What is Severs?
Severs disease is an inflammatory problem found in the young dancer/athletes, and is related to periods of sudden growth. The problem is located at the back of the heel region. It has a similar mechanism to oschgood slatters disease found in the knee on the tibial tuberosity.
Causes of Severs
When we go through growth spurts, it is usually the bones that grow first. The muscles and then finally the nerves catch up later so that everything “fits” again. If the calf muscles are slow to catch-up they become tighter and relatively short, and as a result they can pull and tug on their insertion point at the calcaneum until it becomes inflamed and painful. It is called a “traction apophysitis”
The foot is made up of many bones, the large heel bone being the calcaneum. It is around this bone that is effected by severs disease and often the site of pain.
Attaching onto this bone are the muscles of the calf region. We contract these muscles in order to point the foot and bring us onto demi pointe and pointe. They are also used to propel us into the air on jumping and leaping.
The calf region has many muscles. Some are very deep and move the toes, and help support the arch of the foot. These are called Flexor Hallicus Longus (FHL), Flexor Digitorum Longus (FDL) and Tibialis Posterior (TB) on the inside, and the Peroneals to the outside of the ankle and calf.
At the back of the calf is a muscle called gastrocnemius. This muscle has two bellies, and starts from the bottom of the thigh bone (femur), and forms a strong thick tendon, called the Achilles Tendon attaching onto the “heel” (calcaneum) bone of the foot.
A second strong muscle sits below gastrocnemius, and it is called Soleus. This muscle arises from the back of the “shin” (tibia) and joins to gastrocnemius to also help form the Achilles tendon.
When these muscles work together they point the foot, and also assist with take offs and landings in jumps.
Diagnosis will be made by your physician or therapist following a series of questions, and hands-on assessment of the area. There is normally no need for x-ray.
The condition will settle in time, normally over a 6-12 month period.
It is important to keep the body conditioned if on a period of relative rest. Exercise that is pain free may be undertaken to maintain CV fitness such as swimming. Pilates matwork is also beneficial to maintain strength throughout the body.
Although we cannot alter our growth patterns and rate we may be able to recognize if we are having a growth spurt and lessen the amount of activity that we undertake during this period. This will involve especially exercise that involves a lot of eccentric muscle work for example landing activities such as allegro.
What is Mortons Neuroma?
Although the codition is known as a neuroma it is not a tumour of the nerve. Mortons neuroma is actually a swelling of the nerve with occasional scar tissue formation around the site . it normally affects the nerve between the 3rd and 4th metatarsals of the foot.
A mortons toe is a shorter first metatatarsal , and therefore length of toe, compared to the second . This makes the 2nd toe appear longer than the first. It can also mean more difficulty with balancing as the balance platform made by the met heads are not even.
It is common to see a callus under the head of the 2nd met as more weight is taken on this area in walking as opposed to the first met.
Above the nerve is a structure called the deep transverse metatarsal ligament. This ligament is very strong, holds the metatarsal bones together, and creates the ceiling of the nerve compartment. With each step, the ground pushes up on the enlarged nerve and the deep transverse metatarsal ligament pushes down. This causes compression in a confined space.
Common symptoms of a mortons neuroma consist of Pain radiating to the toes. This can be accompanied with pins and needles, numbness, and a burning sensation.
Symptoms are usually worsened when the foot is compressed such as in a narrow fitting shoe or in high heels.
Such symptoms should ease off when the foot is at rest (non weight bearing)
There will normally be no bruising or effusion, but the area can be sore to touch.
A diagnosis can normally be made by a health professional on a subjective history and objective testing.
In clinic the therapist is looking for pain on compression of the foot, some local tenderness over the site of the swelling/scarring and response to weight bearing.
They will be looking at ant contributing factors such as foot placement and alignment, muscular asymmetries in the leg and dynamic control in the hip.
The therapist will need to differenciate between other common causes of foot and toe pain such as
Stress fractures, freibergs disease, capsulitis, bursitis and nerve realted problems from the back and pelvis.
An MRI scan can be preformed to rule out an actual tumour. By looking at an MRI we can determine the size of the neuroma which can indicate which treatment path will be best.
It is interesting to note however that a neuroma may be Present on MRI with no symptoms to the client at all.
Treatment can take one of 2 routes, conservative or surgical management.
With the conservative route we are looking to reduce irritation to the nerve and subsequent swelling. Simple icing can help here initially.
Off loading the foot with modalities such as orthotics or a met dome can also provide relief as they support the transverse arch of the foot and reduce the compressive pressure on the area. These types of aids can be issued by your physiotherapist in clinic.
