This lovely professional ballerina with the hard to spot accent was sent to me by her company orthopedist to be casted for orthotics for her street shoes. Despite the frustration she'd experienced over the previous 5 years, she was charming and full of youth. She would need it. She was already a brilliant dancer by the age of nine when her dad, a native of Italy, had died. Shortly thereafter she left her mom in Finland as she was offered the opportunity to further her dance studies at one of the world's foremost ballet schools here in New York City. Although she was impeccably trained and well cared for at the school, a nurturing environment alone was not enough to prevent the string of injuries that would harass her adolescence.
She'd had ankle surgery at the age of fifteen to remove a piece of bone blocking her ability to pointe. Later she took significant time off for a pinched nerve in her low back that had prevented her from executing arabesque, and had incurred multiple sprained ankles thereafter. She'd graduated ballet school at the age of 18, and despite the down time was immediately recruited by three of the world's top companies without so much as an audition. Having danced professionally for barely a year, when she came to see me she was enduring a bizarre ankle injury that had prevented her from dancing for the prior three months. She experienced pain and clicking all around both sides of her right ankle whenever she tried to go up on tip toe. She'd worn high heels to a party the night before visiting me, and presented to my office limping as a consequence. Her orthopedist had just performed another thorough exam, as had several physical therapists. Recent X-rays, MRIs and CAT scans were all completely clean. She had just moved from her company city in Europe to New York City to visit the dance doctors here until she got an answer. No one had an answer. Still what struck me most was her cheer and her personable way.
Almost as striking were two unusual physical characteristics I don't usually see in dancers. One was a big lump like a squared tablespoon under her skin at the site of where one of her toe muscle bellies should be back by her heel. The other was a sharp increase in the apparent inward curvature of her lower leg just before it met the ankle. On closer examination, I would determine that the leg curvature was due to the lack of bulk of her main calf muscle, the soleus, which normally hides the bone curvature and instead donates its straighter shape to the lower inside leg. These circumstances made me pretty confident I had solved the problem, but I proceeded further to make sure I wasn't applying a "Novella boiler plate".
I couldn't wait to do my dance range of motion tests. As I expected, she had a very low-toned calf muscle: her demi-plie, or ability to bend her foot upwards at the ankle, was hugely too great (this motion is normally arrested by a strong soleus). I measured the circumference of her involved-side calf and it was an inch less than the good leg. Even a half-inch difference is significant, let alone a whole inch. I rekoned she'd lost her soleus strength during the back injury, as the L4-5 disc she mentioned that was getting pinched controls the soleus. I then checked the strength of her big toe. I knew it. This waif had one of the strongest big toe muscles I'd tested in 32 years! Nearly pushed me off my stool. The tablespoon at her inside heel was one of the big toe helper muscles, the abductor hallucis. The main muscle, the FHL or flexor hallucis longus, runs behind the ankle bone, directly under its big brother, the soleus muscle. I figured she was able to resume dance after her back calmed down by unknowingly building up strength in her FHL to do the job of her soleus. No therapist had seen the need to spot-strengthen her soleus, because she was able to dance now thanks to the FHL, which I often see take over for dancers in the presence of a low-toned calf. As her FHL got stronger, she unconsciously employed her big toe muscle to elevate her heel instead of her calf muscle. Subsequently the muscles that stabilize the toe onto the foot had to get stronger. Weight lifting reshapes the body most efficiently during adolescence. She said the (big toe stabilizer) muscle back there by her heel at one time had looked like it had been transplanted from Arnold Schwarzenegger's foot. It had actually forced her to order bigger pointe shoes! She thought it was strange that this hard-boiled egg quickly reverted to a tablespoon in size as soon as she began resting from dance. In addition to all this, she had excessive mobility in all her joints, including the ones in her back. She'd been given abdominal muscle crunches to rescue her back, but she'd let them slide during her recent three-month down time from dance.
