For a long time I've believed that my practice philosophy is unfortunately more unique than universal. There shouldn't be anything special about my practice. Yet, for many of the nearly forty years since I've begun seeing patients I've been told I'm the last resort, the best, the only one to see. Of course this could never be verified for any doctor, and I would have a big problem if I let myself believe that, though it's sobering to have such responsibility in patients' eyes. Now that I'm trying to put it in words, I guess the best way to concisely describe the guiding light of my approach is doing everything possible to put your best interests first.
My ability to formulate what "your best interests" means is based on certain factors. I have to get to know you a little, so when we first meet, we'll chat about your family, your work, your trip in to my office, someone who referred you, etc. This gives me an idea of the best way we can communicate, and just breaks the ice. I want you to feel comfortable and get to know me as well. It helps.
I have to get an idea of your lifestyle, both long-term and immediate. Like how important walking or certain sports are to you, or how adapted you are to the activities you want to do. I have to determine if your work, or your family requirements, like taking care of a big family or an ailing husband, put excessive strain on your injury, for example.
When I'm satisfied with that, we'll get into your injury. Most times it's best to tell me exactly what the problem is first, then give me a detailed list of things that may have contributed to it. That's usually the best order to do it, because I thus will have a feel for how the subsequent information flow I want you to give me should be directed. Things will click better in my brain if we do it in this order. If you think some other order is best, we'll try. The information flow I'll want will include anything pertinent, like accidents, surgeries you've had, other parts of your body causing you to shift weight to the injury, changes in shoes, any orthotics or heel lifts, any change in activity, or sport, or body weight, dance teachers, tennis courts, running surfaces, changes like that. Even if you never come to see me, you should always approach your life, at least from an orthopedic point of view, as a "living history." Changes like these can trigger problems. As soon as you feel a problem starting to roost, think chronologically about such factors. You might be able to avoid the doctor, or at least help a doctor figure out your problem.
Then I'll want to know what treatments you've had, and your response to them. If something helped, it'll help me to figure out your problem and how your tissues respond. If something hurt in a treatment plan, likewise. You may not even be aware of these factors before you come visit me. It's my job to pluck them out.
We'll do our best to figure the current status of your injured and uninjured tissues. I'll use my eyes, my hands, my fingers, my practiced ability to sense temperature, and tissue quality, and feel irregularities in your tissues. We'll check your strength and flexibility. I'll ask you to walk, and I'll look for blatant or subtle aspects of your gait which may be big-time clues in getting you better (see some of the case histories on this site). I may ask you to demonstrate how you dance or run. I'll look at any necessary additional sources, such as MRIs, X-rays, bone scans, nerve studies, blood tests, CAT scans, or letters from consultants. If I don't think the data package is complete, I'll order what's needed.
I'll check the angle of your bones, shapes of your bones, motion in your joints, length of your legs, status of other problems or tissues, whatever is necessary to complete the picture. All this to see how bad the injury is, whether it's worsening or healing, and why.
Now for that big "why" I just mentioned. If your tissues should be healing, but they're not, there may be a gremlin in the mix. Every problem has a reason. Most often the reason begins to evince during the history, which I must allow to develop and evolve along a free path, yet keep shepherded in a coherent direction. Maybe something you're doing, either on your own or thanks to some therapy, is perpetuating your injury. The reason may indeed lie in the string of injuries or treatments you've had before you come to see me. Or maybe you've been asked to do certain therapy and you haven't done it. Maybe you've been asked to do certain therapeutic exercises and you're either doing them incorrectly, or you were shown them incorrectly. We may go there, too.
Maybe some shoes, slippers, or even orthotics you were given are peppering your life in such a way as to sustain your injury. Maybe there's been a change in your bone density, or some systemic illness or some medication or even dietary foible is making your problem look orthopedic but it actually is not. Perhaps there's a systemic arthritis or other condition, like Lyme disease, which should be taking you to a rheumatologist or infectious disease expert instead of a podiatrist. Don't worry, you may not realize any of these things when you come in for your visit. It's my job to be acutely aware of these possibilities, and hone your history and physical exam to make the necessary discoveries.
I have to be ready to click upon any of these factors. I can't describe how my mental flowchart starts, or why a visit takes me in any particular direction with any particular patient, but I can say I will not be satisfied until I have arrived at your diagnosis and the reason for your problem and I will tell you if I'm not satisfied.
After all of the above, and quite possibly even more, I'll attempt to nail down both your diagnosis, or exactly what your injury is, and its cause. Now we can get to work.
We must decide the most likely, quickest, safest, and if possible, cheapest way to get you better. We have to determine if this will be just a short-term fix, or will things like orthotics, exercise prescriptions, shoe caveats, heel lifts, avoidance of certain activities or sports, etc., become more or less part of your life for some duration. I may perform prolotherapy, a simple injection technique I frequently perform under ultrasound guidance, to restore stability to sprained ligaments, tendons or plantar fasciitis. I may refer you to interventional radiologists to perform more elaborate techniques best done by more than one doctor. And I have to figure if I'm the right doctor for you, or do you need consultations with other doctors, or to be better off in the hands of another doctor, or surgeon, as we proceed.
Finally, I have to put this whole package together and see if the urgency you had displayed, or the depression you may be experiencing, is commensurate with the degree of difficulty I think it will take to get you better. Some people have low pain thresholds, some high pain thresholds. Each of these situations can be a double-edged sword. If you experience a lot of pain for relatively little tissue damage, it's my job to point out that there is but little damage, and turn your sensitivity problem into a bit of reassurance that you likely will get better easily. If you have a high pain threshold, I must guide your approach to your treatment so that you "pull back on the reins" a bit. Otherwise, you may incur so many cumulative injuries here and there that the whole thing mushrooms into something more difficult to rescue.
