make the diagnosis apparent. Treatment is and posterior laterally, whereas soft tissue impinge- symptomatic. ment occurs anterior laterally and posterior medially. When motion in the ankle is limited by impingement, dancers and sometimes dance teachers often blame a “tight” Achilles tendon for the lack of dorsiﬂexion and spend hours trying to stretch the posterior structures of the calf to obtain a better plié (a deep knee bend) when in reality there is no more dorsiﬂexion possible in the talocrural joint. (It would not increase even if the Achilles tendon were severed.) This fact often must be explained to the dancer. The most common cause of anterior ankle pain in the dancer is the anterior impingement syn- drome.20,30,34,47 It is typically seen in the older male ballet dancer who has cavus feet and who has spent his career dancing “bravura” technique (big jumps and deep pliés) and in the male Broadway dancer who has spent his career as a tumbler (gymnastic dancing involving ﬂips and big jumps). Impingement of the tibia and talus, one against the other, stimulates the Figure 28–16 Rolling in (pronating) to gain additional cambium layer of the periosteum to form exostoses, turnout (arrow). like stalactites in a cave. When they form, they limit CHAPTER 28 Foot and Ankle Injuries in Dancers 1621 dorsiﬂexion, facilitating further impingement and Broadway dancers often tolerate heel lifts and orthoses resulting in more periosteal stimulation, thus setting much better than ballet dancers do because they up a repetitive cycle. As the spurs grow, they can break usually perform in character shoes. Female Broadway off and become loose bodies. dancers rarely develop this problem because so often Traction on the capsular insertion in plantar ﬂexion they are required to dance in character shoes with has been mentioned as a cause of the formation of heels as high as 3 inches. these osteophytes. However, careful inspection of the Dancers with loose ankles secondary to repeated anatomy shows that they do not form in the actual ankle sprains also tend to have impingement spurs. In capsular insertion but directly where the bones come this situation, consideration should be given to tight- together. ening the ankle ligaments at the time of the anterior Diagnosis is made on the basis of the history, phys- cleanout, preferably by the Bröstrom-Gould proce- ical examination, and x-ray ﬁlms. On physical exami- dure. nation, the following signs are usually present: If symptoms are disabling, an anterior debridement • Anterior tenderness and thickening of the syn- either through a small anterior medial incision or with ovium, often with an effusion the arthroscope may be indicated. The anterior impingement syndrome of the ankle in dancers • Palpable osteophytes usually is one of three types depending on the loca- • Limited dorsiﬂexion when compared to the oppo- tion of the exostoses: site ankle • Type I: Osteophytes primarily on the anterior lip • A positive dorsiﬂexion impingement sign (pain of the tibia (arthroscopic treatment) with forced dorsiﬂexion of the ankle when the • Type II: Osteophytes primarily on the neck of the knee is ﬂexed) talus (arthroscopic or open treatment) A standard lateral x-ray ﬁlm of the ankle usually shows • Type III: A combination of types I and II (mini- the spurs. An additional weight-bearing lateral view arthrotomy) with the ankle in maximal dorsiﬂexion (the plié view) may be helpful to demonstrate anterior impingement The ﬁrst type can be easily removed with the arthro- (Fig. 28–17) and is a useful visual aid in explaining scope. The second and third types are best treated with the problem to the dancer. a small arthrotomy behind the anterior tibial tendon. Conservative treatment should include educating The open method in these cases is faster and more the dancer about the problem so that he or she does thorough than the arthroscopic method. When ankle not hit bottom and impinge when landing from a arthroscopy became popular, many arthroscopic ante- jump or plié. Heel lifts help open up the front of the rior debridements were performed in the hope that the ankle and relieve the symptoms, but ballet dancers dancer could return to dancing earlier. However, in our often ﬁnd these difﬁcult to use when dancing. Male experience, it has taken an average of 3 months to return to full dancing with either technique. The clinician should always look for an exostosis on the medial neck of the talus impinging against the ante- rior portion of the medial malleolus. This spur, the “hidden osteophyte,” can be hard to visualize on a stan- dard radiograph but can be seen on an oblique view of the foot and often is contributing to the symptoms. Dancers undergoing these operations should be warned that although the cleanout is a relatively minor procedure with minimal risk, it could take 3 to 4 months before they can perform a complete plié and the ankle no longer swells. Several conditions, including the following, can mimic the anterior impingement syndrome: • Osteochondritis dissecans of the talus • An acute or chronic “high” ankle sprain involving the anterior tibioﬁbular ligament16,39 • Bassett’s ligament, an aberrant distal insertion of Figure 28–17 Type 1 anterior impingement of the ankle the anterior taloﬁbular (ATF) ligament that can (arrow). cause persistent symptoms (Fig. 28–18)1 1622 PART VII Sports Medicine rare in ballet dancers. Symptoms in this area are almost always caused by ankle impingement. Irritation of the extensor tendons under the anterior extensor retinaculum can occur. This is often caused by a gan- glion, an osteophyte in the region, or tightness in an elastic strap passing over the ballet dancer’s cavus fore- foot. The dancer sews this strap into the shoe to hold it on. The position of the strap on the dance shoe should be adjusted so that it does not press against the extensor retinaculum. Irritation of the EHL can occur in the region of the medial cuneiform–ﬁrst metatarsal joint. A bossing, or exostosis, is often found on the dorsum of this joint in older dancers, exactly where the EHL tendon and the deep branch of the peroneal nerve pass over it (the anterior tarsal tunnel syndrome). A tight ballet or char- acter shoe or strap in this area presses the tendon down against the underlying bone and causes pain and irri- Figure 28–18 Bassett’s ligament in the right ankle, seen from tation. It is rarely necessary to remove this exostosis the medial arthroscopic portal (arrow) surgically; instead, the dancer should simply avoid direct pressure on the tendon in the region of the exos- • Ferkel’s disease, an accumulation of debris and tosis. Recurrent or recalcitrant symptoms may be indi- synovitis in the anterolateral gutter5 cations for surgery. The surgeon should be extremely careful when operating in this area, because incisional • Degenerative joint disease of the tibiotalar or neuromas here are very common. talonavicular joints, especially in the early phases when the x-ray ﬁndings are subtle • A stress fracture or an osteoid osteoma in the tarsal navicular. (Fig. 28–19) THE LATERAL ANKLE These conditions usually give a characteristic picture and can be differentiated by the x-ray ﬁlm, MRI or The most common acute injury in dance is the inver- bone scan. sion sprain of the ankle.16,20,26,53 (By deﬁnition, liga- ments “sprain,” and tendons and muscles “strain.”) Sprains can occur in any ligament in the foot or ankle, Tendinitis but the most common ones involve the lateral liga- Anterior tibial, EHL, and extensor digitorum longus ment complex of the ankle (the anterior taloﬁbular (EDL) tendinitis, like posterior tibial tendinitis, are [ATF], calcaneoﬁbular [CF], and posterior taloﬁbular ligaments [PTF]). The posterior taloﬁbular ligament is rarely injured. Other conditions, however, can closely resemble the classic lateral ankle sprain. The exact mechanism of injury might not always be apparent, especially in dancers who were in the pointe position when the injury occurred. In this position, many possible com- binations of forces can take place. Some of these injuries even occur in a helical or corkscrew manner, placing both inversion and eversion forces on the ankle in the same injury. The physician should examine the patient carefully for the following conditions that can simulate or accompany a simple sprain: • A complete tear of the lateral collateral structures (in actuality, a medial dislocation of the talus that Figure 28–19 Osteoid osteoma