On the plus side, she had copious pointe, so the bone-removing ankle surgery had been supremely successful, and very strong sprained-ankle protector muscles (the peroneals). That was great. One less hurdle. I also realized that she must be dancing in some pain in all these injury and surgery sites, but never felt the need to report it. When dancers grace my office I regard them as demi-gods. If there has been any constant in my career, it's been the degree of professionalism and sacrifice dancers demonstrate through their willingness to live with pain throughout their careers. This young lady was a poster child for the a priori knowledge dancers have that they will get back to dance if they just can figure out what is wrong. They don't give up. Imagine how this has bolstered my tenacity when I try to figure out people's problems. I will forever be indebted to dancers for the inspiration they have given me.
OK, back to our dancer. As I mention in another dance case history on this site, the FHL rides behind the talus bone. The talus bone is the topmost bone of the foot where it joins the leg, forming the ankle joint. Now the FHL tendon is a very strong string, like a bass string on a Steinway D. There's a groove for this tendon in the back of the talus, so it has the potential to really leverage the talus forward. This young dancer had experienced many ankle sprains, which loosened her ankle. This allowed the FHL to readily bully her talus forward each time she'd try to lift her heel off the ground. She was lifting her heel with her FHL, rather than the muscle that should be doing this job, the soleus. The ligamentous structures about her ankle were being strained as the talus then also squirted forward way beyond where it was supposed to go, causing the clicking and the pain about her ankle. Her flabby soleus not only wasn't doing its job to elevate her heel and arrest her plie, but it also was too lazy to help retain the foot from pushing forward when the FHL fired.
By now I was confident I had a handle on it, so what do we do? How many of you vote for soleus strengthening exercises? Me too. Guess what? They're not easy to do even in the best of circumstances. They involve a somewhat complicated bent-knee tiptoe maneuver. In her case they would become doubly complex, because at first when she tried to strengthen her soleus, she'd experience the same ankle pain, since she couldn't isolate the big toe (and therefore the ankle pain from the overuse of the FHL) out of the picture when she tried to elevate. I wound up giving her bent knee barefoot single-leg tip toe exercises with the ball of her foot rocking on two strapped-together 2 by 4 pieces of wood covered in gel and no toe contact, holding one finger sideways against the wall for balance. I also asked her to resume her crunches for her back stability, lest any disc problems recur to sabotage her soleus strengthening.
I deliberated on whether I should make her the orthotics her orthopedist called for. Orthotics often help the FHL when it's hurting. Dancers with FHL problems usually love orthotics. That's why I decided not to give them to her. I didn't want to help her FHL at all. So long as her FHL wasn't hurting per se, I wanted life to be as difficult as possible for it from now on. Hopefully this would get the muscles that should be working, a la the soleus, back up to speed quicker. I even told her to wear flimsy, not supportive shoes for the same reason. Her toe muscles (which support the arch) were so strong, she had no need for orthotics. That doesn't mean I didn't cast her for the orthotics. I did. That's what her orthopedist asked for, and politics have a lot to do with keeping the machine oiled. I just had no visualization of ever actually giving them to her. I visualized her saying she was feeling better already by the time she came in to pick up the orthotics. That's why I made a little white lie and told her the orthotics would take a month to come in from the lab instead of the normal two weeks. I'd figured, with her youth, intelligence and professionalism, she'd apply herself to these exercises and if my theory was correct she would be feeling so much better in about a month she'd realize she didn't need the orthotics by the time of her orthotic appointment. I advised her, "Make sure you bring your sneakers and their removable insoles to the office next month when you come to pick up your orthotics, or I won't be able to give you your orthotics, because I have to trim them to the sneakers."
When the fourth week rolled around since her initial visit, she cancelled. She rescheduled again for the fifth week, and re-cancelled. My confidence in having solved her problem was beginning to shake.
But on the sixth week she came back to my office, wearing slightly high heels, not limping, beaming. "Where are your sneakers," I said?
"I decided not to bring them, because I don't think I'll be needing the orthotics. But I do now find myself having to dance in pointe shoes a full size smaller. Would you mind checking and make sure they fit OK?"
Is this a great job or what?