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Foot and Ankle Injuries in Dancers

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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
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

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

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


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
   • 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).

                                                               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
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


                                                                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

                                                                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
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
                                                                   • 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,
                                                                   (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
   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
                                                                      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


                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

                                                              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
                                                              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
  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
                                                       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
   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.

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


                                                              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.

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