While we're talking about pain thresholds, let me offer that pain-killer and anti-inflammatory medicines have limited value when treating many injuries, especially if you take them while you continue doing whatever is causing the injury. An early-stage injury should not be treated with anti-inflammatories alone, or you can take your small amount of tissue damage and keep beating it up until it turns into something you'll have to deal with long-term. This especially happens as we get older, but it's a crime to let it happen in youth. Thus, you may keep your injury from yelling at you at first, but masking it will only coax the injury to scream and be more difficult to ultimately calm down. If you take anti-inflammatories, it's of supreme importance to figure out why the injury occurred, do whatever has to be done about that, and cut back on your activities till it heals, before gradually going back to hot and heavy activity.
This is what I meant in my first paragraph by in "your best interests." And this is what I mean by "there shouldn't be anything special about my practice." Isn't this the way you expect to be treated when you go to a doctor?
I will tell you what I believe I'm good at, and what I think you'd be best treated by someone else for.
I'm most confident at treating mechanical aches and pains. The whole list of sports, dance, and walking-related problems you'll see linked on hundreds of other podiatry websites. But you won't see links to definitions and treatment plans for these myriad injuries here. By all means, visit those doctors with links. I sincerely hope they get you definitively better for ever. But if the doctors you've seen can't get you better, please call me.
I believe I'm good at defining a diagnosis, and spotting the reason for a person's problem. Why? Because I believe there is a reason for every diagnosis. Thus I do not feel it is a waste of effort to seek a reason.
You may be referred to me for orthotics. Don't be disappointed if I tell you to forget about orthotics. If they're not right for you, I'll tell you. If you've had 33 pairs of unsuccessful orthotics and you show them to me, I'll probably try to help you without orthotics. But don't be surprised if I ask to adjust an old pair of orthotics that never worked for you. I love running into my shop and turning a disaster into an instantaneous success. If I think you need a 34th pair, you might not detect the courage it takes me to tell you, but you can count on my giving you an explicit, soup to nuts reason.
I may prefer to give you pristine or modified over the counter orthotics or a cheap slip-on ankle brace, or some exercises. I may simply advise you to change to a higher or lower heeled pair of shoes. It's a pleasure when this gets someone definitively better who'd expected to pay hundreds of dollars for orthotics.
If I think you need surgery, or rather, that surgery would be the most likely way to get you best, fastest, I'll tell you. I don't do surgery, though I did one of the best podiatric surgical residencies in the U.S. Despite the vaunted status of the residency, when I started my practice I didn't feel adequately prepared to decide who should have surgery and who shouldn't. That's one reason I started this Sherlock Holmes-y job and didn't become a surgeon. Now I know who should consider surgery over conservative treatment, but I did not acquire this realization till years after the surgical expertise of the residency had dulled.
Other things I don't like to do? Though I love salvaging nails from unnecessary surgery, and teaching patients the right way to cut them, I don't love treating severely ingrown toenails. I'll do them, and be certain to do a thorough job. I just don't like them. I love dermatology, was tops in my class in dermatology, but not being a surgeon, I don't biopsy, so I might refer you.
Don't be surprised if I refer you to a different doctor for many things (except investigative things). I refer approximately 5% of initial patients without treating them. After we have our visit, I feel it best that I don't assume their management. Some come back to me after they've cleared up important possibilities with consultants, some are best only in the hands of the consultants. I refer about 20% of patients while I'm still in charge of their case for consultations with specialists, physical therapists, or diagnostic services. Recently a patient said to me "Are you competitive? Are podiatrists competitive?" My response just came automatically, "I'm not competitive. If I think there's someone who can treat you better than I can for any problem, I'd sure better refer you to them. Otherwise, I'm doing you a disservice, no?"
Ulcers?I have a love/hate relationship with ulcers. I'm extremely strict at getting rid of the cause of an ulcer. I had wonderful training in my residency, and this mixed with my love of improving contact forces gives me a high degree of confidence when I exorcise a mechanical cause for an ulcer. The problem is ulcers require frequent visits and I may not have a convenient spot in my schedule for you available at your required frequency. I'll see you to eliminate the cause of your ulcer, but may refer you to another podiatrist or a wound management specialist for your repeat visits. I'll probably ask you to return to me at critical junctures to make sure things are going according to plan.
While we're talking about appointments, I hate being tardy. I like to run on time, and I have acquired a cadre of patients who love counting on being seen on time so they can get on with their day. If you're late beyond the minimum time required for me to treat you without seriously inconveniencing the succession of subsequent patients counting on their appointment time, you may be asked to reschedule. Unless I have an unalterable obligation that evening, I will be delighted to stay late for you and ask my secretary to stay so I can see you that day after my regularly scheduled patients. I'll come in early or stay late for you.
And I don't take insurance. We'll be happy to fill out your insurance form, and fight for you to get reimbursement in the form of letters of medical necessity or phone calls to your insurer. I remember several days when my secretary seemed to be on the phone all day long to help one patient get reimbursed.
