This 27 year-old came to me on referral from a top foot-orthopedist here in NY City. She'd joined a gymnastics-oriented dance group and was experiencing worsening pain in the ball of her foot over the course of a year. She recently had to stop dancing. He asked me to try to create a pad or an orthotic for her to see her through the rest of the season before he performed surgery on her foot to remove a small bone (a sesamoid bone) beneath her big toe joint. She was concerned, because from what she'd heard, and from what the surgeon had explained, removal of this bone could cause her to quickly develop a bunion (angulated big toe joint), or even end her career. But the pain was extremely intense to the point of causing tears in her eyes, every time she tried to dance.
There were some very curious elements in this presentation. First, for such brutal pain dancing, she experienced little to no pain with everyday walking. That's not the way bones which have to be removed from the foot usually behave. Secondly, I looked at her MRI and X-rays. Neither showed anything wrong with the bone the doctor was going to take out. Then I took a closer look at her MRI. There was a very tiny, yet intense focus of inflammation in the soft tissues between the bone in question and the skin. I then looked for this with my fingers as I palpated the ball of her foot. At first, I couldn't get anything to hurt. It was hardly swollen. None of this looked like a surgical situation. I kept palpating, and finally, rolling my thumb in a certain way at the site, found a little spindle-shaped thickening I could roll under my thumb. She gave a surprised "yelp"! It was the first time any doctor had been able to make the spot hurt by palpating. The spot corresponded exactly to the intense focus on the MRI.
"Hmmm?and it only hurts when you're dancing," I thought. "Gremlin alert!!!!" I said, "Did you bring your dance shoes?" She took them out of her bag. She handled them so preciously. They were the last possession she had retained from Russia, her beloved gymnastics shoes which she'd used continuously for many years, up to this day, whenever she danced. As I held them, I had the feeling I was handling sacred objects, based on the esteem she had for them. But I was about to do something sacrilegious.
I first asked her to relevé or go on her tip-toes, bare foot. She said she never danced bare foot, but I asked her to do it anyway. No pain. I then asked her to relevé with her slippers on. Instant, horrendous pain. I then asked if I could mark the pain spot I'd isolated via palpation with a trusty skin-marking pen. I then asked her to put her slippers back on and relevé again. When she took her slippers off, I looked inside. I beheld what I'd anticipated. The purple mark from my skin pen had transferred to a nasty thick seam inside those slippers. Now comes the courage part.
I asked if I could snip away the section of the seam where the purple mark was. Of course, this would ruin her beloved slippers, but it would answer the question of whether she should risk her career to have her bone removed, or simply change slippers. Through her tears she finally allowed me to perform this insult to her beloved slippers.
I then asked her to put them on and relevé. No pain. It was comforting to savor that the instantaneous and highly charged string of Russian epithets that followed was directed at those slippers, and not me.