When I was three my Uncle Art taught me how to play chess. He often stayed with us for weeks at a time, and each time would bring me a breathtaking new chess set from his travels. Within 8 years I was able to visualize the board five moves in advance. I didn’t realize I was practicing to be a podiatrist.
About three years ago, I met a 32-year-old ballerina from Asia. She’d hoped to continue her career for another two years or so, but unfortunately had been disabled from dance for six months prior to seeing me. Her problem was worsening, unsolved, finally impeding her ability to walk more than a few blocks. She complained of a tight band and pain and weakness in the sole of her right foot. She was unsure of her foot placement. Moreover, the issue was not constant, but only occurred when she descended stairs, walked quickly or for long distances, or did relevés (tip-toe) or tendus (a pointing gesture with the foot) in dance, moves which are employed in 80% of ballet choreography.
Her polite and cheerful manner couldn't hide the frightened, distraught dancer under the surface. She’d bought tickets for some New York City Ballet performances, but wished she could take dance classes again. She’d seen 10 specialists in Asia, but no one could help her. Then she traveled to New York. I was doc number 13.
Her X-rays were non-contributory. She’d had several sets. She’d had a high-radiation CT scan, which was also non-contributory. She’d had an MRI, looking for tendon or ligament tears, stress fractures, or space-occupying lesions pressing on her nerves...again, fruitless. She’d had ultrasound scans, again, no pathology was noted. She’d been told her problem was everything from plantar fasciitis to sciatica. My two NY colleagues, as well as myself, were convinced it was “tarsal tunnel syndrome”, which is akin to the carpal tunnel syndrome many typists get when not sitting at the keyboard ergonomically. Not atypically, her nerve conduction studies were not definitive. Adding to her diagnostic misfortune, ironically, none of the expected causes for tarsal tunnel syndrome showed on the MRI. Thus her consultants were afraid to take invasive action fearing making her worse. <1. e4 e5> *
Since I often see dancers with difficult to treat and diagnose problems, I decided to do my routine dancer’s foot and ankle exam, which I’ve designed to target unheralded, but frequently-causative insufficiencies leading to injury. Significantly I discovered her right ankle was unquestionably loose, as is often seen after a sprain. She, like most dancers, had had many. I also found that her peroneus longus, which is the muscle one must trust to balance on the ball of the foot after a sprain, was weak. I look for this all the time, as it’s rarely strengthened properly. Finally, I looked to see if her calf was loose or tight, and it was vastly more flexible than it should be for a ballerina. I see this nefarious trilogy so often, and it so often leads to a negative spiral of compensation. You may read about it in some of my other cases on this site. <2. Nf3 Nc6>
If you look at some of these cases you’ll find I mention the FHL tendon, which is the tendon which starts in the calf and works its way down to the underside of the big toe. This tendon, as it traverses the ankle, comes precariously close to the nerve which causes tarsal tunnel syndrome, the posterior tibial nerve. Despite her sonograms, her sonographers did not think to perform a dynamic test, resisting the dancers’-overused FHL tendon. This may be because her sonographers were unaware of the pervasive morbidity attributable to the FHL in the dance demographic, or simply that they hadn’t all the data assembled in front of them as I had. Regardless, there is one thing dancers have taught me over the past 40 years, which with profound gratitude I apply to all my patient encounters, dancer and non-dancer alike: every problem has a cause.
I took hold of my ultrasound transducer and traced her FHL tendon, all the way back through her tarsal tunnel. Sure enough, it was resting on top of her posterior tibial nerve. I marked the spot with my purple pen. I tapped that spot with my finger, producing a shooting pain into her foot, replicating the discomfort which caused her to travel 7,000 miles. There was no other spot on the nerve which replicated this discomfort when I tapped it as I traced the nerve with the probe. So I again placed the probe over the spot where the FHL and the nerve met, and I asked her to curl her great toe downwards, into the resistance of my thumb. I at once saw the FHL bowstring into the nerve, and my patient jumping back in a combination of pain, surprise, and of all things, joy. No one had been able to replicate the pain before on clinical examination. <3. Bc4 Bc5>
OK, so how do we get that FHL, supercharged in compensation for the weak calf, to calm down and stop beating up on the poor posterior tibial nerve? <4. Nc3 Nf6> I took a logical approach, having worked our history forward from those inadequately treated ankle sprains which devolved her into this status. I first gave her a light ankle brace which would hold her ankle in a position that would foster stability, without being so vigorous as to further weaken her muscles. I then crafted some over-the counter orthotics to support her arch. The FHL is an accessory arch-supporter, so the orthotics took some of the overwork away from the FHL. I then showed her specific ankle strengthening exercises for the peroneal muscles the ankle must trust in order to safely execute tip-toe. This is necessary to get the calf to tone-up, again to purpose FHL relaxation. The calf becomes weak after all these things occur in a sprained ankle, and the FHL has no choice but to take over. So finally, I showed her exercises to strengthen her calf, on a semi-cylinder of foam placed on the floor which made it impossible for her to engage her big toe. <5. Ng5 Nxe4>
I asked her to return one week after she’d ceased taking her daily Ibuprofen. I then administered an ultrasound-guided prolotherapy shot to her anterior talofibular ligament, the one which was loose, and asked her to use the brace and orthotics and do the exercises for a month. The purpose of the prolo shot was to enable her to trust putting her weight forward with her calf, and hopefully, get her ankle more stable for dance if we could see this through to a happy ending. I’m glad I did all that, because she returned in five weeks, distress free. My sonogram showed the hoped-for scar-replacement in her ankle ligament. As the ankle was still a bit too loose, I gave her a repeat prolo shot. <6. Nxf7 Qf6>
As she’d been doing her Pilates all along and was familiar with her choreography, she felt confident that she could return to dance if she continued several weeks of rehab back home. So did I. Some months later, I received a lovely inscribed photograph of our ballerina receiving bouquets on stage after her first return performance.
< 7. Nxh8 Qxf2#> (checkmate in seven moves)
I always tell medical students to learn chess.
This one’s for you, Uncle Art.
* chess moves notation