Thursday, July 23, 2009

Part 4

This is the last of the article I am deciphering, link.

"Top Treatment Tips For Tendinitis

Although tendinitis can be an acute condition, the frequency of recurrence and the nature of dance tend to make chronic tendinitis a common occurrence in dancers.

You will frequently see Achilles tendon problems that are associated with muscle weakness of the feet, lower leg and thigh musculature. Tight-fitting pointe shoes or shoe ribbons that cut into the tendon may also cause Achilles tendon problems. When the gastrocnemius and soleus muscles are tight, dancers have difficulty with plié and often have poor weight distribution, resulting in faulty technique.
Treatment includes contrast baths and NSAID medication. During the initial acute phase, employing a small heel lift in street shoes can be effective. However, the cornerstone of rehabilitation and prevention of re-injury is a structured stretching program the dancer or patient performs in conjunction with eccentric and concentric progressive resistant exercises.
Flexor hallucis longus (FHL) tendinitis may manifest as posterior medial ankle pain, arch pain or great toe discomfort. The dancer typically experiences posteromedial ankle pain with a “clicking” or locking sensation of the great toe when he or she points the foot or when going from the fully pointed position to a more dorsiflexed position. Sometimes, an audible pop occurs with this maneuver.
During the physical examination, you will note tenderness over the posteromedial aspect of the ankle in the zone between the retomalleolar region and the sustentaculum. Passive motion of the great toe and ankle may induce symptoms of tendinitis when palpating along the FHL. Be advised, however, that this does not often induce the popping unless the patient actively contracts the FHL tendon with the foot pointed and the toes plantarflexed.
Distinguishing between a posterior impingement and the FHL tendinitis is challenging because the two structures are in close proximity and these conditions may co-exist (see “Detecting Posterior Pain Syndromes Of The Ankle In Dancers” above).
When conservative treatment is indicated for these patients, emphasize relative rest and avoidance of the offending positions. A course of NSAIDs and physical therapy with phonophoresis or iontophoresis is warranted.
For resistant cases, you may employ a boot brace or a steroid injection. On some occasions, FHL tendinitis may be recurrent and disabling. In these cases, operative tenolysis may be indicated, but one should only consider this option after at least a year of conservative therapy in the young dancer or six months in a professional."

This is typical tendinitis meaning tendons are damaged due to various factors; muscle inbalance or excessive wear with restrictive or tight fitting shoes not allowing full movements and blood circulations. Like most tendinitis, use RICE, Rest-Ice-Compression-Elevate. Perhaps not Elevate. The rehap is the key to recovery. Whatever exercise you do, you need to do both sides not just the side with problems.

Part 3

"A Guide To Anterior Ankle Impingement And Os Trigonum Syndromes
The extreme dorsiflexion required by the demiplié position in ballet can lead to impingement of the anterior lip of the tibia on the talar neck. Anterior ankle impingement results from osteophytes occurring on the anterior tibia and talar neck.
The dancer’s first recognition of the syndrome is lack of depth in the plié, which is often associated with poorly localized ankle pain. With time, the dancer may experience more localized symptoms to the anterior aspect of the ankle. These symptoms often include mild swelling. You can attain symptomatic improvement by encouraging the use of a 1/4-inch to 3/8-inch heel lift in street shoes, antiinflammatories and having the dancer discontinue forced plié.
Definitive treatment consists of excising the offending osteophytes, either arthroscopically or through an anterior arthrotomy. Keep in mind that you’ll often see secondary inflammatory changes involving the capsule, the fat pad and local synovium. An exostectomy merely extends the dancer’s career. Repeated impingement will invariably lead to recurrent exostoses, usually within three to four years. Repeat excision may therefore be required in some cases.
While it is rare in the general population, posterior impingement of the os trigonum is common in dancers. In extreme plantarflexion, an os trigonum, a large posterior tubercle or less commonly, a large dorsal process of the os calcis, is compressed intermittently for periods of up to six hours a day from the dancer standing in the demi-pointe position. The dancer with symptomatic posterior impingement presents with posterior ankle pain aggravated by relevé and relieved somewhat by plantar grade stance.
The differential diagnosis includes Achilles, peroneal and flexor hallucis tendinitis. However, for these conditions, the symptoms are rarely aggravated by plantarflexion. You can reproduce the pain of posterior impingement via forced plantarflexion. When it comes to treatment, you should emphasize a flexibility program, with attention to stretching, and an antiinflammatory medication. If symptoms become disabling, surgical excision of the bony mass is indicated."