It is then imperative to strengthen up the foot and maintain arch control in the transverse and longitudinal arches by use of the muscles within the foot. These specific exercises are taught in the clinic setting and then carried out at home. A constant sense of correct foot placement is required to build up endurance within the foot.
It is possible to have an Injection into the area to reduce the swelling, the effect will vary from patient to patient.
With a surgical method there can be 2 approaches wherein the nerve is resected.
1. The dorsal approach involves making an incision on the top of the foot. The benefit here is that you can walk soon after surgery because the stitches are not on the weight-bearing side of the foot. However, this procedure can lead to instability in the forefoot that may cause a problem in the future.
2.The second procedure involves a plantar approach, in which the incision is made on the sole of the foot. It is then required to use crutches for about 3 weeks and the scar that forms can make walking uncomfortable.
Surgery will run the risk of re occurance of swelling and scarring with a stump formation, bleeding, and loss of sensation from nerve damage.
A third procedure called Cryogeneic neuroablation is also an option. An initial study has shown that cryo neuroablation is equal in effectivenesss to surgery but does not have the risk of stump neuroma formation.
Recovery will be dependant on which treatment method was chosen. In either case foot strengthening exercises and correction of any lower limb weaknesses will be indicated.
If you have a mortons toe it will be beneficial to have a foot and lower limb assessment to commence with foot strengthening exercises and orthotic if required. It may even be of use to start with a met head dome early on in the prevention programme.
What Is An Ankle Ligament Sprain?
An ankle ligament sprain involves damage to one or more of the outside ligaments that support the ankle joint. Ligaments provide the ankle joint with stability by attaching from one bone to another. If these ligaments ever become over-stretched (usually during a trauma), it results in a complete or partial tear of the ligament fibres.
Causes Of A Ligaments Sprain?
Ligament sprains are an acute injury and are usually caused by trauma. There will an incident where the ankle either rolls in or out without control and pain will result. It is more commonly seen with dance with landing from jumps and leaps or rolling off demi point. Additionally, if you have high-arched or flat feet, you may be more susceptible to an ankle ligament sprain. People, who have sustained an ankle ligament injury in the past, can be more likely to re-sprain the same ankle again particularly if their management and rehabilitation was insufficient. A diagnosis will then need to be made by a physiotherapist to determine the nature of the sprain and the course of action required for rehab.
The Treatment path will differ according to severity of sprain. Initial treatment for ALL sprains should follow RICE regimen. (Rest Ice Compression Elevation)
Recovery will be dependent upon the nature of the sprain. Full recovery will take about 12 weeks although full activity will normally be possible prior to this time.
It is important to continue rehab through to the end even if feeling good, as it is common to re sprain the area again if full balance training had not been completed. Rehab will include ankle strength, hip strength and balance exercises.
What is Heel Pain
Heel pain can be felt anywhere in the heel region from underneath the heel , the back of the heel where the Achilles tendon attaches, the inside or the outer borders of the heel.
Because of this there are many reasons as to why we may experience heel pain.
Some of the causes of heel pain are listed below:-
• Plantar fasciosis or tear
• Nerve entrapment ( medial calcaneal or lateral plantar) and sinus tarsi
• Muscle trigger points of muscles both within the foot and in the calf
• Referred pain from the pelvic region (S1)
• Fat pad bruising
Symptoms will vary depending on the mechanism of injury. Below are some brief outlines of common symptoms for the conditions mentioned above.
• Nerve problems tend to give a sharp or burning sensation and can be accompanied with small areas of pins and needles and numbness. This would be felt over the sole of the foot in this case.
• Muscle origin pain will often get worse with activity, and trigger points in soleus (deeper calf muscle) often increase in symptoms going uphill.
• Plantar fasciosis is often worse in the mornings on rising, and may actually improve with movement and activity. It will be normally be tender to touch on the inside part of the heel bone.
• Pain from the pelvic region will often get worse in sitting as the nerve root gets irritated and pain is felt along the path of the nerve. This type of pain can increase with flexion based activities.
• Fat pad contusion is normally due to a traumatic event and knock to the underside of the heel. It will be very painful on weightbearing although visible bruising is often not present.
Diagnosis will need to be made by a health professional to differentiate between the different causes of heel pain. As outlined above there are many different causes of heel pain that will all need a slightly different approach to treatment.
An MRI scan can be useful in supporting the diagnosis of plantar fascia pain, especially if there has been a tear in the tissue. The tear is often as a result of chronic stress of the fascia and may therefore require some immobilisation.