One final sidebar…
I can’t expect a patient to get better unless I nail the diagnosis. Exactly, precisely, comprehensively. Hands-on, feel for little irregularities under the skin, visualize, check the strength, flexibility, color, temperature, appropriate size of the part for the body, injuries to the area of complaint, history of injuries to the area, check treatments rendered to that area… were they complete, appropriate, inappropriate, did the treatments help, have no effect on or worsen the areas? Check shoes and orthotics for perpetuating the injury, habits like crossing ankles over the complaint site, check X-rays, MRIs, ultrasounds, CT scans. Look at all the reports of the radiologists and insist on looking at the images. If the images are poor quality, fight with the insurance company to have a better facility redo the images. Look for uninjured areas on the MRI the radiologist may have therefore overlooked, but areas where an extra muscle or tendon happens to be, or a muscle which is attached to a funny place on the bone, because you’ve been studying MRI’s of this tiny foot and ankle every night to the point of eye fatigue for 24 years. Question all the radiologists reports until you verify them with your eyes by looking at the images. Question all the therapy a patient has been given until you verify with your eyes and ears that it was appropriate and still is. Estimate the degree of tissue damage. Look for likely insufficiency or possible damage to other tissues or structures which might be perpetuating the presenting complaint. And so on.
Put all this into the stew. Stir it around, figure out the injury, what it will take to get it better, and prevent recurrence and/or further injury. Look at the injury and associated circumstances broadly, with respect to the dancer’s career. Advise the dancer steps that should be taken to prolong the career and minimize injury in the future. Be familiar with the dancer’s choreography and class. Does your diagnosis make sense? That said, is it something that you’ve never seen before? Don’t discount it just based on statistics. Believe in what you’ve arrived upon. Estimate within a few days how long the 6-month long, heretofore unsuccessfullytreated injury will take to get better.
Give the dancer an exact return to activity schedule, something like…OK, in 3 and a half more weeks, begin weaning out of the camwalker boot. Gradually, one hour less each day boot, one hour more each day those sneakers I advised you to buy. But if you have to go on a long walk, sling the boot back on. You are welcome now to do flat pedal vertical, not recumbent bike cycling in the gym, as long as you use a stiff-soled shoe and push with your arch, not the ball of your foot. And keep the gearing light because of your history of sacroiliac pain. You may also swim now, just take the camboot to the edge of the pool, be careful not to push-off, and keep the water at armpit level so the buoyancy will float the pressure off the injury. Keep doing your Pilates in the meantime, but don’t go overboard on the hip abductor work after you come out of the boot because we have to get your calf stronger and the Pilates might keep your calf a little lazy. Begin the physical therapy for your ankles and toes and balance as soon as you start weaning out of the boot. Make sure you do the peroneus longus strengthening properly…that is key. If you have had no pain for 10 days walking, begin single-leg releves on a dense half-foam roller, eventually working your way up to 20 6- second round trips twice per day, using the roller to keep the work out of your toes and focus on the calf. If you can do 10 of these foam roller releves without pain, then you may give yourself a 20-minute home barre, double leg, in flat shoes. Every other day. Stop doing any of these things I’m telling you, and tell me, if there is any pain whatsoever. Continuing, if there is no pain with the home barres double leg, go to “XXX”’s class, as she is known for healthy teaching, has a great floor, and will let you take a slow barre in the back of the class. Take her regular barre, yes single leg, and sit out the rest of the class or go home. Do this or your own version of this at home every other day for a week. If no pain, then take this barre for five days in a row. If no pain, then barre + adagio (obviously no partnering) for five days. Do all of the above in flat shoes. At the end of the week, just try some temps leves and sautés. Wait two days. If there is no pain. you can take barre, adagio, and petit allegro the following week, up to but not including the turns. Oh wait, you are 29 and you’ve been out for three months…do the petit only every other day, not 5 days in a row. If there is no pain halfway thru that week, you can begin doing pointe class on the same schedule as you’d done for flat class, starting with the single-leg barre. Back to flat class…if there is no pain after a week of the abbreviated flat class, you are home free and the next week you may resume full class! This should time out right for rehearsing Snowflake, as there is so much pas de bourree. And ps, don’t forget to check your future shipments of pointe shoes that the platform is angled the way I told you to the vamp!
Tell the dance company manager or physical therapist our estimate so they can arrange replacement dancers and rearrange their schedule, or include or not include this dancer on the European tour. Don’t give in to your plan if the dancer “really wants to go”, remembering those dancers early in your career you gave in to this way who horribly had a complete recurrence of the injury thanks to your acquiescence. But don’t be unnecessarily rigid if there is something she can get away with, like a character role. And be sure that your assessment of what it takes to get better stands minimal chance of making the patient worse, and even under that aegis, closely monitor the patient to be sure. Do this for 42 years. And subconsciously apply all you’ve learned from treating dancers to your regular population of patients.
I owe my career to dancers.
Now please keep the following a secret, because I cannot apply it to anyone else if I wish to stay in practice, but if you are an obviously dedicated struggling dancer I often find myself charging you a very small percentage of my regular fees, quite modest compared to NYC doctor’s fees.
This, my dedication, and my forever gratitude and devotion, is my thank you.
I feel my career has been shaped in a very unconventional way compared to my podiatric colleagues. Early on I was welcomed into collaborations with top orthopedists, physical therapists, chiropractors, osteopaths, family practice physicians, and rheumatologists within the first six months my career.
Although my career has been blessed with several fortunate events, the most fortunate is to have earned the trust of dancers for over 40 years.
In 1980 after finishing my surgical residency and my pediatrics and biomechanics fellowships, I was hired as a clinical instructor in orthopedics and biomechanics at the NYCPM. I taught at their adult and pediatric foot and ankle clinics in Harlem, considered one of the busiest and best in the country at the time. There I had the opportunity to meet several dancers at the clinic looking for help.