in the tarsal navicular has spontaneously reduced or the ultimate grade (arrow). III sprain)39 CHAPTER 28 Foot and Ankle Injuries in Dancers 1623 • An injury to the anterior inferior tibioﬁbular lig- TA B L E 2 8 – 1 ament: the high ankle sprain (more common in Working Classiﬁcation of Acute Ankle Sprains external rotation than inversion injuries)39 • A complete tear of both the distal anterior and Anatomic Physical Exam X-ray posterior tibioﬁbular ligaments (the syndesmo- Grade Injury (Drawer Sign) (Talar Tilt Stress) sis) and the interosseous membrane without frac- I Partial tear of Negative or Negative ture of the malleoli but with diastasis of the ankle ATF or CF 1+ mortise and fracture of the proximal isthmus of II Torn ATF, 2+ 1+ the ﬁbula: the Maisonneuve fracture intact CF III Torn ATF and 3+ 3+ • A sprain of the subtalar joint with disruption of CF the interosseous talocalcaneal ligament, calcane- ATF, anterior taloﬁbular ligament; CF, calcaneoﬁbular ligament. oﬁbular ligament, and lateral talocalcaneal liga- After O’Donoghue DH. In Treatment of Injuries to Athletes, ed 4. ment Philadelphia, WB Saunders, 1984. • A fracture of the base of the ﬁfth metatarsal • An undisplaced fracture of the lateral malleolus or malleolar epiphysis in a young dancer Grade I sprains are partial tears, usually of the ATF • Fracture of the lateral process of the talus28 ligament or occasionally the anterior tibioﬁbular liga- ment with little or no resultant instability. On physi- • A fracture of the anterior process of the os calcis cal examination the drawer sign and the stress ﬁlms (Fig. 28–20)27 are normal. After the initial 48 hours of rest, ice, com- • Subluxation of the cuboid38,42 pression, and elevation (RICE), the patient should • A fracture of the posterior lip of the distal tibia or begin early active use of the limb with a compression fracture of a trigonal process behind the talus bandage, taping, or an Aircast. (Shepherd’s fracture)57 (see the section on acces- Grade II sprains are complete tears, usually of the sory bones of the foot in Chapter 10) ATF ligament, with minimal damage to the calcane- • A sprain of the tarsometatarsal (TMT) joints 3, 4, oﬁbular ligament. They produce a moderately positive 5 (lateral Lisfranc’s joints) drawer sign and a moderate talar tilt on the stress ﬁlm. They often result in some residual instability, although • Superior peroneal retinaculum disruption with this can usually be controlled by good peroneal acute subluxation or dislocation of the peroneal strength. Treatment consists of some type of support, tendons (an air cast, or removable boot) for 3 to 6 weeks fol- lowed by aggressive rehabilitation. Classiﬁcation of Ankle Sprains The Grade II sprain is the ankle sprain most com- monly seen in all dancers. It usually occurs when they Ankle sprains are usually graded I, II, or III depending are plantar ﬂexed on demi-pointe. In this position, the on the extent of injury (Table 28–1).44 ATF ligament is almost vertical, in the position nor- mally taken by the calcaneoﬁbular ligament when the foot is plantigrade, and it is easily torn when an adduc- tion–inversion force is applied. In this position, the calcaneoﬁbular ligament is almost parallel to the ﬂoor, so it is usually spared. Grade III sprains are rare. They consist of a complete rupture of both the ATF and CF ligaments. (We have never seen a tear of the posterior taloﬁbular ligament in an ordinary ankle sprain and doubt that such a thing exists). This injury results in gross instability. It is actually a spontaneously reduced medial dislocation of the talus.39 The drawer sign and stress ﬁlms are grossly positive on physical and radiographic exami- nation. The healing time is long and uncertain (3 to 4 months), and the likelihood of signiﬁcant permanent laxity of the ligaments is signiﬁcant. Dancers with Figure 28–20 Fracture of the anterior process of the os calcis residual laxity of the lateral ankle ligaments from this (arrow). injury often complain as much of rotatory instability 1624 PART VII Sports Medicine as of varus instability; that is, they develop anterolat- eral rotatory instability of the ankle analogous to lig- ament injuries of the knee. For this reason, in serious dancers we feel that grade III lateral ankle sprains should be surgically repaired within 7 to 10 days of the injury. The repair itself is a simple procedure done under regional anesthesia with a small incision over the distal ﬁbula (see the section on the modiﬁed Bröstrom-Gould procedure described later). The liga- ments are easily identiﬁed because they are within the capsule, similar to the anterior capsule of the shoul- der. They are usually avulsed from the ﬁbula rather than torn in their midsubstance, which makes them Figure 28–21 Testing peroneal strength. The dancer should easy to reattach. Postoperative immobilization in a be able to resist full manual pressure (arrow). short-leg walking cast for 4 weeks is followed by pro- tection in an Aircast and early rehabilitation. Recre- ational dancers with this injury should be treated in a the dancer on her or his side using a weight bag in full short-leg walking cast or analogous removable boot plantar ﬂexion (Fig. 28–22). Abduction exercises are for a month. If the ankle causes problems later, it can performed with the ankle supported so that it can be reconstructed at that time. move only upward and the patient can relax the ankle Stress ﬁlms of both ankles can be obtained in the between lifts. Dancers lift 3 lbs 25 times slowly ofﬁce using a local anesthetic if necessary. The drawer morning and evening, increasing the weight in the bag sign is also an indication of the extent of the injury as by 3 lbs each week to a total of 12 to 15 lbs. When well as a predictor of later dysfunction, along with the they can lift 12 to 15 lbs slowly 25 times, the ankle is inversion stress x-ray ﬁlm.6,16,20 adequately rehabilitated. This method will restore normal peroneal strength unless there is internal derangement of the ankle or peroneal tendons. Treatment Surgical Treatment Conservative Treatment Secondary or delayed ankle ligament reconstruction is Regardless of the method of treatment, adequate phys- occasionally necessary in a dancer, but it should be ical therapy and proper rehabilitation are necessary to considered only after full peroneal strength has been restore normal use after injury. Restoration of full per- obtained (see previous section) and the dancer is still oneal strength is essential. Unrecognized peroneal unable to dance. Often, as previously mentioned, the weakness is a common condition in dancers20 and can be the cause of a myriad of obscure symptoms such as unexplained swelling and discomfort and poor timing with beats. Dancers complaining of these symptoms should be checked for weak peroneals. This is done by having them place their feet in full plantar ﬂexion, a neutral position (the tendu position) and asking them to hold this position against varus stress (Fig. 28–21). Well-conditioned dancers should be able to resist almost as much force as can be manually applied to the foot. The uninjured side can be checked for com- parison if necessary. Often, dancers’ ankles have not been adequately rehabilitated, or the dancers have been exercising in a neutral position rather than in full plantar ﬂexion—the dancers’ position of function. (Cybex and other exercise machines are not very good for ankle rehabilitation because the ankle cannot be placed in full plantar ﬂexion for strengthening.) We use resistance bands and a home exercise Figure 28–22 Peroneal exercises done in full plantar ﬂexion program done over the arm of a sofa or couch, with (arrow). CHAPTER 28 Foot and Ankle Injuries in Dancers 1625 problem is rotatory instability as much as varus instability. capsule and mobilized so that it can be Reconstruction should be done only for functional pulled over the repair at the end of the pro- difﬁculties and not simply on the basis of a positive cedure (Fig. 28–23B). Care should be taken drawer sign or positive stress x-ray. Many professional when working anterior to the malleolus dancers perform quite well with loose ankles that are because the lateral branch of the superﬁcial not symptomatic enough to warrant surgical repair. peroneal nerve often lies in this area and The entire peroneus brevis tendon should not be can be damaged by dissection or a sharp used for ankle reconstruction in a professional dancer retractor. for two