I met this 29 year-old professional dancer late one afternoon, coming in with the fatigued/energized halo dancers have right after a ballet class. She wrote in her bio she'd had an ankle problem for three years. She had health insurance. Already things didn't compute. If she was a professional dancer with a three year-old ankle problem, this should be a Worker's Comp case, but it wasn't. If it was bad enough to see a doctor, how come she's been dancing on it for three years, taking full ballet class no less? A 29 year-old professional dancer is a vigorous individual, and she looked it. How could a three-year old injury stay minor enough for three years in someone who's so obviously robust? By now, my ears were reflexively aimed straight towards her. "So, how can I help you?"
"I'm a Broadway dancer but I've had to turn away a lot of roles in the past three years since I sprained my ankle."
"But I thought you just took a full ballet class."
"I did. I have no pain at all when I dance ballet. Even with the grande jetes (high leaps) at the end of class. I only have a problem when I put my character* or tap shoes on, and then I get this horrible pain at the outside of my ankle when I put my weight into my big toe."
"Does it matter if you releve?"**
"No. If I have my character or tap shoes on, and then I push my big toe down towards the ground to get stable, I get this searing pain at the outside of my ankle."
"Does it ever bother you when you walk?"
"Only when I have my high-heel boots on."
Now this was a major hmmmmmmm…. She'd sprained her ankle shortly before the problem started. She was aging, and the most productive years of her jazz career were evaporating because of this mystery pain. She'd seen several other doctors and a few physical therapists. One orthopedist prescribed an MRI. The images showed a lot of scar tissue at the area of the sprain. He prescribed physical therapy. Another gave her a cortisone shot at the pain site a year prior to her seeing me. That worsened her symptoms so that she couldn't dance at all for three months. Both of these treatments were perfectly acceptable at the time they were given. She was distressed, not wanting to give up hope. I knew that the jigsaw puzzle was spread out in front of me. I just had to assemble the pieces into something coherent.
I started with the basics. Her strength was excellent. Her obvious ranges of motion were perfect. One occult range of motion in her ankle however was starkly deficient. For proper ankle motion, the foot must to glide forward, in the direction of the toes, away from the leg, when the ankle points (the ankle is automatically pointing when one has high-heels or character shoes on). When I tested her ankle for this forward movement, I found virtually none. The scar tissue in her ankle post-sprain was preventing the foot from displacing forward. I took a closer look at the MRI. The only area where the scar tissue was not present was exactly where her pain was. OK, pawn to king four. The cortisone shot in that area must have softened this relatively weak site, making it sprain more when she did whatever she did with her big toe to cause the pain. Knight to bishop three. Now, the big toe tendon runs right behind the foot bone that must displace forward (the talus) when character shoes are on. What would cause that big toe tendon to have to work so hard that it caused spraining of the soft outer ankle capsule? Pawn to king four.
OK, now I had to delve out of standard orthopedic dogma into the aerie of the statistics I'd accumulated after having seen dancers for three decades. I knew that a patient who performs vigorously in heels should have a rather tight calf. Thus, the calf muscle still has some tone when in higher heels. If the heel is high and the calf is not rather tight, the heel height renders the calf rather flaccid, or weak. This calls upon other muscles to take up the slack. Her calf was not at all tight. This often happens after a sprained ankle. When I put her foot in a position perpendicular to her leg and asked her to push her big toe down onto the resistance of my thumbs, she had no pain at all. When I put her foot into a pointed-down position, and asked her to push her big toe down into my thumbs, she experienced the searing pain in her ankle. I postulated her big toe tendon (the FHL***) was overworking because her calf, which should have been doing its job, was accordionized out of the picture by the heel height. The FHL then pushed her talus forward and found and stretched the only soft spot in that scarred-up ankle. Queen to rook 5. Checkmate.
OK, we're there, maybe. What do we do now? I had to figure out a quick way to test the theory, and a strategic way to make her better suited to dance long term. There are two muscles which exert downward power to the big toe. The one we've been talking about, the big toe tendon or FHL, which was working overtime, and the FHB++, which does not course behind the ankle, being located strictly in the sole of the foot. I'd already tested the muscles in her foot. They were very strong. I knew if something so subtle as a heel height change were enough to bring on the symptoms, perhaps something just as subtle would keep pains at bay. I decided to try to take some of the work out of the longus and hand it to the brevis. I gave her a gel toe cap, shaped like a ring, made out of ace-bandage material with a thick wad of gel on top. But I asked her to put it on upside down, with the gel beneath her toe, and to snuggle it all the way back to get it away from the tip of her toe. The FHL tendon, or mischief-maker in this case, finishes up at the tip of the toe, and the FHB, or toe muscle which does not cross the ankle, connects to the big toe bone closer to the ball of the foot not the tip. Therefore, the gel pad might increase the leverage this short toe muscle has, taking just enough work out of the FHL to stop it from so aggressively displacing the talus forward in high heels.
I kinda didn't think it would work. Too convoluted a thought process, but the only thing that made sense. So we put the pad on, she put her character shoes on. Up she went and she pushed her big toe down into the ground. She was amazed that there was no pain. I was amazed that the thought process perhaps actually held water. Lots of time these baroque conjectures of mine don't play out and I have to re-conjure a plan. I was already working on two other contingencies. But she had no pain, and it had been consistently replicated each time she'd put the heels on over the past three years. I said,
"OK, here are various kinds of pads you can use to do the same thing, in case this thing is too slippery or loses its oomph halfway through class. I have a long-term and a short-term plan for you, and we'll see how everything plays out. First, keep using the pads and call me in two weeks. By then we'll know if we have a real finger in the dike or not with the theory and the pads. I also want you to begin strengthening your calf to reacquire the tone you need to dance safely in character shoes, and here's how I want you to do that. If this becomes difficult, call me and I'll send you back to the physical therapists, but I bet you can do this on your own. When things have been calmed down for a good time, I may send you to the p.t.'s to mobilize away some of that scar tissue, but I don't want to upset the apple cart with any motions which would potentiate the sprain right now. Please call me in two weeks."
She called, and was dancing in her character shoes pain-free, using the little toe gel cap. She was doing her strengthening exercises, and promised to call me in three months. Which she did. Pain stayed gone. She returned three months later. Back on the audition circuit. We were both very grateful.
* Character shoes are robust stacked-heel ankle-strap pumps which you'll commonly see in Broadway dancers. These shoes are often affixed with taps for tap dancing.
** "Releve" means going up onto tip-toe
*** FHL stands for Flexor (pulls down) Hallucis (big toe) Longus (long)
++ "B" stands for brevis, or short. As it is only located in the sole of the foot, not behind the ankle and up the back of the leg like the FHL.