Working with dancers forced me to seek the causes of a problem, delving far back in the dancer’s history often perpetuated and compounded by a constellation of carry-over compensatory injuries; each requiring regard, but some, especially if they require unavailable adequate rest, not adequately treatable.
This realization forced me straight away to do dogged detective work in my history, neither squashing useful information a patient might be about to offer, nor letting important punctuation points in the history be ignored; points which would be developed and integrated onto a canvas displaying the roadmap to most effectively help the dancer. Taking a history is an exciting tightrope, really a delving and recognition skill which illuminates essential information. And this methodology naturally also evolved into my general practice.
Sports medicine was in its infancy. I was a consultant in a sports medicine group practice back in the early 80’s, collaborating with a physician and a physical therapist, treating Olympic and world class athletes for Adidas Running, Track and Field. Thinking about my personal and the general advances in both diagnostic and treatment procedures then versus now...I only wish I had what is now available back in those times.
Performing Arts Medicine, which focuses on the care and treatment of problems affecting performing artists, including musicians, dancers, singers, and actors, was not even a term yet. I began reading everything I could find about dance injury.
Back around 1980, when I had just finished my surgical residency and my orthopedic-biomechanics and pediatrics fellowships, I was offered a consulting position at one of the rare dance medicine clinics in NYC by a biomechanics fellow who was leaving this post at the clinic and moving to Maine. I immediately recalled an article I’d read in a newspaper when I was younger, about Edward Villela who was told he was dancing on shin splints, would get to the to theatre on crutches, perform heroically, and go home on crutches. It turned out he was dancing on nine stress fractures in his shins. I said to myself, “I’d like to be a doctor and treat patients like that.” I took the gig.
How I started caring for performers.
I soon was enlightened to the alternate world of the dancer. We are expected to perform our human tasks well, but still we’re allowed mistakes. The demi-gods are expected to perform super-humanly and perfectly. And on top of that they go ahead and regularly further elevate their artistry to amaze us, if only for but a unison gasp from the audience. For the past 49,000 encounters I’ve seen the same words stamped on their dog-tags: enthusiasm, commitment, creativity, courage, oneness with the music, resilience of spirit, self-sacrifice, strength, humor, intelligence, beauty both physically and in consummate expression, willingness to stick to a plan to get better, separation from family and home, and professionalism. Demi-gods speed ahead knowing that even the most successful career is short by any standards. Often they race to this end without a backup career, and follow it by some degree of permanent injury. For you to have just one of these characteristics would be special, to be blessed with more than one would be unusual. To have them all makes you a dancer.
It’s a tribute to humanness that so many are called by dance. A dancer requires a body which can comply with the rigors this spirit will exact. Eighty percent of even the most physically gifted professional dancers will experience career-threatening foot and ankle injuries. Instantly capable of adapting a super-human technique to a teacher or choreographer’s correction, they often require this talent to compensate for injury. When such a transcendent creature as a newbie visits me with a less-perfect frame, and I must explain that some physical inadequacy could lead to a career short, injury-spritzed, and dampened by unending chastisement from teachers or skipped-over roles, I must banish my despair even before I unload on my patient. And here it’s tough to not feel puny. Reality can be a real bully, a career-long sparring partner.
At this point my mind is racing to come up with a plan, a solution, a compromise, another opinion; an exercise, a pointe shoe modification, an injection, a padding or taping; sometimes the situation may be helped by surgery, though surgery attempting to create God-given physical attributes for dance is often not as successful as surgery on competent frames which have been injured. We must root our plan more in realism than hope.
Many times there is something, sometimes there seems nothing. In cases of seemingly the latter, the expression in dancers’ eyes is to overcome, not to give up. Because there is really never nothing. That only happens when a dancer retires.
In ballet newbies, I may try to suggest alternative types of dance, like modern, tap, African or theatrical, if the body looks like it would allow. It is here that I might disbelieve that teachers could have been unaware or worse, could have allowed such a spirit to continue without advising of the potential for physical failure. In fairness to the vast majority of teachers, often the dancer is aware of a physical limitation, but sidetracked by faith, commitment or idealism. And sometimes family members do the pushing. It’s easy for me to feel puny with the most youthful ones, especially those dressed more like dancers than dancers. It‘s only slightly less difficult with high schoolers, who are beginning to taste reality. It’s tragic when I try to grasp for a rationale or a way to keep an inadequately-endowed college dance major dancing. It’s even tougher to forget their eyes.
Some dancers lack relevé. Some lack pointe. Some won’t have turnout. Some have pain that prima facie can not be definitively explained by the most sophisticated medical tests or physical exams (although the truest test of a diagnosis is ultimately a successful outcome).
Some cry before I even began examining them. Some sit calmly with me in the exam room only to have my office assistant hand them tissues after our visit. Some parents understand.
And crying can also happen in professional dancers, especially those advancing in a company facing injury which might prevent them from their premiere in a lead role. This is especially a tightrope now in the post-covid short season, where we must weigh the risk of further injury vs loss of advancement and performance(s). Here again we must pull out all the stops and more so.
One of my goals has always been to help potential dancers and their families decide whether, and to what extent, they should invest in the study of dance. I am motivated by young dancers, most often with their families in tow, who’ve visited me when career choice has gotten serious. One of the saddest features of my practice is when a young dancer has been sucker-punched by either a physical or psychological blockade to making dance a career. With the help of many of my friends, including dance teachers, choreographers, movement specialists, physical and psychological therapists, other dance-medics, and dancers themselves, I try to give insight into my perspective on what it takes to become, and maintain oneself, as a dancer.