reasons. First, the peroneus brevis is too impor- 5. The capsule is then divided along the ante- tant as a support tendon for dancing on full pointe to rior border of the ﬁbula down to the per- be sacriﬁced. Second, it is not necessary to use it: Excel- oneal tendons, leaving a 2- to 3-mm cuff. lent results can be obtained using the Bröstrom-Gould The ATF ligament lies within this capsule, repair as described by Gould et al.6 The procedure is similar to the anterior glenohumeral liga- simply a reeﬁng of the ATF and CF ligaments with reat- ments of the shoulder. It can usually be seen tachment to their anatomic locations on the ﬁbula, as a thickening in the capsule (Fig. 28–23C). then sewing the lateral extensor retinaculum over the 6. The calcaneoﬁbular ligament must now be tip of the ﬁbula in a pants over vest manner to limit identiﬁed. It lies deep to the peroneal inversion. The patient is placed in a short-leg walking tendons, running obliquely downward and cast for 1 month and then taken out for rehabilitation posteriorly to the calcaneus. It is often and swimming; the ankle is protected in a removable stretched and attenuated, or it may be dis- airsplint for another 2 to 3 weeks. In more than 40 lodged so that it lies outside the peroneals. professional dancers, this technique has not failed to If it is in continuity, it is divided, leaving a give an excellent result with full range of motion and cuff at its insertion in the ﬁbula. By leaving normal strength. A 15-year follow-up has not revealed a cuff of tissue at the insertion of the liga- any stretching of the repaired ligaments in spite of ments, the surgeon will be able to repair the another sprain in the same ankle.26 ligaments in their anatomic locations, thus preserving isometry and an unrestricted range of motion. 7. The ligaments must now be shortened and MODIFIED BRÖSTROM-GOULD REPAIR repaired. The ankle should be placed in the Surgical Technique fully reduced position (no anterior drawer present) in neutral dorsiﬂexion and slight 1. The modiﬁed Bröstrom-Gould repair is per- eversion. The stumps of the ligaments are formed with the patient in the lateral decu- pulled up, and the redundancy is trimmed bitus position. A thigh tourniquet is placed (Fig. 28–23C). over cast padding, so general, spinal, or 8. The ligaments are then sutured to their epidural anesthesia is needed. anatomic locations with 2-0 nonabsorbable 2. A curvilinear incision is made along the sutures, starting with the calcaneoﬁbular lig- anterior border of the distal ﬁbula, and it ament because it is the most difﬁcult to stops at the peroneal tendons. The sural visualize and then proceeding to the ATF nerve is just below this area, lying directly ligament. This repair can be done by end- over the peroneal tendons (Fig. 28–23). This to-end suture, by a pants-over-vest suture, incision should be made carefully because or into drill holes or suture anchors (Fig. the sural nerve occasionally crosses over the 28–23D). At this point the ankle should be distal ﬁbula, following the lesser saphenous examined for stability and full range of vein rather than the peroneal tendons. The motion. lesser saphenous vein crossing the distal 9. The previously identiﬁed lateral extensor ﬁbula at this level will have to be divided. retinaculum is then pulled over the repair 3. The dissection is carried down to the joint and sutured to the tip of the ﬁbula with 2-0 capsule along the anterior border of the chromic catgut (Fig. 28–23E). This reinforces lateral malleolus. the repair, limits inversion (the position of 4. The lateral portion of the extensor retinac- injury), and helps correct the subtalar com- ulum is then identiﬁed. It is dissected off the ponent of the instability. (If the calcane- 1626 PART VII Sports Medicine B A C D E Figure 28–23 A, Skin incision. B, Lateral extensor retinaculum is identiﬁed and mobilized (left ankle). C, Capsular incision. The calcaneoﬁbular ligament is being trimmed. The anterior taloﬁbular (ATF) ligament is seen as a thickening in the capsule (arrow). D, Capsular repair after the ATF and calcaneoﬁbular ligaments have been shortened. E, Extensor retinaculum is sewn over the capsular repair. (From Westwood WB: Strateg Orthop Surg 9:1, 1990.) oﬁbular ligament is attenuated, there has to Postoperative Care be some degree of subtalar instability. The calcaneoﬁbular ligament is one of the sta- bilizing ligaments of the subtalar joint.)16,20 When the swelling has subsided, in 5 to 7 days, 10. The ankle is once again checked for stabil- a short-leg walking cast is applied for 3 to 4 ity and taken through a full range of motion. weeks and weight bearing as tolerated is A layered closure is then performed with an encouraged. The cast is then removed, and the absorbable subcutaneous suture and adhe- ankle is protected with an air splint. Swimming, sive closures (Steri-Strips). The patient is range of motion, and isometric peroneal exer- placed in anteroposterior plaster splints cises are begun. Unrestricted activities are and discharged with crutches, non–weight allowed at 8 to 12 weeks if full peroneal strength bearing. is present. CHAPTER 28 Foot and Ankle Injuries in Dancers 1627 Sprained Ankle That Won’t Heal • A rent in the ligament with a synovial hernia39 Miscellaneous problems after ankle sprains are • Entrapment of synovial tissue in the syndesmosis common. A trigonal process may be fractured (Shep- • A fragment from a Tillaux fracture that is too herd’s fracture) at the time of the injury and can con- small to see on the x-ray ﬁlm tinue to be symptomatic after the sprain heals.57 A • Bassett’s ligament, an accessory slip of the ante- bone scan is recommended to identify a fracture of the rior inferior tibiotalar ligament that inserts so far trigonal process. down on the ﬁbula that it causes irritation of the Dancers often develop FHL tendinitis, posterior lateral shoulder of the talus1 impingement, or both problems after an ankle sprain, • Ferkel’s phenomenon, scar tissue in the anterolat- occasionally involving an os trigonum that had previ- eral gutter, similar to Bassett’s ligament5 ously been asymptomatic.13,17 These complications are not always related to the severity of the sprain. Acute peroneal dislocation is usually obvious, but The following problems around the tip of the ﬁbula chronic peroneal subluxation in dancers can some- can persist after the sprain heals: times be difﬁcult to diagnose. This diagnosis should be kept in mind for any dancer with vague but per- • Soft tissue entrapment (the meniscoid lesion of sistent symptoms such as giving way in the peroneal Wolin and Glassman)65 area. The procedure for the repair of recurrent dislo- • An avulsion fracture of the tip of the ﬁbula cating peroneal tendons is similar to the Bröstrom- Gould procedure (i.e., taking down the retinaculum, • A previously asymptomatic accessory ossicle (the shortening it to its proper length, and reattaching it to os subﬁbulare) its anatomic location on the posterior border of the • An unrecognized fracture of the anterior process distal ﬁbula). If the peroneal groove is shallow, it of the os calcis (this fracture is an avulsion frac- might need to be deepened with a bur. Care should be ture of the extensor digitorum brevis origin) (Fig. taken not to repair the retinaculum too tightly, pro- 28–20)27 ducing a stenosis. The patient must be kept in a short- • Damage to the peroneal tendons found after leg walking cast for 6 weeks. As usual, postoperative sprains (often the peroneus brevis has longitu- rehabilitation is essential. dinal tears, and the tendon becomes enlarged and ﬂattened. This condition can usually be diagnosed with MRI or more accurately by POSTERIOR ANKLE injection of a local anesthetic into the peroneal sheath)20,52 Two things separate ballet from other forms of dance: the 180-degree turnout of the legs and female dancers • Peroneus longus tendinitis at the cuboid tunnel20 dancing on full pointe in a toe shoe. Thus the full • A fracture of an os peroneum, the POP (painful equinus position is essential for proper ballet tech- os peroneum) syndrome59 nique, especially in female dancers. There should be at • A lateral process fracture of the talus28 least 90 degrees of plantar ﬂexion in the foot–ankle • The sinus tarsi syndrome60 complex and preferably 10 to 15 degrees more than that to compensate for the recurvatum usually present • Subluxation of the cuboid38,42 in the knee above. The high ankle sprain of the distal