This is a problem of your ankle as you spend more and more time standing on your tibia and locking your ankle. You would have to spend a lot of time doing this not a beginner's problem.

Part 2 - Metatarsus


These are little bones in your foot. There are five in each digit.

"How To Address Metatarsal Stress Fractures
Metatarsal stress fractures do affect ballet dancers, but the most common one you’ll see is at the base of the second metatarsal. As with many stress fractures, it is often difficult to see these injuries on the X-ray film, especially within a week or so of the onset of the symptoms. Persistent tenderness in the proximal first web space or around the base of the second metatarsal in a dancer usually indicates a stress fracture until proven otherwise.
This condition is usually an indication for a bone scan. However, if the dancer is very young, you would simply instruct her or him to refrain from jumping and doing grand pliés until the pain and tenderness are gone. You usually don’t have to put this fracture in a plaster cast. Activity modification for six to eight weeks is usually sufficient for the fracture to heal providing the dancer has not been working on it for a prolonged period of time while it was hurting. If she or he has, it will probably take longer to heal.
The most common acute fracture you’ll see among dancers is the spiral fracture of the distal one-third of the fifth metatarsal, also known as the “dancer’s fracture.” Dancers sustain this fracture when they lose their balance while on demi-pointe and roll over the outer border of the foot.
If it’s a displaced fracture, it may be necessary to put the dancer in a walking cast for four to six weeks while it heals. (One can accept a considerable amount of displacement with this fracture.) In fractures that are minimally displaced, it is often sufficient to emphasize a comfortable running shoe and restricted activities until the fracture heals. This approach will allow dancers to swim and stay in shape while they are waiting to dance again. Occasionally, you may see a markedly displaced and comminuted fracture. In this case, performing reduction and internal fixation will be necessary."

This is an obvious injury of a fracture of any bone out of 25 pieces in your foot. It is a marvel to know there are 50 pieces enabling you to do all those fancy moves. Fracture occurs when maximum presssure is applied and you go over a tipping point. Basically you will feel this one and will require you a cast and rehab.

Deciphering Foot Troubles - Part 1

Following text is from a link which summarizes most of problems the dancers have by placing much pressure so often, link.

There is a lot of jargons.

"The collateral ligaments of the lesser metatarsophalangeal joints can be torn by a dorsiflexion sprain or, in an older dancer, can be stretched out, slowly leading to instability in the joint".

Smaller ligaments of smaller toe joints can be torn by sprain involved in stretching at the end. There is no difference between stretching or tear of ligaments.

"When the dancer relevés onto the ball of the foot, the base of the phalanx subluxes onto the dorsum of the metatarsal head, forcing it downward (the dropped metatarsal), leading to metatarsalgia. When the dancer comes back down to the floor, the phalanx relocates and appears normal."

This means when your habit of doing this exercise strongly and causing the damage, afterwards, it looks normal but the damage is done.

"The regular set of X-ray films will also be normal. To pick this condition up during the physical exam, you must do a Lachman test on the metatarsophalangeal joints. This test is similar to that which is done on the knee. When you test the joints in this manner, the affected toe will easily dislocate and then relocate, making the diagnosis apparent."

This says metatarsophalangeal joints are so loose that you move parts of these joints and see them moving too loosely. Given minimal time doctors spend with you and they don't know exactly what is normal for you, it would be up to you to describe what is normal. Dancers brag about how flexible they are, this is exactly how you damage youself by making yourself even more flexible.

Once the ligaments are loose, you cannot tighten them without surgical intervention. Sometimes flexion exercises and a toe retainer with padding under the metatarsal head will at least make the problem workable.
The subluxing cuboid is a common but poorly recognized condition. It presents as lateral midfoot pain and an inability of the dancer to work through the foot, i.e., go smoothly from foot flat to relevé. This condition may present as an acute sprain or an insidious overuse injury. The dancer is unable to run, cut, jump or dance without a marked increase in discomfort or a feeling of weakness and lack of intrinsic support in the foot. Pressing on the plantar surface of the cuboid in a dorsal direction is painful. The normal dorsal-plantar joint play is reduced or absent when compared to the uninjured side."