What makes a dancer? Mr. Balanchine often would sit quietly on the side of the stage during the New York City Ballet orchestra rehearsals. Once after a rehearsal, as he was walking off the stage, a first chair instrumentalist ran up to him and said, "Excuse me, Mr B! Do you think my son should study ballet?" Mr. B turned and asked, "How old is he?" The father replied, “12”. Mr. B said that was unfortunately a little old to begin his dance studies at his fabled School of American Ballet. Instead, he offered, “Sure, send him to a ballet school. He'll develop posture and confidence," and turned to walk away. But suddenly he stopped and said, "By the way, does he play any musical instruments?" Dad quietly said, "He can play anything by Mozart in any key on the piano." Mr. B, who like all great teachers respected musicality, or a body effortlessly in unison with the music more than anything else said, "Please send him to me tomorrow for a personal audition!" The young man was post haste enrolled in SAB. He put a sign on his bedroom door: "New York City Ballet, Watch My Smoke". Four years later, he was in the Company. He was my patient till he retired many years later.
Early in my career, a principal dancer for a major ballet company visited me for soft corns. She would become a regular visitor. I was so impressed by her openness, sweetness, and super-sharp mind. Yet there was a quality about her that impressed me most of all. I just couldn’t define it for several years. Perplexing because that quality shone brilliantly each time she visited. I only knew it had to do with her dance-entwined being. She’d see me for corns, toenail issues, sprains, strains and stress fractures which festered till she had to visit. She was also attended by world-renowned orthopedists and physical therapists. She had chronic hip problems, knee injuries, some requiring surgery, surgical repair of metatarsal fractures, and every tendinitis you could think of. Two-thirds of the way into her career her big toe tore off except for the skin when she fell entering the stage doing pirouettes. This required a major surgical reconstruction, leaving her with permanent loss of relevé in her great toe. Still she came back. In the last 365 days of her career she visited a chiropractor daily. At her final performance, the world’s dance glitterati studded the audience. She could not even stand unsupported. That evening she was carried lyrically and beautifully about the stage by several male principles. Two weeks later at 44, she had both hips replaced. I can recall each of her visits to me. Through all these injuries she was cheerful, sharp, and driven. She was so confident that she’d dance again that nothing had the power to derail her. On returning to the stage after each injury, the grace and rock-steadiness of her dance and even more, the look in her eyes (if I could see it through my tears) are things I’ll remember all my life. Like a kid’s, those eyes would say, “Watch this! “Isn’t this great? “Isn’t this fun? “I hope you’re having as wonderful a time as I am!” Being touched by her spirit, and that of dancers throughout my career, has enriched my life immeasurably.
I have a lovely patient who has been teaching ballet to little children for over 40 years. I asked if there was anything she could spot in a youngster from the get go, even before learning pliés, relevés, and the rest of the physical vocabulary of dance. Specifically, was there a characteristic which reliably signaled whether the child had a chance, if the physicality held up, to make dance a career? She answered without a blink, “Oh yes, musicality.” If the child’s body moved rhythmically and naturally in time with the music, she explained, there’s a chance. Although she’d seen some kids learn this who were not naturally gifted, the vast majority who went on to make dance a career had been born with the talent to physically and beautifully express music via their movement. I imagine this is the equivalent of predicting who might anticipate a career as an opera singer…a child with no sense of pitch or one with near-perfect pitch before ever reading a musical score? Another teacher, a former principal dancer, instantly replied, “Oh, yes, the student’s ability to quickly respond to suggestions from the teacher.”
There is no better definition of the word “professional” than the example most every dancer I’ve ever met has given me. Not a one would be surprised to be injured. That’s a given. Of the twelve hundred per annum professional and serious recreational dancer encounters I’ve had in the past 43 years, I can recall perhaps five who came in with their first injury after the age of 27! Joy of movement, need for movement, responsibility to audience, company, and that fire inside obliterate any inhibition due to risk of injury. When inhibition finally knocks on a dancer’s door, a dancer finally knocks on my door. Thus they often usually bring along a satchel full of compensatory injuries due to weight shift, as they try to dance through the initial injury. For many years I’ve seen these delightful patients always shaken, but rarely if ever broken by a mere career-threatening injury.
I as an outsider can only guess why dancers feel this way about movement. I didn’t feel passionate about being a doctor when I was a kid (though I love and am driven by my work, thanks in large part to the grounding a career with dancers has given me). I do know dancers careers are short, perhaps mercifully so. Athlete’s sports are seasonal, giving the body the necessary down time to recover. But during the brief years of a dance career nearly every single day is somehow occupied emotionally and physically with dance. Lacking this recovery time breeds injury. Let’s look at a typical day in the life of a professional dancer…
AM: 8:30 Get up, soak in tub, eat breakfast
10:00 Arrive at theatre to prepare for class
10:30-12:00 Class
PM: 12:00-2:00 Rehearsal (add an extra 3 hour performance here twice a week for matinees)
2:00-4:00 Eat lunch, or run to therapy
4:00-6:00 Rehearsal
6:00-8:00 Eat and prepare for performance
8:00-11:00 Performance
11:00-12:30 Shower, eat, take care of your body, unwind from high of performance, and go to bed
You want to dance, but you’re worried about getting injured. Your friends dance but their struggles with injuries have discouraged you from taking the plunge. They’ve had trouble finding dance-savvy doctors, and they couldn’t afford the treatment anyway. Maybe you’ve taken some classes and have already experienced some injuries you’re frightened may worsen. Or possibly you’re a professional or serious amateur dancer and just want a clearer idea of what all is going on.