tibioﬁbular syn- The shape of the dome of the talus can vary consid- desmosis should be recognized as a different entity erably from one person to another. Some are round than the common sprained ankle seen at the lateral like an oil drum and have excellent motion, both in malleolus. This injury represents a partial tear of the plantar ﬂexion and dorsiﬂexion. Others are congeni- anterior tibioﬁbular ligament at the distal syndesmo- tally ﬂattened and have very limited motion. It is pos- sis, usually by an external rotation force. It can take an sible that these tali can be molded and improved to extraordinarily long time to heal and may be associ- some degree by beginning training at an early age ated with an avulsion fracture at the tibial or ﬁbular while the bones are growing, but a stiff ﬂatfoot and origin of the ligament, the Tillaux fracture. Treatment ﬂat-domed talus will never achieve the desired amount of this injury should be aggressively conservative, and of motion, and this dancer is far better off choosing a the dancer should be warned at the beginning that it career in some form of dancing other than ballet. can be symptomatic for as long as 3 to 6 months. Some A considerable amount of this dorsiﬂexion and cases remain symptomatic in spite of time and con- plantar ﬂexion comes from the subtalar joint and from servative therapy. Surgical exploration of these ankles the basic turned-out position assumed by the dancer. has revealed any of the following states: This position of mild forefoot pronation and abduc- 1628 PART VII Sports Medicine tion loosens the subtalar joint and allows maximal motion. This can be seen by comparing a lateral x-ray ﬁlm in the plantigrade position with one on relevé. The subtalar space usually opens when the dancer goes on pointe (Fig. 28–24). Dancers with a tarsal coalition are usually weeded out of ballet early because this condition limits motion in the foot–ankle complex and produces a poor relevé, often before the onset of pain and dis- comfort. Lack of subtalar motion can be very subtle, because tarsal coalitions can exist in a spectrum from solid and bony to cartilaginous or ﬁbrous with only a moderate loss of motion. These subtle coalitions are sometimes located posteriorly and are caused by marked ﬁbrosis and thickening of the posterior talo- Figure 28–25 Notch in the neck of the talus that allows a calcaneal ligament complex. deep plié (arrow). Early training usually produces a notch in the neck of the talus to accept the anterior lip of the tibia and allow a deep plié (Fig. 28–25). Conversely, some pos- terior molding may be necessary, especially if an os ankle to go down as far as the “good” one. These trigonum or a trigonal process is present. In the include hooking the toes under the piano and lever- younger age group (13 to 16 years), posterior ankle ing the forefoot into equinus and sitting on the heels pain often occurs when an os trigonum is present and with the foot in full plantar ﬂexion or having a friend full plantar ﬂexion is limited, especially if the other sit on the heels. The diagnosis should be made and the ankle is normal. The symptoms in this situation are problem explained to the dancer and her family. The usually caused by the machinations that the young symptoms usually subside when she stops forcing the female dancer is going through to force the “bad” ankle. Posterior Impingement Syndrome The posterior impingement syndrome of the ankle, or talar compression syndrome (Fig. 28–26),17,20,29,49,61 is the natural result of full weight bearing in maximal plantar ﬂexion of the ankle in the demi-pointe or full pointe position, especially if an os trigonum or trigo- nal process is present. It manifests as posterior lateral pain (Table 28–2) in the back of the ankle when the posterior lip of the tibia closes against the superior border of the os calcis as in assuming the tendu, the frappé, or the relevé or in leaving the ground in a jump. It can be conﬁrmed on physical examination by localized tenderness behind the peroneal tendons in back of the lateral malleolus (it is often mistaken for peroneal tendinitis) and by pain with forced passive plantar ﬂexion of the ankle the plantar ﬂexion sign (Fig. 28–27),20 The syndrome is often but not always associated with an os trigonum or trigonal process in the back of the ankle. On occasion, it can be caused by soft tissue entrapment between the posterior lip of the talus and the os calcis.50 It also can be found in association with lateral ligament laxity. It is often mis- taken for heel pain, Achilles tendinitis, or peroneal tendinitis and is a common problem in ballet dancers. Figure 28–24 Opening of the subtalar joint in the relevé The posterior aspect of the talus has two tubercles, (arrows). the medial tubercle and the lateral tubercle. Between CHAPTER 28 Foot and Ankle Injuries in Dancers 1629 Figure 28–27 The plantar ﬂexion sign for posterior impingement. rior impingement syndrome is rare in athletes and in other types of dancers. In ballet dancers, it may be symptomatic, but the degree of the symptoms is not always related to the size of the os trigonum: large ones can be minimally symptomatic, and small ones can sometimes be disabling. Usually the symptoms are mild, and on the whole, the os trigonum is more often asymptomatic. Many famous ballerinas have asymp- tomatic ossa trigona, and they work with them on full pointe without any trouble. It is important to stress Figure 28–26 Posterior impingement on an os trigonum this fact to the patient and the parents when discussing (upper arrow). Plantar ﬂexion is limited by an os trigonum. the problem because the condition is commonly over- Compensatory motion has been obtained in the subtalar and diagnosed and surgery may be recommended unnec- midtarsal joints. essarily, perhaps because of the dramatic appearance of the bone on the x-ray ﬁlm. This condition is best seen on a lateral view of the the two tubercles lies the ﬁbro-osseous tunnel of the ankle on pointe or in full plantar ﬂexion. The diagno- FHL tendon. The os trigonum is the ununited lateral sis can be conﬁrmed if necessary by injecting 0.5 to tubercle on the posterior aspect of the talus. It is 0.75 mL of lidocaine (Xylocaine) into the soft tissues present in 7% to 10% of people and has a 50% inci- of the posterior ankle behind the peroneal tendons. If dence of bilaterality.7 Most people who have an os the pain is relieved by this small injection, the diag- trigonum are not aware of its presence, and the poste- nosis is almost certain. If the patient is not free of pain, another diagnosis should be considered (Table 28–2 and Table 28–3). The differential diagnosis includes TA B L E 2 8 – 2 the following: Posterior Ankle Pain Syndromes in Dancers • Posterior process (Shepherd’s) fracture: hairline or stress Posteromedial Posterolateral • FHL tendinitis (dancer’s tendinitis) FHL tendinitis Posterior impingement • Pathologic condition of the peroneal tendon52 (os trigonum syndrome) Soleus syndrome Posterior process fracture • Posteromedial localized talocalcaneal coalition (Shepherd’s fracture) • Osteoid osteoma Posterior tibial tendinitis Peroneal tendinitis Posteromedial ﬁbrous tarsal Pseudomeniscus syndrome Treatment coalition Treatment should follow an orderly sequence. The ﬁrst FHL, ﬂexor hallucis longus. approach, similar to treating tendinitis, is modiﬁcation 1630 PART VII Sports Medicine TA B L E 2 8 – 3 and removal of the adjacent os trigonum can then be performed safely. Flexor Hallucis Longus Tendinitis versus Other causes of posterior impingement include a Posterior Impingement of the Ankle previously asymptomatic os trigonum that becomes FHL Tendinitis Posterior Impingement persistently symptomatic after an ankle sprain as a result of disruption of its ligamentous connections and Posteromedial location Posterolateral location Tenderness over the FHL Tenderness behind the ﬁbula a subtle shift in position. A posterior pseudomeniscus tendon or plica in the posterior ankle with or without an os Pain or triggering with Pain with plantar ﬂexion of trigonum can also cause posterior impingement.22,50 It motion of the hallux the ankle can cause the posterior impingement syndrome in the Thomasen’s sign61 Plantar ﬂexion sign absence of an os trigonum or loose ligaments. Bucket- Condition mistaken for Condition mistaken for posterior tibial tendinitis peroneal tendinitis handle tears have been seen in this structure, causing locking and other