Treatment will vary depending on the condition. Apart from maybe S1 pain origin, treatment will almost always consist of postural correction of the lower limb and foot. Exercises and advise will be geared towards correct foot placement into neutral and strengthening the small muscles of the foot to support the arches. Passive support from orthotics can also be of great assistance and can be prescribed by your physio. It will important to address hip control and the association with foot placement.
Soft tissue releases can be of benefit if the nerves are restricted in their paths which is more common with sinus tarsi problems and with any pain that is a result of trigger points.
If pain is of an S1,2 origin treatment of the spine and pelvis will be required.
A bruised fat pad in the heel will normally require rest and footwear modification such as a gel heel pad for the shoe.
Recovery will vary on the condition which has been diagnosed. Sypmtms could easly diminish in the case of trigger point referral pain. On the other hand recovery may take a few months if surgery was required such as in the case of a tarsal tunnel release (sinus tarsi nerve related pain.
As with all lower limb and foot pain problems it is essential to have a thorough assessment of posture and dynamic control of the lower leg and and foot. It is possible here to pick up on weaknesses that can be corrected and may prevent any further problems arising. Correct biomechanics of the lower limb are essential in preventing future problems in the foot and with subsequent heel pain. Such an asseement should be able to be carried out by a physiotherapist.
What is Freibergs disease?
Freibergs disease appears to be a relatively uncommon condition affecting the bones of the forefoot.
Although it is seen more commonly in girls aged 12-15 years it can present into adulthood also, again mainly affecting women.
This condition affects the articular surfaces of the second or third metatarsal heads leading to collapse of the bone in this area. The second metatarsal is more commonly affected. It is rare to be affected in both feet.
The main symptoms are forefoot pain. This constant dull ache can worsen especially at the end of joint range movement. There can be an area of localised tenderness on palpation over the met heads. It may be possible to see the development of calluses in this region too. The joint may feel and become stiff over time.
Symptoms usually worsen over time. However in some cases there are no symptoms present, and other cases may resolve spontaneously prior to even seeking treatment.
Pain is often noticed initially with dynamic exercise such as running, but can progress later with walking or even standing.
Diagnosis will rely on the presenting symptoms as mentioned previously:- Symptoms of activity-related forefoot pain with passive motion of the MTP joint and pain with palpation over the metatarsal head.
X ray can also be useful in diagnosis. In the early phases a small fracture may be seen within the bone. In later stages xrays reveal flattening of the metatarsal head and joint space narrowing and irregularity.. Varying degrees of thickening of the metatarsal shaft may be present as a result of a period of abnormal stress along the metatarsal.
It is important to get the diagnosis correct as there are other forefoot conditions such, Mortons neuroma, stress fracture of the metatarsal,sesamioditis and synovitis of the joints that have similar symptoms.
In the early days of the disease process the problem can be treated conservatively with immobilisation in a cast. In later stages, a metatarsal pad can be used to offload the met heads. Low heeld shoes are also beneficial to reduce the stress on the 2nd met head. This should be continued during athletic activities until the epiphysis closes and symptoms settle down. NSAIDS (non steroidal anti inflammatories) may help relieved discomfort from swelling.
Surgery is only indicated if pain persists after conservative management or the met head becomes deformed.
Surgery entails removing fragments of articular cartilage and rejoining the upper part of the metatarsal head, to allow the joint to move freely and painlessly.
Recovery again will vary depending on the route of treatment taken. As mentioned previously the problem may resolve spontaneously without any treatment being required.
Recovery with conservative management will vary from case to case. I may take up to 12 weeks to settle with modifications to footwear.
If surgery is required (less common option) recovey will follow in the guidlines of the surgeon but will no doubt follow a period of immobilisation followed by some intense physical rehab.
As the onset to this problem is poorly understood it is difficult to state any preventative measures.
What is a lisfranc injury?
This injury affects the mid foot region at the tarsometatarsal joint. The injury is named after a French surgeon who had described an operation in this area of the foot. Luckily the injury is very rare but can vary in its severity form a sprain to a full fracture and dislocation. The injusy is normally sustained with too much pressure in full plantarflexion/ pointed foot. This injury leads to injury of the ligaments over the joints, and sometimes even a fracture at the bottom of the metatarsal heads.