If you dance, you’re going to get injured. Maybe right off the bat. Workers Comp surveys consistently report that 80% of professional dancers will have career-threatening foot/ankle injuries. Other surveys state that on averaage a professional dancer will have up to seven career-threatening injuries during the 100-150K hours of dance in their careers. So if four out of five of you will have career-threatening injuries, prepare yourself that you will have several non career-threatening injuries. An American Journal of Sports Medicine paper reasserted that the greatest percentage of dance injuries occur at the foot and ankle. During periods of significant injury, it might take all your professionalism and trust in your doctor to look beyond what may be a very depressing chapter in your life. Don’t be ashamed to ask your doctor for advice or a reference for psychological counseling. Icing, going to therapy, taking cabs you can’t afford because crutches slow you down, constant elevation of the limb and doing repeat exercises make it impossible to get your mind off the injury, especially if the healing is slow, as it often is.
If you are one of the elite who will be contracted with a company, when you get injured you will be obliged to attend rehearsals, possibly attend performances. You’ll have no time for chores. Injury time is at least as tiring as performing. And if you know a role that a dancer more injured than you had to be taken out of, be prepared to be called on to substitute. That’s how injuries carry over from season to season, and cause compensatory injury to other parts of the body.
When we treat you, we are inspired by your professionalism. We have to be pretty sharp. We must nail the diagnosis. We just can’t be casual. And we have to nail the underlying cause of your diagnosis. So we must learn about choreography, floors, teachers, repertoire, all your dance terms and elements of a dance class and being in a company or a show. We have to observe your particular dance technique critically, from an injury-causing perspective. We have to know how much motion each of your joints should have to perform healthily. We must be able to accurately check strength and flexibility. We have to know dance shoes and street shoes. We have to know how theatre wardrobe people think (and how you think). We have to know pointe shoe fitters and find cobblers who work on dance shoes. We have to inquire into your other daily activities, injury history, and treatment history. We have to accurately predict how long it will be before you can return to dance. We have to tell you what activities you should do while healing so you don’t become sitting ducks for other injuries. We have to know dos and taboos (like not being a runner and dancer simultaneously). We have to get you back, healed, as quickly as possible, in better shape than before the injury. We have to read everything there is to read about dancers’ health, attend conferences of dance medicine professionals, attend performances, watch classes, go backstage, watch rehearsals, and even take some dance classes.
We have to find you the best physicians, physical therapists, teachers, pilates instructors, and dance rehab coaches. We may have to help you with diet, finding an acupuncturist, or finding psychological counsel. We must be armed with all sorts of other doctors of varied specialty, in case they’d be better than us at getting you better. We have to ask the right questions: there’s an epiphany in your history if we keep plugging. We have to be cautious about recommending surgery…and also about not recommending surgery, depending on how much and for how long you’ll have to deal with the injury. With all this, we can’t help but regard each dancer who comes in as a little deity, because treating you will make us not only better doctors, but better people. It doesn’t matter if you’ve won a big competition, if you’re in a major company, a pick-up group, or if you just started to dance for your personal passion. I can tell if you’ve dedicated your life to dance. And I my life to you. You’re deity, baby.
I’ve been applying what I learned from treating dancers to my regular patients population for all these years. So on behalf of my non-dance patients, I thank each dancer who’s trusted me to treat them. I charge dancers minimal fees. With dancer patients, it’s always payback time.
But we really can’t help you fully if we can’t work with you to suss out the cause. So and your dancer friends, I’d like all of you to make a pact with me: keep a diary. In this diary you will only list new pains, and what things were different in your circumstance that may have caused them to arise. Changes in floors, new teachers, new or additional choreography (perhaps even taking away time from strength or other rehab training), changes in pointe shoes, harking back to old injuries which were never treated or perhaps treated inadequately (help me here...prepare a list of all injuries you can remember, in as chronologically-correct an order as you can muster). This diary will serve two purposes. First, you’ll obviously have wonderful information at your fingertips as to the cause of a problem so you can try to correct it before it gets too severe, or afterwards, if it is the source of a mushrooming series of compensatory injuries, one or more of which has caused you to present to my office. If necessary, the record will thus help a doctor piece together the etiology of your problem. Secondly, the diary will start you thinking like your own personal doctor. One who’s trying to head off any potential cause of a very special dancer’s problems: yours.
Four and a half decades ago seems like yesterday when my first ballerina patient took off her shoes. I looked forward to her appointment all week, but these weren’t feet. They were gnarled, sinewy wedges, with bumps and tendons sticking out all over the place. I almost hung up my scalpels and bought a deli. They were unlike any of the 5,000 feet I’d already doctored. With reverence I soon realized that in my presence were not simply feet, but world-class, painstakingly and precisely adapted instruments of dance.
A doctor visit won’t be because of this sobering appearance. This appearance is de-riguer for a dancer, a visage earned after thousands of hours of dance. Without this adaptation, an injury is significantly more likely. Injuries stem from a disruption of the equilibrium between the sustaining ability of tissues and the challenges of a particular activity. These foot bones have to get bigger and thicker over the learning years for their own good. Those who try to dance too aggressively without adapted feet will more likely sustain injury. The recently empty-nested mom who finally succumbs to her dream of studying pointe would exemplify this. Our would-be ballerina may have been totally successful as a 15 mile/week runner for twenty years, but the ranges of motion, stresses and strains upon the lower extremity in ballet, especially pointe, are far different from those in running. My practice goal is to enable my patients to maintain a safe, satisfying, and if desired reasonably accelerating equilibrium.