mechanical symptoms more often FHL, ﬂexor hallucis longus. seen in the knee than the ankle. CONSERVATIVE TREATMENT of activities (“do not do what hurts”), nonsteroidal Acute fracture of an undisplaced posterior process of anti-inﬂammatory drugs (NSAIDs) if the dancer is the talus should be treated with a short-leg walking 15 years or older, and physical therapy. (Posterior cast. In the chronic condition (an old fracture or impingement is rarely seen in dancers younger than 14 nonunion), physical therapy modalities (cortisone years because female ballet students usually do not phonophoresis), low-heeled shoes, and modiﬁed start on pointe until they are 11 or 12). As previously activities should be used. If the pain is relieved by a noted, if an os trigonum is present, patients must be small injection of lidocaine, the injection of 0.15 mL instructed not to force the foot into equinus to achieve of cortisone can give dramatic relief. further plantar ﬂexion. Patients should be told that it will take a few weeks for the pain to subside, usually SURGICAL TREATMENT about the same amount of time as they have been Surgery is indicated when conservative therapy has dancing with the condition before treatment began. failed and after the diagnosis has been conﬁrmed with For example, if they danced with the pain for a month, lidocaine. A posterior cleanout can be done from then it often takes a month of treatment and reduced either the medial or lateral side of the posterior ankle. activities before they can resume normal activities The lateral approach should be used if the dancer has without discomfort. an isolated posterior impingement syndrome without In cases where this approach has failed or if the a history of FHL tendinitis or medial difﬁculties. A symptoms recur and the patient is 16 years or older, medial incision is indicated if there is a combined an injection of a mixture of long- and short-acting cor- problem of FHL tendinitis and posterior impingement ticosteroids can often give dramatic and permanent or if the problem is primarily FHL tendinitis with an relief of symptoms. Before the steroid preparation is incidental os trigonum that needs to be removed along injected, the diagnosis should be conﬁrmed with lido- with a FHL tenolysis. The medial incision is safer and caine. If lidocaine does not relieve the symptoms, there more utilitarian because the lateral side can be worked is no point in injecting the steroids. It should be on safely from the medial side, but it is dangerous to stressed that the os trigonum is not usually a surgical work medially from the lateral side because the neu- problem; most dancers with ossa trigona do not need rovascular bundle cannot be isolated and protected to have them removed surgically. from a lateral approach.22 Occasionally, this condition does cause enough dis- ability to warrant surgical excision, but, as with most elective surgery, it is indicated only after conservative EXCISION OF THE OS TRIGONUM USING therapy has failed in a serious dancer at least 16 years THE LATERAL APPROACH22 old. An isolated os trigonum with no medial symp- toms can be approached posterolaterally via an inci- Surgical Technique sion between the Achilles and the peroneals (taking care to protect the sural nerve). Frequently, there is a 1. Under anesthesia, the patient is placed in the combined problem of FHL tendinitis and the os lateral decubitus or prone position with a trigonum syndrome. In these patients, the posterome- pneumatic tourniquet on the leg or thigh dial approach is used so that the neurovascular bundle over the cast padding. (Because dancers can be isolated and protected. Tenolysis of the FHL CHAPTER 28 Foot and Ankle Injuries in Dancers 1631 have increased external rotation of the hip, 7. A layered closure is then performed with it is extremely difﬁcult to excise the os catgut sutures. The wound is closed with a trigonum with the patient in the supine running subcutaneous absorbable suture, position.) and the ankle is placed in a posterior plaster 2. A curvilinear incision is made at the level of splint for 3 to 7 days. the posterior ankle mortise. There is a ten- Postoperative Care dency to make this incision a little too distal and posterior. Exposure is easier if the Weight bearing with crutches is begun as toler- approach is slightly proximal and just behind ated when the posterior splint is removed. The the peroneal sheath. The sural nerve is iden- dancer is encouraged to swim and progress to tiﬁed and protected in the subcutaneous barre exercises after the wound is healed. The tissues. average return to full dancing is 2 to 3 months. 3. The dissection is carried down in the interval between the peroneal tendons laterally and the FHL tendon medially. 4. A posterior capsular incision is then made with the ankle in neutral ﬂexion or slight dor- Tendinitis of the Flexor Hallucis siﬂexion. The os trigonum or trigonal process (Stieda’s process) can be found on the supe- Longus Tendon rior surface of the os calcis just on the lateral Tendinitis of the FHL tendon behind the medial malle- side of the FHL tendon. It has attachments olus of the ankle is so common it is known as dancer’s on all its sides: superior (the posterior tendinitis.13,14,17,20,22,48 It is often misdiagnosed as pos- capsule of the talocrural joint), inferior (the terior tibial or Achilles tendinitis, but careful exami- posterior talocalcaneal ligament, at times nation usually reveals the true diagnosis. The FHL is quite thick and ﬁbrous), medial (the FHL the “Achilles tendon of the foot” for the dancer. It tunnel with its sheath), and lateral (the origin passes through a ﬁbro-osseous tunnel from the poste- of the posterior taloﬁbular ligament). rior aspect of the talus to the level of the sustentacu- 5. The bone is removed by circumferential dis- lum tali, like a rope through a pulley. As it passes section. The surgeon should be careful not to through this pulley, it can be strained. When strained, stray too far medially because the posterior rather than moving smoothly in the pulley, it begins tibial nerve rests directly on the FHL tendon. to bind. This binding causes irritation and swelling, The proximal entrance to this FHL tunnel can which in turn causes further binding, irritation, and be opened if there are muscle ﬁbers attached swelling, setting up the familiar cycle: because it is distally to the tendon that crowd into the swollen and irritated, it binds, and because it binds, it tunnel entrance when the hallux is brought becomes swollen and irritated. If a nodule or partial into dorsiﬂexion (often associated with a tear is present, triggering of the big toe (hallux Thomasen’s sign).61 The surgeon must not saltans20,61) can occur (Fig. 28–28), or the tendon can dissect medially without adequate visualiza- become completely frozen in the sheath, causing tion. Sometimes, terminal branches of the pseudohallux rigidus. posterior interosseous artery in the ﬁeld must This tendinitis usually responds to conservative be avoided or controlled. The surgeon measures. Rest and modiﬁed activities (no pointe should check for loose bodies. Small ones work) are important components of therapy so that have been found in the FHL tunnel. the chronic cycle can be broken. NSAIDs can help, but 6. The foot should be brought into maximal they should be used only as part of an overall treat- plantar ﬂexion to look for any residual ment program and not simply as a painkiller so that impingement. At times, it is necessary to the dancer can continue dancing and ignore the symp- remove more of the remnants of the poste- toms. As with most other tendon problems, steroid rior lateral tubercle. Often there is a facet on injections should be avoided. the cephalad portion of the os calcis that In some professional or high-level amateur ballet articulates with the os trigonum, and this can dancers, FHL tendinitis may be recurrent and dis- be large enough to impinge against the pos- abling. In these cases, operative tenolysis may be indi- terior lip of the tibia after the os trigonum has cated but only after the failure of conservative been removed. therapy.22,35 The situation is similar to De Quervain’s stenosing tenosynovitis in the wrist. FHL tendinitis 1632 PART VII Sports Medicine TENOLYSIS OF THE FLEXOR HALLUCIS LONGUS AND EXCISION OF THE OS TRIGONUM FROM THE MEDIAL SIDE22 Surgical Technique 1. A curvilinear incision is made over the neu- rovascular bundle behind the medial malleo- lus, beginning just above the superior border of the os calcis and continuing to a line just posterior to the tip of the medial malleolus. This incision should be made carefully (Fig. 28–29A). The deep fascia and laciniate liga- ment in this area are often quite thin. If the incision is made too deeply, the surgeon may cut into the neurovascular bundle. 