This says, you stretched it too much and it requires an operation to shorten stretched ligament. It also tells you can dance but can't improve or achieve optimal activities.

"Severely subluxed cuboids leave a shallow but definite depression you will see on the dorsal aspect and a palpable fullness on the plantar aspect of the cuboid. Treatment usually involves a manual reduction called the cuboid whip. This reduction should be performed by a practitioner who is familiar with the condition. You may also need to repeat the maneuver."

Please read this article, link.

Definition of subluxation from Wiki

"An orthopedic dislocation of any joint will never need medical attention to help relocate or reduce the joint. Nursemaid's elbow is the subluxation of the head of the radius from the annular ligament. Other joints that are prone to subluxations are the shoulders, fingers, kneecaps, toes, elbows, eyebrows and hips affected by hip dysplasia. A spinal subluxation is relatively rare, but can sometimes impinge on spinal nerve roots causing symptoms in the areas served by those roots."

Ankle Sprain - Fast Recovery

Lots of people sprain their ankles every year. I was walking from the car to the camp and stepped over sloped rock and twisted.

In keeping with techniques I learned, I sought to heal myself. It turns out it is easier. First off, it does not take 4 weeks. If you follow this process, it will take a week and half.

My method is as follows but I am following Robert Kennedy's method which is close enough but better with Hot-Cold therapy. First, Ice 10 minutes. Use plastic cup to make ice. RICE method means Rest Ice Compression and Elevation, [1][2]. First 24 hours is crucial. Keep applying ice with a rest of an hour minimum. As long as you keep your swelling down, you are doing good. If you are using an ice bucket, ice 5-10 minutes and no more. Rest and elevate. Watch taping method in this video. I used a ready made one. I now believe taping is better.

In most cases, you can have swelling down soon. The key is not to re-injure your ankle. As soon as you can, walk. Walk and move and rehabilitate as soon as and as long as you don't have pain.

Stop when you have pain. You get full range of motions. Use your hands to stretch and find where and when it hurts.

See these exercises. Note you need to do them on both feet. This is important.

I am able to move without pain and have full range of movement after a bad sprain. But I learn how difficult it is to have a sprain ankle. There is a minimal exercise you can do to avoid sprain ankle for the rest of your life. Here it is; stand one foot at a time for a minute. Switch. Do it once or twice a day. Here is the NYTimes article.

Here is another interesting article from NY Times. Another article by John Kennedy MD.

"Phase 1: Immediate early treatment goals are minimizing soft tissue swelling and regaining range of motion. This is done by applying a compression bandage around the ankle and foot. Elevate the ankle higher than the heart. Apply an ice pack for 20 minutes to control internal bleeding and fluid accumulation. Apply ice every two hours while awake for the next 48 hours. When the foot is elevated, perform range-of-motion exercises by keeping your heel still and tracing the alphabet in capital letters with your big toe.

Phase 2: After 48 hours, the goals are to eliminate all swelling and pain, regain full range of motion and restrengthen the muscles that stabilize the ankle. Remove the compression wrap and immerse your ankle comfortably in a container of hot water (104 degrees Fahrenheit). Perform the air alphabet. Next, place your foot into a container filled with crushed ice and cold water. While keeping the heel of the injured foot on the bottom of the container, lift and rotate the foot up and out until it makes contact with the side of the container. Hold that position for eight seconds, relax for two seconds, and repeat.

Start the hot-water exercises and perform them in descending periods of five, four, three, two and one minute. Alternate each of them with one-minute intervals of cold bath exercises. Continue using the compression wrap until the ankle has no swelling and is pain free.

Phase 3: The goal is to restore range of motion and regain strength to the muscles stabilizing the ankle. You want to be able to stand and balance on the injured foot for 20 seconds without wobbling. Heel raises are excellent. Stand on the injured foot and slowly raise your heel off the ground, then slowly lower it. Repeat 10 times for three sets. Once you can stand and balance on the ball of the injured foot for 20 seconds and have regained full range of motion, begin a jogging program on a flat, smooth surface for up to 20 minutes. When finished, ice the ankle for 20 minutes. When you are able to run on a field or court in a large figure eight pattern at quarter speed, advance to half speed and then full speed. At that point, you can return to full activities."



MAYBE the problem is that it is hard to understand what your body is saying.

This blog is dedicated to dancers and their pain.

rehabs, prevention, exercises