This happens to be one of my favorite cases in recent memory. It combines a delightful patient on the verge of a dance career, presenting with a mysterious, debilitating injury. Her case develops into a tangible diagnosis and treatment plan thanks to the experience I've gained and the statistics I've published from having seen thousands of dancers. Then a simple, logical treatment plan evolves, and is elegantly fruitful in a very brief time. Most rewardingly, my patient is able to resume her dance classes and continue with what she loves to do.
Ten weeks ago, this 25-year-old dance major from a well-known university presented to my office in no small distress. She had pain on the inside of her right ankle, which, despite X-rays, MRI, and diagnostic ultrasound, not one of the previous several orthopedists or podiatrists had explicitly diagnosed. Three times she'd been advised to "just stop dancing." The pain was worsening over the course of a year. She had to drop out of dance, changing to a psych major. Her personality struck me as one dichotomized…a robust, zesty young woman with happiness just itching to burst out, in despair because she could no longer move without pain. This was for a moment gut wrenching for me, but not for long.
As I often do, I asked her to point with one finger to the site of her pain. She drew a line from the inside arch of her foot, to the inside of her ankle, and upwards towards the back of her calf halfway up. Mix the site she just pointed to with the fact she was a dancer, and I'd wager very few dance-savvy doctors would take more than a second to think flexor hallucis longus tendon injury. A brief physical exam affirmed this. She told me the MRI was done early in the string of doctors she saw, which may explain why I saw only just a little fluid along the course of this tendon on the images she brought with her. But it was there (it wasn't mentioned by the radiologist in his report to the treating doctor, so apparently it went unnoticed). I could forgive the previous several docs for not diagnosing the injury…it's only common in the dance and gymnastics population. I couldn't forgive the doctors who declared she should quit dance. Not one had referred her to a dance specialist.
OK, so we had a diagnosis, but we needed a cause. She had no idea why it started…there had been no change in her activities, no pain-coincident event. I took a history, really pried into her history local to the onset. Fruitless. My confidence dropped down a notch, but not my determination to get to the bottom of this. So I proceeded with a set of examination procedures I've been performing on every one of the several thousand elite dancers I've had the privilege of treating for the past 28 years. These are numerous range-of-motion and strength protocols I've published. I've found a high correlation with specific dance injuries and inadequacies or excesses a dancer may have when I examine her/him for these protocols. If I couldn't find out the cause by asking the right questions, I trusted I'd find the questions by going through my protocols. So I proceeded and soon had the required information literally at my fingertips.
Her pointe range was fine. Her plie was too deep. Her calf was way too flexible. Her big toe joint had plenty of releve, and her big toe muscle, the flexor hallucis longus, yes, the one causing the problems, was disproportionately super-strong. Her peroneals, or outside ankle protector muscles which weaken after a sprained ankle, were strong when I tested her with her foot at 90 degrees to her leg, but when I tested her in the pointed position, these outside ankle protector muscles were terribly weak. Her peroneals and calves were much too weak for such a powerfully-built young woman. Her ankle ligaments were a tiny bit unstable. Her other muscles were normally strong, her leg length even, her hip turnout perfect. The jigsaw puzzle was now spread out on the table in front of me, and I could already envision what the picture would look like.
"Did you ever sprain this ankle?"
"Yes, but that was several months before my pain started."
"Did you go to physical therapy?"
"No, I went to the emergency room, and they put me in a soft cast and took X-rays and said nothing was broken."
"Did they give you any exercises?"
"Did you do any exercises?" Again, "No."
"May I watch you walk?"
As she walked down the long gray corridor to my offices, I saw what I expected to see. Her left leg, foot, and ankle functioned in perfect synch. On the involved side, however, she walked apropulsively. That is, she walked in total foot contact throughout her stride, not heel-ball, heel-ball as one is supposed to do. After about two minutes, she started to limp.
Now it's time to let you in on the circumstances that I pieced together, and the treatment plan and results we obtained. I believed her ankle sprain was the cause of the problem, despite the time lag between the sprain and the onset of her great toe tendon pain. You see, when a person sprains an ankle, about 40% of the strength in the muscles that protect against another sprain is instantly lost. Until this strength is regained through properly-executed exercises, and I emphasize properly, the ankle will have two distinct positions: a position of stability, and a position of instability. The position of stability for such an ankle is in the heel-down or foot-flat position, the position she displayed on the involved side as she walked. The position of instability will be in heel-off or tip-toe position, the position her uninvolved side happily displayed during the latter half of each stride. The tip-toe position is unstable for a number of reasons including muscular, ligamentous, and joint, until properly-executed exercises regain strength in this position.
Thus, for stability, compensation takes place. When the ankle must stay in non heel-off position for stability, strength in the muscles which protect it in heel-off is lost. This is unfortunate, because these are the muscles I told you automatically lose strength after a sprain. Moreover, if one doesn't go into heel-off, one loses strength in the calf. These were the muscles I found weak earlier in the exam. But in the case of a dancer, one normally spends a lot of time in heel-off, or releve.
This is where my protocols and their copious statistical correlations came in handy. I have found flexor hallucis longus tendinitis correlates at over 80% in dancers with weak and overly-flexible calves. I postulate that this is because the flexor hallucis longus (FHL) is an accessory plantarflexor of the ankle, i.e., among this tendon's many jobs in a dancer is to assist with releve or heel-off. If a calf loses strength in compensation for a sprained ankle to stay in the position of stability, the FHL will begin to overwork, acting as a "mini-calf" in addition to its numerous other dance-related jobs. Although my patient compensated during walking, and lost calf and peroneal strength in so doing, as a dance major she choreographically had to spend a lot of time in heel-off or releve position. Having to releve on a weak ankle as she attempted her dance classes, shifting weight away from the outside ankle weakness towards the big toe, caused a terrible FHL tendonitis.
Her treatment was simple, because in her favor she had youth, lack of tissue damage, an understanding of the situation, and most importantly that soul-based knowledge all dancers have that they somehow, someway will return to dance. I asked her to ice her ankle. I gave her an ankle brace, one which was lightweight but equipped with laces and straps to assist in ankle stability, to enable her to start walking normally, propulsively, without risk or worry of respraining, to break the cycle of gait compensation. And I gave her one and only one exercise. I showed her how to use a thera band, a thick elastic band, to strengthen her outside ankle protector muscles, the peroneal muscles. But I emphasized to an extreme there was only one correct position she could be in when she did her exercises: foot pointed. Thus she would strengthen in the position of instability. Thanks to the brace, she would be able to apply this strength as she gained it to her everyday walking, and hopefully return the synchrony of strength and gait normalcy required to her everyday walking. The plan was that this would relieve the FHL of its double-duty. I also warned her to keep her toe muscles, top and bottom of the foot, inactive as she performed my exercise. One exercise, three times a day, ice, brace, walk. Come back in four weeks. She did. Peroneals strong. Calf strong. Walking propulsively on both sides. Pain gone. We talked about weaning back to dance and resuming her dance major. Huge joyful smile. I love my job.