2. The deep fascia is then divided carefully, and damage to the artery and nerve beneath it avoided (Figure 28–29B). At this point the surgeon must decide whether to go in front of the bundle or behind it. The posterior approach can involve the variable branches of the nerves to the os calcis. It is generally safer to pass anterior to the neurovascular Figure 28–28 Nodule on the ﬂexor hallucis longus tendon bundle. All branches of the tibial nerve at this causing triggering of the hallux (arrow). level go posteriorly, so the safe plane is between the posterior aspect of the medial malleolus and the neurovascular bundle. 3. The bundle is taken down off the malleolus usually occurs behind the medial malleolus, but it can by blunt dissection (Figure 28–29C). Several occasionally be found at the knot of Henry under the small vessels crossing the ﬁeld may need to base of the ﬁrst metatarsal, where the FDL tendon be ligated, but once the bundle is mobilized, crosses over the FHL tendon, and under the head of it can be held with a blunt retractor such as the ﬁrst metatarsal, where the FDL tendon passes a loop or Army–Navy retractor (never with a between the sesamoids.54 sharp rake). The posterior tibial nerve is A ﬁbrous subtalar coalition may be present in the larger than expected, usually about the medial or posteromedial ankle and can mimic FHL diameter of a pencil. The surgeon should tendinitis or tarsal tunnel syndrome. This condition examine the neurovascular bundle carefully. should be suspected when there is less-than-normal There are often anatomic variations within subtalar motion on physical examination. the tarsal tunnel. Both the nerve and the artery divide into medial and lateral plantar Treatment branches as they leave the tarsal canal. It is Tenolysis of the ﬂexor hallucis longus and excision of not unusual for one or both of them to divide the os trigonum can be performed with the patient above this area and lead to reduplication supine because dancers usually have increased exter- within the tunnel. There may also be redu- nal rotation of the hip that allows visualization of the plication of the tendons: the ﬂexor hallucis posterior aspect of the ankle from the medial side. A accessorius, an accessory FHL, can con- bloodless ﬁeld is desirable, so a tourniquet is used on tribute to FHL tendinitis. the thigh over cast padding. For this reason, the pro- 4. With the neurovascular bundle retracted pos- cedure cannot be done under local anesthesia or an teriorly, the FHL tendon is easily identiﬁed by ankle block. moving the hallux (Figure 28–29D). The thin fascia is opened proximally, and a tenolysis is performed by opening the sheath proximally to distally (Figure 28–29E). Usually it is CHAPTER 28 Foot and Ankle Injuries in Dancers 1633 A B C D E F Figure 28–29 A, Posteromedial incision. B, Division of the laciniate ligament. C, Taking down the neurovascular bundle. D, The underlying ﬂexor hallucis longus (FHL) tendon. E, Tenolysis of the FHL tendon. F, Removal of the adjacent trigonal G process. G, Closure of the wound in neutral dorsiﬂexion. stenotic and tough, and often the FHL can visualizing the os trigonum, it helps to iden- enter at an acute angle. Care should be taken tify the subtalar joint by moving the os calcis distally because the FHL tunnel and the into adduction and abduction. The subtalar nerve are quite close together at this loca- joint leads posteriorly to the os trigonum. tion. As the tenolysis approaches the area of 7. The subtalar joint is then dissected medially the sustentaculum tali, the tunnel thins so to laterally to get under the os trigonum. that there no longer seems to be anything Once the os trigonum is identiﬁed, it can be more to divide. removed by circumferential dissection. Care 5. The tendon should then be retracted with a should be taken to stay on the bone when blunt retractor and inspected for nodules and performing this part of the procedure. This partial or longitudinal tears. If present, these can sometimes be somewhat difﬁcult should be debrided carefully or repaired. because of the attachment of the posterior 6. At this point the FHL tendon can be retracted taloﬁbular ligament, especially if the os posteriorly with the neurovascular bundle. trigonum is quite large. Once it is removed, The os trigonum or trigonal process is found the posterior ankle joint should be inspected just on the lateral side of the entrance to the for remnants, bone fragments or loose FHL tunnel. If the posterior aspect of the bodies, soft tissue entrapment, or a large talus cannot be visualized, a capsulotomy articular facet on the upper surface of the os should be performed. If there is difﬁculty in calcis that articulates with the os trigonum. If 1634 PART VII Sports Medicine present, it should be removed with a thin ACHILLES TENDON osteotome (Figure 28–29F). 8. The wound is then irrigated and checked for The Achilles tendon is the largest tendon in the body. any residual impingement by putting the foot It connects the triceps surae (medial and lateral gas- in maximal plantar ﬂexion. The wound is trocnemius and soleus muscles) to the os calcis and closed in layers with plain catgut or transmits the forces necessary to propel the body in absorbable sutures, while holding the ankle walking, running, and jumping. These forces range in the neutral position (Figure 28–29G). The from 2 to 3 times the body weight in walking to 4 to FHL tunnel is not closed. A posterior plaster 6 times the body weight in running and jumping.18 splint is applied, and the patient is sent home Their magnitude makes the Achilles tendon a common with crutches. site for tendinitis secondary to repetitive overload or faults in technique in dancers and athletes, such Postoperative Care as rolling in (pronation) and landing hard on the heels. When the wound is healed, the patient bears weight as tolerated with crutches. Swimming and physical therapy are begun, and early Achilles Tendinitis motion is encouraged to prevent adhesions. If the tenolysis is performed without excision of Achilles tendinitis, similar to other forms of tendini- the os trigonum, the recovery period is usually tis, is an inﬂammatory response surrounding the 6 to 8 weeks. If the os trigonum is removed tendon that is triggered by microscopic tearing of the along with tenolysis, the recovery time is 8 to 12 collagen ﬁbers secondary to overload. The tearing may weeks. If there is a large os trigonum, it is nec- be on the surface or in the substance of the tendon essary to warn the dancer that once it is (interstitial); thus clinically there are types and grada- removed, the ankle does not just drop down tions of severity. The simplest type results in pain, ten- into maximal plantar ﬂexion. The dancer must derness, swelling, and thickening of the pseudosheath realize that the bone has been there since birth surrounding the tendon, usually at its isthmus or nar- and that removing it does not result in immedi- rowest point. Crepitus may also be present on active ate motion. The increase in plantar ﬂexion is motion. If the condition is chronic, nodules usually obtained slowly and can be accompanied by form around the tendon or on its surface. These can many strange symptoms, both anteriorly and result in adhesions between the tendon and its sheath. posteriorly as the soft tissues adjust to the new A more severe strain results in a localized, fusiform range of motion. swelling of the tendon itself, “like a snake that has swallowed a pig.” This type of injury is slow to heal Results and has a guarded prognosis. In 1996 Hamilton22 presented the results of A number of factors can contribute to the develop- these procedures. A total of 41 operations were ment of Achilles tendinitis. Heel cord tightness is the performed on 37 dancers: 26 for FHL tendinitis most common cause of Achilles strain in the recre- and posterior impingement, 9 for FHL tendinitis ational athlete and dancer. A “ribbon burn” is caused alone, and 6 for isolated posterior impinge- by dancing with the toe shoe ribbons tied too tightly ment. Evaluation revealed the following results: around the lower