The foot can be split into 3 parts, the forefoot (metatarsals and phalnges) the mid foot (small bones cubiod, cuneiforms, navicuar) and the hind foot (talus ad calcaneum). The lisfrac joit is inbetween the fore foot and the mid foot. The Lisfranc ligament is a large band of tissue that spans the medial cuneiform and the second metatarsal base on the underside of the foot.. The joint capsule and ligaments on the top of the foot form only a small amount of support on the top surface of the Lisfranc joint.There are also a lack of transverse ligaments between the 1st and 2nd met bases. This anatomy establishes a “weak link” that, with stress, is prone to injury.
As there is normally a traumatic event wherein the foot is injured the symptoms will arise quite quickly. As with all soft tissue injuries there will be pain, swelling, heat and some redness. Pain will be felt in the mid foot area increasing with walking or even standing. There will be alot of swelling over the top of the foot and it will be tender to touch. It will be sore to point the foot also. If fractures have occurred there will be some pain at rest too not unlike a tooth ache.
Diagnosis can be very difficult and may not even show much on xray unless substantial disruption is present. Diagnosis is made from symptom presentation and history of trauma. Remembering that the trauma may be external, from a knock or blow, or from too much twist/force on a planted foot in either point or demi point.
Treatment protocol will vary depending on the severity of the trauma. A period of immobility in a boot is often required from 4-8 weeks. This will need to be followed by foot rehabilitation exercises in the clinic setting.
Operative procedure may be required if the injury is severe. It doesn’t always have a great outcome and may lead to further mobility problems in the future with arthiritc changes in the lisfranc joint.
Recovery time will depend on the severity of the injury. If the sprain is relatively small and only a small amount of time is required to immobilise then recovery may only be a couple of months.
If surgery is required however , or non surgical treatment of a bad sprain/dislocation, recovery time will be longer.
As with all injuries it is important to see your rehab through until th very end. This means working on range of movement, strength, balance, power and integration into sport.
This type of injury is often sustained by external forces that are beyond our control.
Having a strong foot and dynamically stable leg however can help to reduce the risk of trauma from twisting or instability when dancing on 1 leg. It is therefore advisable to be assessed on foot control and single leg hip and pelvic control
What is a trigger toe?
Trigger toe is the name for when the toe (normally the first toe in ballet) gets stuck in flexion and needs releasing manually, often accmpnaied with a clunking sensation. It is most common in female ballet dancers.
Why does it happen?
The catching is due to the tendon of FHL as it passes around the inside of the ankle. If the tendon becomes damaged over time it can become course and thickened, there may even be the presence of micro tears and some swelling. This thickening causes a catching sensation in the normal glide of the tendon in its sheath and under the retinacula keeping the tendons in place.
The space behind the medial malleolus (inside ankle bone) houses the tendon of FHL, FDL and tib post, along with nerves and vessels. It is a relatively small area when the foot is pointed and so unforgiving if there is any swelling or thickening of the tendons.
The FHL tendon can become thickened over time from incorrect use of the big toe, commonly seen with clawing. FHL is also under extra strain from feet that pronate excessively in standing and with jumps as it has a role in supporting the arch.
Symptoms and Treatment
It is not necessarily painful at first , and is often felt with a clicking sound and catching feeling usually on lowering from demi to flat.
The tendon can be thickened to palpate and will often have a crackle feeling to it when the toes are moved with a pointed foot. This is often tested by your physio as part of the assessment.
Treatment will comprise of releases into the muscle of FHL, FDL and tib post. Icing may be useful, especially if there is swelling around the tendon.
It is them imperative to look into technique to understand why the muscles are ‘unhappy’. Training will need to be commenced with the smaller intrinsic muscles of the foot to stabilise the arch and lessen the load on the extrinsic muscles.
If the thickening and nodules are quite bad surgery may be required to exise the nodule and smoothen the tendon to enable it to glide.
Recovery from surgery will need to be overseen by your dance physio.
Trigger toe can also be seen in other toes and result from a muscle imbalance which causes the ligaments and tendons to become unnaturally tight. The toe has a hooked appearance and may be rigid (unable to straighten) or flexible (able to straighten but returns to hooked position). It is common to find calluses or blisters on the top of the toes where they rub onto shoes .Trigger toe found in the other toes is more commonly seen with feet that have high arches ( pes cavus)
A tailored exercise programme to mobilise and improve the function of the intrinsic foot muscles (small muscles in the foot which control the toe movements) can prove very effective in this case also.
What Are Shin Splints?
“Shin splints” is an umbrella term often used to relate pain below the knee along the shin bone or even in the calf. Pain is felt either along the front of the shin bone or along the back of the bone especially in the lower third closer to the foot. It is an inflammatory problem in nature but if left unattended it may even progress to stress fractures developing.
