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Hi Lisa!

I am a Physiotherapist in British Columbia, Canada.  I work as an orthopaedic manual therapist in a private practice. My Daughter is 10, and has been plagued with foot problems on and off for 3 years.  Even in my line of work, I am stumped by it.

She has been dancing since the age of 3 and for the past 3 years has been dancing 10-15 hours per week in all disciplines, including Ballet.

She has been suffering from postero-medial "impingement" type signs and symptoms.  At first i thought it was Achilles Tendinitis, but then realised the pain was with plantar flexion, but equally with passive vs active movement.  In mid-September of this year, the foot was at it's worst. Her range of plantar flexion was diminished by about 50%, with a springy blocked end-feel.  Since relatively resting for 8 weeks, her ROM has improved to about 75% normal, and the pain is not constant, but is definitely exacerbated by dance (she likes to run too, and has completely eliminated that since early October)

She has been to see an orthopaedic surgeon (though not a paediatric one, nor one who is terribly familiar with dance)  He seems to think it may be a Tibialis Posterior syndrome, but I'm not so sure given the springy block.  In any event, he has ordered an MRI (which will take forever in our medical system).  Her plain XRay seems to look quite normal, however the radiologist reported "sclerosis and fragmentation of the posterior calcaneal apophysis and a tiny ossific density at the superior aspect of the apophysis."  The surgeon was non-plussed by this finding.

My concern is that, if it is a growth plate issue or a chronic tendinosis, should we be backing off even more so as not to risk long term problems.  Dance IS her passion, but I don't want it to be at the expense of not being able to lead an active lifestyle down the road.

I am thrilled that you are pursuing these dancer's injuries...I agree with you...they get brushed off by the medical system....as do many juvenile sports-related injuries...unless they are from Hockey!!!! (Here in Canada, at least!)

Thank you so much for any information that you can provide.

Sincerely,

Sandi

Dear Sandi

Thanks so much for your email - sorry that it’s taken me so long to get back to you! (We had a LOT of emails on this topic!) I hope that I am able to shed some light on some possible issue for you! It is often frustrating for parents who are medical professionals themselves to find information that will really help their children - if it is not an area that they actively work in.

Pain at the back of the ankle is a big issue for many dancers, and often gets misdiagnosed as Achilles Tendonopathy. In many cases this is not actually the issue, so coming to a correct diagnosis is essential. The MRI will hopefully shed some light on the actual structures that are affected, however there are lots of functional things that you can assess, and begin working on while you wait! It is great that your daughters pain has reduced with rest, which may indicate some inflammatory component, however there is also most likely an issue with her foot mechanics in relation to dance, as it is getting exacerbated again so easily. It is very important to identify this, no matter what structures are affected, to ensure that it does not occur again.

The constant and repetitive demands placed on dancer’s feet, along with training and performing in non-supportive shoes, requires them to have great biomechanics and exceptionally specific control of the muscles that support the foot and ankle. As I have worked with dancers for many years I am acutely aware that it is not enough for dancers to be able to 'do'  an exercise. Even more important is how they do it - i.e. the patterning of muscle firing that goes into the performance of the task. Very subtle changes in performance of a seemingly simple step can have huge implications to the long term health of the dancers feet, the development of their bony structure, the stability of the muscle chains further up the leg, and of course injury, especially overuse injuries of the tendons of the muscles in the lower leg, foot and ankle.

This is why I spend most of my life on my knees - analysing movement strategies in the foot and ankle - and refining ways of teaching dancers how to correct them!

But before we get into that - lets look at the structures that may be involved - based on your description... If you have pain in the back of the ankle it is important to make sure that it is not coming from any of the other structures in the back of the ankle. Other things that may cause pain in the back of the ankle include:

Now, you don't mention an Os Trigonum in the x-ray report, so I will take that out of the equation - however the sclerosis of the calcaneal apophysis and ossific density do raise a flag for me.... Even if there is no sign on palpation of Severs disease... there is obviously some excessive load being put through that area, that needs addressing, especially due to the fact that she is just 10 years old and obviously in an active phase of growth. The reporting of fragmentation at the apophysis may indicate this.

To narrow down the diagnosis, I would try combining specific muscle testing of each of the muscles that have a tendon passing through the area, combined with palpation of the tendon. This will often isolate the location of pain to just one tendon (hopefully) to give you a clear diagnosis, that will be confirmed on MRI.

I would also be assessing the mobility of the subtalar joint, compared to the other side. In chronic tendonopathies - I often find that there is a restriction in the accessory glide of this joint, that when treated, makes a huge difference to the dancers point range. If it is blocked, pointe range can feel restricted, resulting in the dancer 'trying harder' to point their foot, and as a result, overloading the structures around the area. Try stabilising the talus, and testing the rotational and sagital plane glides of the joint. A combination of a lateral glide bringing in a slight rotation in line with the joint surfaces is often very effective.

But then, we need to know what to do.

I am not sure how much you have heard of the new research that is going on into tendonopathies - however my staff and I were listening to a Podcast just a few weeks ago, by well known Physiotherapist and researcher Jill Cook, and she made a few very good points.

  • Much research has demonstrated that most tendon injuries are in fact tendonopathies (degeneration of the tendon) rather than tendonitis (inflammation of the tendon). Therefore, the old treatment of RICE will not be effective on reducing symptoms, however icing can help reduce vascularity in the tendon (as a result of increased sensitisation due to overload) and can help reduce the pain.
  • Tendonopathies usually have 2 stages - and initial sensitisation phase - when it has been overloaded and the cells in the tendon become ' activated'  and degradation of the tendon in a more chronic tendonopathy.
  • You will also not get an injury in a tendon, if there is not already an underlying degeneration in the tendon - so her technique definitely needs a look at.

Common problems for overloading the tendons in the area where she is sore are:

  • Poor firing of the medial gastrocnemius
  • Clawing of the toes (FDL + FHL)
  • Pushing over on the big toe in tendus (FHL)
  • Rolling in of the arches, (Tib post)
  • Over correcting the arches using Tib Post instead of intrinsics
  • Poor control of the intrinsic muscles of the feet, in standing and with movement
  • Hypermobility and poor support of the position of the heel
  • Pes Cavus foot - resulting in poor shock absorption with jumps
  • Poor control of the Soleus muscle in eccentric lowering
  • Using a Foot Stretcher to try to improve pointe range

Now that is a pretty full on list, but if you assess her doing a plie, a rise and a jump in both parallel and turnout - with these things in mind - then you will probably pick up lots of things to work on.

As for her case load of dance, I would definitely back of rising and jumping until you can settle the pain. Taping to offload the Achilles attachment into the heel may help reduce the pain as well.

Sorry to do a product plug - but this is exactly why I wrote the Advanced Foot Control for Dancers ProgramAdvanced Foot Control Program

So many of the foot and ankle injuries that plague dancers trace back to the simple problem of one muscle not pulling its weight, another taking the strain, and then over time an overuse injury occurring. What I have done to help advanced dancers, teachers and health professional out, is to make the book about the correct function of each muscle for the dancer, and I have then created lots of Injury Reports about all of the common injuries that I get questioned about. These reports outline what the injury is, how it occurs, how to treat it, and how to stop it from coming back!!!

This makes it easy for someone like you to take on the treatment of your own daughter if there are no dance therapists around by learning the specifics of how it all should work in a dancer, or for dancers to learn the anatomy and options for treatment if there are no health professionals who know about dance around. They can also take the information to their therapist to help develop a great rehab program that is dance specific!

Hope this helps!

Let me know how you go with this, and with the MRI...

Kindest Regards,

Lisa.

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