part of the leg. Dancers with this 73% excellent or good; 15% fair; and 12% poor. problem should sew elastic in the ribbons where they Amateur dancers accounted for a dispropor- cross the Achilles (Fig. 28–30). Dancers with congen- tionate number of the fair and poor results. The itally small or thin Achilles tendons are prone to surgeon should keep this in mind when per- strains and overloads. The size of the tendon varies forming these procedures in amateurs, who may considerably from person to person and from one side have unrealistic expectations. to the other and is not always related to body size. Pronation, which in dancers is called rolling in, or a cavus foot can contribute to Achilles tendinitis. A cavus foot with prominence of the posterosupe- rior os calcis is often a cause of chronic retrocalcaneal bursitis (Haglund’s disease) and tendinitis of the Achilles overlying the bursa. Occasionally, this condi- tion can result in a partial tear at the Achilles tendon insertion that can cause chronic pain and swelling. It CHAPTER 28 Foot and Ankle Injuries in Dancers 1635 to stretch their Achilles tendons while they are waiting backstage during performances and rehearsals. Steroids should not be injected into or around the Achilles tendon or into its insertion in the os calcis. They will weaken the tendon and lead to rupture. Achilles Tendon Rupture Rupture of the Achilles tendon can occur without warning but is usually preceded by tendinitis or degen- eration. A normal Achilles tendon can be lacerated but cannot be torn. Rupture usually occurs in male athletes and ballet dancers older than 30 years and in the general male population in midlife. It is rare in women. Typically, patients feel as if they have been kicked in the backs of the legs and thereafter are unable to walk on the toes. The hematoma that forms can disguise the injury and lead to a missed diagnosis. The injury is often confused with an acute strain of the medial head of the gastrocnemius muscle (tennis Figure 28–30 Elastics sewn in the toe ribbons for tendinitis leg)’24,61), a rupture of the plantaris tendon (this injury (arrow). is usually a strain of the medial head of the gastroc- nemius muscle; very few actual plantaris tendon rup- tures have been documented24), an inversion sprain of the ankle, or a “partial tear” of the Achilles (it is almost is common in dancers because they are selected for always completely torn). having cavus feet. Exploration, debridement of the A ruptured Achilles tendon is easy to identify if it is bursa, partial excision of the os calcis, and repair of the suspected; the patient cannot walk on the toes, there tendon may be necessary if the condition does not is a palpable defect in the tendon, and the Thompson respond to conservative therapy. Care should be taken when injecting steroids in the retrocalcaneal bursa. Repeated injections can weaken the Achilles insertion and can cause the tendon to pull loose. This has hap- pened in several professional dancers. Treatment of Achilles tendinitis, like so many other dance-related injuries, should occur in two phases. First, the injured tendon must be allowed to heal. Rest, anti-inﬂammatory medicines, and physical therapy modalities such as ice, contrast baths, and ultrasound promote healing. Second, rehabilitation, along with correction of any predisposing factors to prevent recur- rence before resumption of full activities, is prescribed to restore strength and ﬂexibility. An injured dancer should not try to get back into shape by performing but should get into shape and then perform. NSAIDs are helpful in treating tendinitis. However, they should always be used as part of an overall treat- ment plan and not used simply to kill the pain so that the dancer can continue to do what caused the ten- dinitis in the ﬁrst place. The New York City Ballet and the American Ballet Theatre have reduced the incidence of Achilles ten- dinitis considerably by the use of the “stretch box” (Fig. 28–31), a wedge-shaped box kept in the wings during the season so that the dancers can stand on it Figure 28–31 The stretch box. 1636 PART VII Sports Medicine test is positive. With the patient in the prone position, ing on the security of the repair and is then instructed squeezing the calf muscles normally produces notice- to wear clogs, heel lifts, or a removable boot and to able plantar ﬂexion in the foot and ankle. If the begin swimming and gentle stretching. Physical Achilles is torn, the foot will not move or will move therapy is also begun at this time and is continued very little when the calf is squeezed. until full strength is achieved. Early active motion with secure repair is becoming popular. We have little expe- Treatment rience with this method of treatment in dancers The no-treatment method involves judicious neglect. because it is risky (see section on Achilles tendon rup- If the patient is too old, too inactive, or too sick, the tures in Chapter 22). situation is best left alone. The tendon will heal by the law of the unsatisﬁed tendon, but it will heal elon- gated, and the patient will walk with a calcaneal gait. Accessory Soleus Muscle, Cast immobilization in the gravity–equinus posi- the Pseudotumor of the Calf tion will produce a tendon with about 75% to 85% A pseudotumor of the calf manifests in teenage normal function. This is usually quite satisfactory for dancers as a slowly enlarging mass in the distal third the recreational athlete and some dancers but has a of the calf, usually on the medial side. It is painless or rerupture rate of 20%. only mildly uncomfortable and produces a feeling of A percutaneous suture will often obtain the correct fullness or tightness. Obviously, it does not contain length without open surgery. Incisional neuromas can ﬂuid, so results of the aspiration biopsy will be nega- be a problem with this procedure. The Achilon device tive. If the symptoms warrant, division of the sheath allows percutaneous suturing through a very small usually relieves mild symptoms. 1-inch incision, which is safer than the blind technique. Operative repair will approximate normal function HEEL PAIN if the physiologic length of the tendon can be restored and if postoperative complications (as high as 20%) are avoided. It is the method of choice in professional Heel pain is not as common in dancers as might be athletes and dancers. expected. An accurate diagnosis is important because It used to be said that a ruptured Achilles tendon there are many different types of heel pain. was automatically the end of a professional dancer’s career. This need not be the case. If tendons can be Heel Spur Syndrome restored to their original length and if the dancers are willing to devote the time and effort (1 full year) nec- Current opinion suggests that the heel spur often essary for the postoperative rehabilitation, they can found on x-ray ﬁlms is not usually the true source of dance again. the calcaneal pain in this syndrome. (The spur lies in The type of repair used is not as important as the the origin of the ﬂexor digitorum brevis, not in the concept of the restoration of physiologic length. The insertion of the plantar fascia.) preferred method is to use the plantaris tendon, if present, as an autogenous ﬁgure-of-eight suture to Plantar Fasciitis approximate the ends of the tendon under proper tension. This tension is best determined by having the Plantar fasciitis is the classic and most common type uninjured leg prepared in the ﬁeld so that the resting of heel pain. Tenderness occurs at the medial plantar length of the contralateral Achilles is available when insertion of the fascia. Physical therapy, stretches, and the tension is set in the repair. By sighting across both a night splint that holds the ankle in neutral are the ankles, the surgeon can adjust the tension to place the usual treatments. Soft viscoelastic heel pads may be injured and uninjured ankles in the same resting posi- worn in the dancer’s street shoes and may occasionally tion relative to each other. An incision placed on the be used in character or tap shoes in the symptomatic medial rather than the posterior aspect of the leg min- dancer. imizes postoperative skin problems, and splitting the anterior Achilles sheath before the repair allows Rupture of the Plantar Fascia for easier reapproximation of the posterior sheath and a layered closure of the wound at the end of the Rupture of the plantar fascia is usually an acute injury. procedure. It