Causes of Shin Splints
Shin splints are common in dancing, and other activities which involve repeated jumping and impact. It is usually as a result of altered stability and movement patterns in the lower limb and pelvis. Symptoms often increase over time as opposed to a sudden onset of pain.
Other causes that may lead to shin pain are:-
Recovery time can be dependent on the length of time of the problem. If caught early pain can disappear within a few days with guided treatment and home exercises. For more chronic problems recovery time will be longer.
Treatment will need to be guided by your physiotherapist and will include exercises, stretches and postural correction. Dancing will need to be modified to avoid the aggravating jumping movements until pain has improved.
What is ankle impingement?
Ankle impingement can become a problem either at the front of the ankle (anterior) or at the back of the ankle (posterior). Dance, and ballet in particular, forces the ankle into a far end range position and the talus bone (top of ankle) can contact the tibia (bottom of shin) or soft tissues and capsule of the ankle and cause irritation.
Anterior impingement will occur in full dorsi flexion (ankle flexed) such as in a deep demi plie or repeated landing from jumps. The talus can make repeated contact with the tibia causing irritation. Small bony osteophytes are produced as a result and this leads to pain at the front of the ankle, a blocking sensation and a reduction in plie depth.
Posterior impingement will occur will full plantar flexion, or pointing of the foot. In an opposite mechanism to the above the talus has too much contact with the tibia at the back and causes irritation in this region. The presence of an os trigonum can also increase the changes of impingement. This is a small bone that has failed to fuse with the talus effectively during growth and can cause repeated compression of the ankle capsule. With such repeated chronic pinching the tissue will become thickened. Posterior impingement symptoms can also arise from tendons of FHL/FDL/Tib post as they pass behind the medial malleolus.
Symptoms Of Anterior And Posterior Impingement (Os Trigonum)
Anterior impingement feels like ankle pain at the front of the ankle that increases on full dorsi flexion. The ankle may feel weak and feel like it can’t be trusted to hold steady during routine activities. When anterior impingement comes from ligament irritation, pain and tissue thickening are usually felt in front and slightly to the side of the ankle. Tenderness and swelling may also be seen over the front of the ankle. There is often a sense of blocking and an inability to reach full plie depth.
Posterior impingement will be felt with full plantar flexion and activities such as tendu, rises and pointe work. The ankle will often feel weak and an inability to gain full range is often present. There is often a blocking sensation at the back of the ankle.
If we are dealing with an os trigonum or longer bone surface in the ankle there can be nothing to prevent this situation as it is structural. However, ensuring correct technique and effective foot strength and use, can help to minimise any symptoms. It is essential to have a screening if you have any sense of ankle pain to minimise the risk of swelling and resulting tissue thickening at the back or front of the ankle.
What Is A FHL (Flexor Hallucis Longus)Tendonopathy?
A tendonopathy effects the tendons of the body. A tendon connects muscle to bone and is a continuation of the muscle. It is therefore involved in movement with the contraction of muscles. A healthy pain free tendon is strong and has its fibres lain down to form lines of strength. (Imagine a bundle of dry spaghetti! )When a tendon, in this case the Flexor Hallucis Longus tendon, becomes injured it takes on water, swells and ends up looking more like wet spaghetti!! It therefore has little order to it and loses its strength. It may also develop a swollen lump/nodule normally found towards the bottom third of the tendon as it passes behind the ankle bone that can be painful to touch.
Causes of FHL Tendonopathy
Long-term overuse of FHL muscle can lead to thickening of the tendon. This thickening is often detected under the inside ankle bone where the tendon passes through a fibrous tunnel of tissue. Chronic misuse of the muscle can come from clawing the toe when pointing, gripping with the toes on standing and rising, or when trying to stabilise a ‘wobbly’ ankle. Chronic overuse and resulting weakening and change in structure of the tendon may be accompanied with a nodule/lump in the tendon which can get ‘stuck’ as it glides behind the ankle. In these cases, the big toe may ‘lock’ and you need to wriggle the toe to unlock it. This is called ‘trigger toe’. Before getting to this stage there may just be clicking behind the ankle as you wiggle the big toe.
A strong foot and ankle combined with correct technique is very important in resolving this problem. Specific exercises can be given by your physiotherapist.
Recovery will depend on the level of damage. If caught early enough it may only take a couple of weeks to resolve or it may take up to 3 months. Continuous treatment and rehab will be required to guide the condition and eliminate any causative factors.
For more severe cases, surgery may be required to remove the nodule. Post surgical rest and rehab will be required in this case.