Regarding dancers’ motivation to create beautiful movement, to do anything within reason (and sometimes beyond) to get better, and to visit with me in a delightful and constantly enlightening way, there is no difference between the dancers I saw from the Boston Ballet in 1978, Caracas Ballet in 1980, Dance Theatre of Harlem in 1981, the Peking Opera Ballet in 1986, the Royal Ballet in 1993, the Toronto Ballet in 1998, the School of American Ballet in 2005, American Ballet Theatre in 2012, the Paris Opera and Bolshoi Ballets in 2017, or the New York City Ballet in 2021. There is no difference between the dancers I saw from a Chorus Line, Oklahoma!, Riverdance, the Paul Taylor company, Twyla Tharp dancers, Lar Lubovich and Cunningham and Limon dancers, the Pina Bausch Company, Les Ballets Trockadero de Monte Carlo, Pilobolus, Cirque de Soleil, Tango Argentina, Carmen, 100-plus other broadway musicals, 75-plus additional modern and ballet companies, or any other dancer I’ve met over these many years. I learned early in my career that the words “just stop dancing” are taboo. I’ve had many patients with severe, debilitating injuries. I’ve had patients who had been born with structural problems which would cause them pain throughout their careers. I’ve only twice advised dancers to stop dancing. These two dancers had the most severe structural problems I’ve ever seen in dancers. Neither of those dancers heeded my advice. To their credit, each was back dancing again in about a year.
Some dancers learned of me by word of mouth. Some have been dancing in shows or in companies and have heard of me through friends. Some were referred by other doctors, by company managers, dance captains, or their schools. Some were just starting out, but the embers in their eyes are unmistakably there. Many came to New York City as youths from homes thousands of miles away, eagerly prepared to sacrifice family time, leisure time, social time, comfort time, salary, career independence, job security, and a pain-free life, for the love of movement. What an honor to be their doctor. What a sense of satisfaction when I can be of help to them. What a responsibility to help keep the fire burning. Communication. That’s the key to my visits with dancers. They’re so aware of their bodies, and give me instant feedback if my ideas feel right (or wrong) to them. They’re most appreciative of a doctor’s familiarity with the dance milieu.
In my non-dance practice, I often hear patients say, “I’ve been to (fill in a number) different doctors, and no one has been able to help me. But so-and-so told me about you, and you’re my last hope. You’re ‘it’.” I first heard that from a patient about 40 years ago. It still scares me to hear it as I’d hate to let this person down. But I I’ve learned how to brush off feelings of onus. I know I can only take the same approach I always have, viz., to listen carefully, find out the cause, estimate the damage, figure out the fastest and if possible most economical way to get this person better, hopefully without reinjury, and predict how long this all will take while enabling as much dance as at all possible during this time. If you’re a health professional who sees dancers regularly, this approach has certainly already become your modus operandi. And I’d wager those of you who’ve seen dancers regularly over the years also have been anointed with the “you’re it” pseudohalo a fair number of times.
To the health professionals who may be listening, if you decide to commit to a career which includes treating this special group, congratulations! The feeling you’ll get when you’re trusted by a dancer will be a special rush. Treating dancers has changed the way I think, and not just with respect to finding the diagnosis and cause. You have to become sensitive to the artist. There are pressures upon the dancer and their funds-shy company that all members stay healthy. Dancers have limited funds, and unless it’s a Worker’s Comp case, are often uninsured. Yet they often require the most expensive diagnostics and treatment. You must be willing to treat them for a fraction of what you might usually charge. If not, they won’t come to you. You’ve got to drop any thoughts of tidy remuneration in the ocean. Your only goal is to get it right. This includes not yielding to their pleas by sending them back too soon for adequate healing, and in the same breath not boiler-plate holding them back if there are ways to incrementally assimilate sooner return with low-risk. Mistakes are costly not only to the dancer, but to your reputation. The dance community is small and extremely tight-knit. If you’re in the mix, the bad news about you will travel fast. The good news will travel, but much more slowly. It takes time to gain the confidence of this community.
A certain amount of creativity is helpful when treating dancers. Look for possible compromises which will keep them active but don’t impede tissue healing. They must return to dance as soon as possible, as healed as possible, without allowing their strength or capacities to deteriorate. Simultaneously, as soon as tissue recovery allows, they must begin eliminating the cause of their injury, via exercises, technique changes, upgrading pointe shoes, physical therapy, whatever therapy. So you must be familiar with all the choreographic and physical factors and then some. You really have to build a “flowchart mindset” which integrates these factors and arrives at likely causes for each diagnosis; and a simultaneous mindset which spits out acceptable treatment plans. It helps to have enjoyed playing chess. In time, all these elements will flash through your mind in an instant as you intuitively assemble the safest course for your patient. And guess what? You’ll automatically apply the same mindset to your everyday population. This is amongst your “remunerations” for treating dancers.
I think it’s important for health professionals and dance teachers to know what comprises the gold standard for a dancer’s foot and ankle. Dancers need balance, drive, coordination, musicality, stamina, intelligence, body awareness, acting ability, resilience, and adaptability. I don’t know how to measure those factors. But dance choreography also demands measurable strength, flexibility, joint motion, and correct technique. Your feet and ankles have to be a certain shape, and so do your bodies. Many dance injuries are caused by deviations from these parameters. I refer to these requirements and how to measure them always. They are basics which I invariably espouse in my dance lectures.