can occur either at the insertion in the os calcis After surgery, the patient is placed in a short-leg (especially after multiple steroid injections) or in the walking cast in slight equinus for 6 to 8 weeks depend- midportion of the arch. The location of the tear is CHAPTER 28 Foot and Ankle Injuries in Dancers 1637 caneus. A small injection of a local anesthetic can help make the diagnosis (see section on nerve entrapments in Chapter 11). Bone Cysts and Tumors Bone cysts and tumors sometimes occur in the heel. One of us (WGH) has seen a Ewing sarcoma that man- ifested with heel pain. X-ray studies, bone scans, MRI, or CT scan should be considered, especially in the dancer who presents with atypical heel pain (night pain or pain at rest). Figure 28–32 Acute tear of the plantar fascia (arrow). LEG PAIN There are many causes of leg pain in the dancer. The usual differential diagnosis is among shin splints, apparent by physical examination. It may be partial or compartment syndromes, and stress fractures, complete. If it is complete, a palpable defect can although other more obscure conditions such as the usually be found in the fascia when both the toes and osteoid osteoma must be kept in mind. Generally the ankle are dorsiﬂexed at the same time (Fig. 28–32). speaking, exertional compartment syndromes are For major or complete tears, a removable boot is worn, relatively rare in dancers, because most forms of and early rehabilitation is advised; otherwise treat- dance require an episodic rather than a sustained ment is symptomatic. Recovery can be prolonged. activity. Calcaneal Stress or Hairline Fracture Stress Fracture of the Distal Isthmus In stress or hairline fractures of the calcaneus, tender- of the Fibula ness is usually noted on the sides of the os calcis rather than on the plantar surface. A bone scan conﬁrms the There is an isthmus in the proximal and distal ends of diagnosis. The fracture heals readily with symptomatic the ﬁbula. Stress fractures are found in these locations. treatment and restricted activity. The distal narrowing is at the level where the toe shoe ribbons are wrapped tightly around the ankle, and this tightness, along with other factors such as pronation, Plantar Calcaneal Bursitis genu varum, and external rotation, contributes to the There is a bursa directly beneath the calcaneus, and condition. It is easy to diagnose because of the extent this bursa can become chronically inﬂamed. A careful and precise location of the tenderness. The fracture can examination sometimes reveals palpable fullness and rarely be seen initially on the x-ray ﬁlm, but the results thickened bands of inﬂamed synovial tissue within of a bone scan are positive. Sequential x-ray ﬁlms this bursa. This condition is often mistaken for plantar usually show callus, and often the callus can be pal- fasciitis and can be treated symptomatically. Vis- pated during bone healing. Treatment should include coelastic heel pads are often helpful. modiﬁed activities until the pain is gone. When the lesion has healed and the ballet dancer is ready to resume dancing, elastic should be sewn into the Entrapment of Baxter’s Nerve ribbons to decompress the ﬁbula and Achilles tendon The motor branch to the abductor digiti quinti, or ﬁrst (Fig. 28–30). (Many professional dancers routinely use branch lateral plantar nerve, can be trapped under the elastic in their toe shoe ribbons). deep fascia of the abductor hallucis muscle as the nerve enters the sole of the foot near the medial cal- Shin Splints caneal tuberosity (and the spur, if present). This obscure condition can be the source of intractable heel Shin splints, which are caused by traction periostitis, pain. It is exacerbated by pronation and is difﬁcult to can be found along the anterior or posterior borders diagnose. The tenderness in this condition is usually of the tibia. They can usually be differentiated from directly over the nerve on the medial side of the cal- stress fractures because the tenderness is usually spread 1638 PART VII Sports Medicine over a larger (three ﬁngerbreadth) area along the tibia. The tenderness associated with a stress fracture, however, is very localized and can be found with the tip of one ﬁnger on a bony excrescence. They tend to occur at the beginning of the season, after a summer layoff, when the ballet dancers are getting back into shape. Stress fractures, on the other hand, are usually seen in midseason or in the middle of a Broadway pro- duction, when the pounding and jumping are begin- ning to take their toll. There are two types of shin splints: posterior and anterior. The posterior shin splint is the most common in dancers. It is usually mistakenly identiﬁed as the origin of the posterior tibial muscle. It is in fact the origin of the FDL tendon. (The posterior tibial muscle origin is on the proximal portion of the interosseous Figure 28–33 The “dreaded black line” in the tibia (arrow). membrane between the tibia and the ﬁbula.) Physical therapists who work with dancers ﬁnd that posterior shin splints are more common in dancers who grab the ﬂoor with their toes when they dance, so dancers An unrecognized or untreated anterior tibial stress should be taught not to do this. The anterior shin fracture often progresses to the “dreaded black line” splint usually occurs in the origin of the anterior tibial (Fig. 28–33).20,21 It is analogous to nonunion of a frac- muscle. Weakness, tightness, or both problems may be ture (the tissue in the black line is granulation tissue). predisposing factors. Once the black line appears, it often takes an extremely The soleus syndrome40 produces shin splint–like long time, 6 months to a year, for conservative treat- ment to work. It is difﬁcult for a professional to be out pain just above and posterior to the medial malleolus. for this length of time. Drilling these lesions can accel- It is caused by tension on an abnormal slip of the erate the healing process. This outpatient procedure is origin of the soleus muscle that runs farther down the done with a small drill with the patient under anes- posteromedial aspect of the tibia than normal. Surgi- thesia and with the image intensiﬁer. (This technique cal release, similar to that done with compartment syn- is called ferrage.) The patient is put on crutches and in dromes, is rarely necessary. a removable boot (for swimming) with a bone stimu- lator until healing is seen on the radiograph. One of us (WGH) has treated eight patients, all of whom have Stress Fractures of the Tibia healed in 6 to 12 weeks. Severe or recurrent or multi- ple stress fractures can require an intramedullary rod Predisposing factors to stress fractures include an ante- (Fig. 28–34). rior bow to the tibia, dancing in the bravura style, amenorrhea, and hard ﬂoors (good dance surfaces should be “sprung” to absorb shock). The bravura style of choreography is danced in the 19th-century classics. It is characterized by dramatic leaps that often land in a “balance,” or pose, and produce large deceleration forces on the tibia. The American Ballet Theatre uses the bravura technique in Swan Lake, Giselle, and other productions. Stress frac- tures of the tibia are relatively common in this company. The New York City Ballet, on the other hand, dances the Balanchine technique, which is known for its ﬂuidity and rapid movements that rarely have a dancer decelerate. Stress fractures of the tibia in this company are uncommon. Amenorrhea, commonly found in female dancers, is associated with stress fractures of the metatarsals.10,20,21,64 It probably predisposes to stress Figure 28–34 Intramedullary rod ﬁxation of a tibial stress fractures of the tibia, but this has not been proved. fracture. CHAPTER 28 Foot and Ankle Injuries in Dancers 1639 ACKNOWLEDGMENT The authors thank Linda Hamilton, PhD, for her assis- tance in the preparation of this chapter. All photographs in this chapter are copyrighted by William Hamilton, MD. REFERENCES 1. Bassett FH, Gates HS, Billys JB, et al: Talar impingement by the anterior–inferior tibioﬁbular ligament. J Bone Joint Surg Am 72:55-59, 1990. 2. Bencardino J, Rosenberg ZS: Symptomatic ossicles of the ankle Figure 28–35 The ﬂexion–adduction sign for a torn acetab- and foot: The roles of computerized tomography and magnetic ular labrum. resonance imaging. Dance Med Sci 4(1):30-35, 2000. 3. Cyriax J: Textbook of Orthopaedic Medicine. Philadelphia, Bailliere Tindall, 1982. 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