I was recently visited by a 36 year-old Broadway dancer. She’d danced a particular role on tour for many months. She took a leave of absence to have a son, then returned to the same role, but now in the Big Apple. Like most other pro dancers, she’d had lots of ankle sprains, and she recovered. This time, not even recalling a provoking sprain, a pain started during rehearsal right where her earlier sprains used to hurt. She was able to dance through this pain for the six consecutive months since it started, but it was steady-state, not getting better, despite countless visits to physical therapists, ice, anti-inflammatories, and acupuncture. She’d visited two dance orthopedists and a podiatrist, all of whom had recommended surgery. When she inquired regarding the specifics of the surgery, each was at a loss to offer exact details.
Feeling unsettled, this prompted her to seek my opinion. Were she to have surgery, she was advised she’d be out of dance completely for 6-10 months. This is a very long break for a dancer her age, as it takes more time to regain strength and balance as one gets older. Knowing I’d performed restorative injections (prp and prolotherapy) for various sprains on her dancer friends who’d referred her to me, she was hoping I might be able to give her such a shot and save her from an uncertain surgical alternative.
The pain was just behind her ankle bone, on the pinky-toe side, not so far back as her Achilles. A little physical therapy had always quieted pain there in the past. Certainly this should pique one’s interest, as there wasn’t even an incident this time. She was performing the same role, in the same costume, the same number of performances per week, except this was after a maternity leave, and in a different theater. She was still nursing. Her recent MRI showed no stress fracture (these occur more frequently in nursing moms, who donate calcium through their milk to their babies).
There are two oft-injured tendons at this site, the peroneals. These tendons commonly heal with asymptomatic battle scars, i.e., patches of scar tissue replacing original tendon tissue. This is called “tendinosis”. Tendinosis is somewhat weaker structurally than original tendon, but it usually does the job fairly well. Her peroneals were tender to my palpation. They also hurt a bit when I resisted their motions. Nothing else hurt to during the exam, and she affirmed this was the site of her nagging discomfort. She’d had an ultrasound study performed, and the report she brought mentioned she had tendinosis of the two tendons, and a small tear in the tiny film of tissue which separates the two tendons.
All right, this really piqued my interest. These findings are common to nearly every dancer whose peroneals I’ve examined, and certainly not enough to bring people into the operating room. I decided to perform my physical exam, a series of tests for normal strength, alignment, and motion I do on nearly every dancer (and most other patients) whose problem requires it. I have been performing this exam, updated of course as my experience guides, since my orthopedics/biomechanics fellowship in 1978. It persists as the go-to foundation of my physical exam. But only because things were not making sense to this point, I also decided to perform an ultrasound exam (a “sonogram”).
Pardon this digression, but I have performed over 7,300 sonograms on over 3,300 patients since 2007. Ultrasonography has become an essential part of my practice. My current ultrasound system, made by GE (this is my ninth machine upgrade) can show detail down to about a tenth of a millimeter. There are not many things that bring one in to a doctor’s office which are that small!
Ultrasonography has a rather stiff learning curve, but like most intimidating journeys, once there you wonder why it seemed so difficult to arrive. Though this tool has only been with me for 1/6th of my practice years, I’ve adapted it to the needs of my patients and the way I practice.
With a sonogram, I can find deviations from normal tissue when I look under the skin at a complaint site. I can see if a tissue behaves abnormally when I move toes, ankles or other structures the tissue is attached to (as opposed to MRI, X-rays and CT scans, where one has to remain perfectly still). I can press a questionable-looking area with the ultrasound probe and ask my patient if it hurts, to help identify the exact injury site. I can interpret how tissues are responding to therapy from visit to visit. I can use ultrasonography to help me predict when an athletic person can safely return to sport. Ultrasonography is invaluable when giving injections, to make sure the injectable is placed accurately at the intended tissue, reducing risk to innocent tissue. I can tell if a mass under the skin is fluid-filled, like a cyst, or filled with solid tissue, and I can tell by looking at the blood vessels if they are abnormal in number or shape, suggesting a benign or malignant tumor. I can find foreign bodies, and even differentiate warts from calluses.
In the case of this dancer, I could see if her tissue warranted a restorative injection, or even surgery. I decided it warranted neither. Just as the three surgeons were hard-pressed to detail what would be done surgically, I couldn’t rationalize a site to inject. I saw the bit of tendinosis, and the tiny tear, perhaps ½ millimeter in width and less than a centimeter in length, way up higher in her ankle than her complaint site. I could find nothing else. I couldn’t see how either of these findings could warrant much “treatment” to the actual tissue.
When I am confronted with such a crossroads, and it happens plenty, I have find other paths. One, a patient’s history. Been there done that, and her history had already given me some clues. Two, my pillar, my 36 year-old clinical exam. We were about to walk down that path. And three, which should never be underestimated, perhaps there was a gremlin (my term for an often unheralded abnormality). We may find such gremlins in shoes, surfaces, exercise habits, therapy, orthotics, pads, etc., which could easily be deemed benign. These untouched gremlins are often the key to the issue. Young doctors: start looking for gremlins, and you will develop a lexicon of these pests and a savoir-faire for discovering others.
OK, let’s do the exam...pointe, OK; relevé, OK; plié, OK; general alignment, OK; turnout, OK; shoes match feet and calf tone, OK; big toe motion, OK; rearfoot motion, OK; after about ten more “OKs”, I got to a “Whoa, wait a second!” This lady had a major forefoot valgus (the ball of her foot was misaligned with respect to her ankle, in such a way that it would place repetitive strain on any weakened structures in the outer ankle, such as the peroneals).
As is my habit, I asked her to let me watch her walk. She did not have the abbreviated stride I expected I might see, which might indicate an inhibition to use the uncomfortable tendons. Again, this finding pointed away from intervention-warranting tissue damage, yet still, I’m doctor number four in six months. And dancers are tough, and often function successfully throughout their careers with a fair amount of pain. Hmmmm......
OK, I needed one more letter before I might call out “BINGO!” Find the gremlin. I knew my patient was performing in a new theatre. Hmmm, what could be peculiar to a theatre which could allow a forefoot valgus to so irritate a mild peroneal tendinosis?
“Are you performing on a raked stage here on Broadway?” (A raked stage is one which slants from a higher elevation upstage to a lower elevation downstage). Her response, “Yes. My other stages were pretty flat.”
The raked stage doubled the adverse influence of her forefoot valgus, and began irritating her peroneals. She didn’t need surgery, she didn’t need injections. She needed to negate the influence of the raked stage upon her peroneals, so she could return to the same equilibrium she’d had on flat stages. Her treatment? Continue icing it and do a little more physical therapy to calm it down from the state it had acquired, but mainly, keep using that little felt wedge pad she’d already intuited. Bless dancers’ intuition. She’d placed the pad under the outer ball of her foot (metatarsal heads 2, 3, 4, and 5) to reduce the forefoot valgus influence and enable her to continue performing on the raked stage. I simply showed her a slightly more effective way of making the pad, gave her a big roll of adhesive felt, and asked her to call me in a month unless she was having any problems.
I know it’s an early read, but she’s had her first pain-free fifteen days since she started rehearsing, six months ago. Based on everything we’d discovered, I had no reason to expect anything but resolution. I’ll keep you posted.