In the early 1980’s I made a real pest of myself. I visited all the major ballet and modern dance companies in New York City with instruments to measure range of motion. I asked the dancers without injuries which could’ve conflicted with my study to let me measure their ankle motion, toe motion and turnout. I’d checked around 170 dancers those first few months. By the end of a year, I’d measured approximately 500 professional dancers. By the end of the decade, I had measured about 2,400 professional dancers’ ranges of motion. I now have the ranges of pointe, plié, big toe motion, calf flexibility and turnout in over 12,000 professional dancers measured carefully by this self-same examiner. I published the technique for measuring ankle pointe many years ago (An easy way to quantity plantarflexion in the ankle: T M Novella. J Back Musculoskelet Rehabil. 1995 Jan 1;5(3):191-9. doi: 10.3233/BMR-1995-5304.) It is now used in many dance clinics worldwide. If I had a smartphone with angle measurement capability back then I would have incorporated it in the study. I do now employ it in my technique.
Why know this stuff? What if a child has such a love of movement that it’s obvious to her parents she should be studying dance, and perhaps even make it a career? What if she’s not sure if she wants to be a ballerina, or a tap dancer, or a modern dancer? Knowing these parameters, and comparing this child’s measurable attributes to the most favorable criteria for the various dance genres might help the family decide which type of dance would be most suitable to the physique of the child. This could prevent disappointment later on if a dance company or school were to reject the dancer because of lack of pointe or turnout, or time off due to repeated injuries, although it seems that to some extent the attributes may be improved with peoper therapy if there are no obvious major detriments. In these cases there should be guarded but not blind optimism as to outcome.
Moreover, matching your body to the types of dance you choose should make your career more enjoyable, less painful, and perhaps land you better roles. It also might reduce the risk of problems appearing after you retire. And knowing ideal extent of motion might prevent unnecessary surgery, if you’re penned in for surgery designed to increase range which you already have. This knowledge or range of motion or strength/flexibility parameters might coax you and your doctor to look elsewhere for the cause of your problem, rather than compounding the injury by unnecessary therapy or surgery on a part functioning healthily. Range of motion familiarity can also provide a yardstick to a surgeon to help fine tune the surgery while you’re on the table, and a framework which can be used to measure your post surgical rehab progress. And finally, knowledge of these criteria can assist your physical therapists who are trying to get your strength, flexibility or range of motion just right again.
I also want to emphasize that the standards I’m mentioning are ideals for the most elite, the professional dancers. These individuals stress their bodies to the limit for forty-plus hours a week for twenty to thirty years. They need most precision machines. I must emphasize that many recreational or casual dancers have seen me over the years with shapes and ranges far different from ideal, who’ve danced quite happily for just as many years, if not more so, than the pros. Their off-ideal dance bodies are forgiven by their less than extreme dance schedules and choreography.
Mentors and important individuals:
My most important and constant debt I have regarding those who had the most influence on my career is of course to every single dancer who’s trusted me to be their doctor. To any particular individuals, I must first bow profoundly and equally to two giants. Richard Schuster, DPM, my orthopedics and biomechanics professor during my schooling and fellowships, who taught me to think outside the box and elevated my appreciation of functional human biomechanics from the academic to the sublime, and William Hamilton, MD, the orthopedist emeritus to the NYC Ballet who trusted me to work with him through the first 38 years of my career until his retirement, from whom I learned so much, but nothing greater than to approach every patient with the attitude that it was I who was sitting in the examination chair and thus how I would expect to be treated.
Besides performing artists, all of them, world-known to unknown, whose names I will not mention for privacy reasons, my unending thanks will ever be profound. Non-performing artists include Bart Nisonson, Donald Rose, Dennis Richard, Paul Jordan, Marc Caselli, Richard Bachrach, Eivind Thomason, Arthur Gelb, Fran Levy, Marika Molnar, Irene Dowd, David Weiss, Jessica Gallina, Abby Corsun Sims, Peter Marshall, David Thomashow, Phil Baumann, Ben Benjamin, Marijeanne Liederbach, and the list is endless and I must stop here and apologize to the many I cannot instantly recall to whom I will be forever in debt.
Obstacles I encountered while building my career
-In NYC in the late 70s early 80s podiatrists had to weather a fair amount of disdain from the orthopedic community in nyc now mostly gone. This influenced my decision to not do surgery after my residency and underscored my critical attitude and the commmunity-wide well known fact that a lot of surgery being done was not adequately vetted with aforethought or conservative attempts, or mindful of the big question: how likely is this patient to better execute their chosen activity whether it be walking or doing a grande jete with any treatment, including surgery. I wanted to explore how to vet…and I, (with copious repect to surgeons with more courage and dedication than I), didn’t have the courage to potentially adversely affect the quality of life of potentially hundreds of people with failed surgery before I figured out how to decide if surgery was the best option. Of course I think now how my career might have turned had I decided to become a surgeon, but I wind up feeling, at least for the time, the era, the freshness of the performing arts medicine field way back then, and the lack of data on etiology and statistical results of treatments when I started, that the decision I made was right, and I wouldn’t have developed the principles I now use, not only on dancers, but have commonly extrapolated to my general population, had I invested the necessary concentration on surgery.
So you may sense how much I owe dancers, respect and love them, and feel so fortunate that I was blessed with this life’s path. With the advent of aerobic fitness classes, I felt years ago that the recreational ballet population had begun to decline and the importance of doing everything possible to keep the genre healthy. And I feel it’s making a comeback. And I feel the Pandemic will spur on our appreciation of dance, and our gratitude to these exquisite demi-gods sacrificing everything to keep it alive.
Let me end by saying that when I attended a pre-pandemic City Ballet performance of Coppelia, seeing all the little kids in their ballet outfits sitting on their parents laps and in rapt attention, I welcomed the tears coming to my eyes, because then I knew that this ancient art form would never die.