Right 1st metatarsalgia in Ballet dancer

A young lady in her (28 yrs old) came to see me with chronic pain (3 yrs) in the Right big toe. The pain would worsen with repetitive jumping and landing during ballet and modern contemporary dance. Despite getting better shoes, she still seemed to suffer from the pain. Her toes was also 'crowding' in her shoes with the big toe moving towards the 2nd toe (Hallux valgus).

She had tenderness at the base of the right 1st metatarsal bone and moreso adjacent to the 2nd toe. Upon treatment with ultrasound she felt better and we taught her some strengthening exercises and taping. She should be feeling much better if she takes adequate precaution and implements RICE treatment when she feels sore after training.

Hip-hop Dance and Fracture in the foot

An 11 yrs old girl came yesterday complaining of a swollen and painful left foot after hearing something snap in her foot while doing hip-hop barefoot. She had been training barefoot for 1 year but it did not cause any pain. Now, she could not walk or put pressure on the side of her foot or even tip-toe.

I examined her left foot and found that she had some bruising and swelling around outer part of her midfoot (lateral aspect adjacent to the base of 5th metatarsal). There was severe tenderness at the base of the the 5th metatarsal.

Her X-rays shown that her left foot had a non-displaced transverse fracture of the base of 5th metatarsal (Jones Fracture). She was treated non-surgically with non-weight bearing posterior slab crutches to allow the swelling to subsides. She would benefit from a daily dose of low frequency ultrasound (Exogen) to promote healing. Once the swelling subsides we may consider placing her foot in a functional walking brace but she would not be allowed to walk until after 6 weeks later.

Interesting links:
Diagram of metatarsal fractures

Extensor Retinaculum Injury and Extensor Digitorum Longus tenosynovitis

A male artistic gymnast was seen a few days ago with complaints of pain in the dorsum of the left foot after intensive training involving runs and jumps since 2 weeks earlier. He had difficulty standing on-toes, taking-off from jumps and landing.

After examining his ankle, I found that he had slightly reduced range of plantarflexion in the left ankle due to pain. There was tenderness and mild oedema of the extensor retinaculum and mild tenosynovitis of the Extensor Digitorum Longus tendons. However, resisted extension was pain free.






I did a simple taping to prevent extreme plantarflexion while enabling him to point his toes during his routine(Two figure of 6, and a double medial and lateral ankle locks and closed up the 'holes'). That seemed to do the trick and he should be back doing some training. However, he was told to refrain from sprinting or jumping to his maximal height as it may aggravate the injury. He was advised to undergo physiotherapy to reduce the symptoms and strengthen his lower limb.

Knee Hyperextension in Ex-Rhythimic Gymnast

Ms Lim is a 35 yrs old ex-rhythmic gymnast who came to see me after a fall on her right knee. It was interesting that she had an extremely flexible left knee with an additional range of 35 degrees in extension. She had been perfectly normal in the left knee and did not suffer from any nagging pain.

She was advised to maintain an active lifestyle to ensure that she looses some weight and also strengthen her back, abdomen, hip and lower limb muscles to prevent injuries.

Ankle Posterior Impingement

Ms Ann (not her real name) is an elite level badminton athlete who came with complaints of pain in the back of both ankles with net-play and jumping smashes since 3 months duration. To her dismay, she still had the pain despite taking a month off from training. These symptoms are also common in gymnasts and dancers who do repeated jumps and en-pointe. Soccer players have been reported to have similar symptoms in literature.

I examined her ankles and found that she had tenderness and bogginess (oedema) of the posterior aspect (back) of her ankle joint (between the Achilles tendon insertion and the calcaneal and talus bones). She had pain when I compressed her hindfoot with her foot plantarflexed (Impingement test). If he jumped repeatedly on the spot, it would give her the same pain. She also had tenderness of her Achilles tendon insertion (Insertional tendinopathy) and associated hindfoot varus.

I have advised her to do some calf stretching with the knees bent slightly and knees straightened. She was also taught to tape her ankle to prevent full plantarflexion. She was planned for an X-ray to rule out Os Trigonum or fracture of the lateral tubercle of Talus. An MRI of the ankle would identify bone bruising, tendon and joint capsule inflammation.

Ultrasound guided corticosteroid has been shown to benefit most athletes with capsule or tendon inflammation. Most of these athletes are symptom free after 2 weeks and return to play within 4 weeks rehabilitation. A selected few with persistent symptoms, os trigonum or a possible nerve entrapment may require arthroscopic surgical intervention.

Find out more about the injury here:-
Posterior Ankle Impingement in Professional Soccer Players: Effectiveness of Sonographically Guided Therapy
MRI features of foot and ankle injuries in ballet dancers

Tibialis Posterior Tendinopathy (Traction apophysitis)

Ms Chia is an 11 years old child who played basketball barefooted last week. She came with Right midfoot pain since a few days duration. She particularly mentioned that she had pain jumping and doing brisk walking. Her mother was worried as she thought it could be cancerous.

I examined her feet and found out that she was flat footed and had a prominent navicular tuberosity(insertion of Tibialis Posterior tendon) on both feet. She had tenderness at that spot but there were no obvious signs except that she had pain standing on her toes and resisting inversion (pushing her forefoot inward against my hand).

I explained to her mother that she would benefit by having good medial longitudinal arch support with orthoses. She could have taping of her foot to provide additional arch support. If symptoms persisted, an X-ray could be done to rule out avulsion fracture (tendon pulls off the tubercle from the bone) or other pathology.

She should recover swiftly with proper footwear, modified activity, isometric and theraband resistance exercises within 2-4 weeks.

Peroneal Tendon Subluxation

Nadia (not her real name) was sub-elite gymnast when she came with sudden pain and snapping sensation in her right ankle after twisting her ankle during training 3 years ago. She was seen by another physician who diagnosed her condition and was treated conservatively with bracing for 1 month's duration followed by rehabilitation exercises for 8 weeks.

She had the snapping sensation when she stands on her toes ("On toes") and pointing her toes. I asked her to dorsiflex her ankle and evert the foot and her peroneal tendon would slip in front of the bony prominence (see photo). She only had mild pain everting her foot against resistance. As expected, there was a tendency for the opposite peroneal tendon to slip forward too due to increased laxity. Ultrasonography may be useful if we suspect a tendon tear.*

According to Ferran et al, the diagnosis and management plan are based on clinical evidence. Conservative management may be attempted in acute dislocations, and can be successful in up to 50% of patients, although there is a trend for operative management in athletes. Recurrent dislocations should be managed surgically.**

*J Ultrasound Med.2007; 26: 243-246
**Sports Med. 2006;36(10):839-46.

Tibialis Posterior Tendinopathy

Ms Wang, a young lady executive shuffled slowly into my clinic. "I think I sprained my right ankle on the treadmill 2 days ago", she said. I was expecting a large swollen ankle but it was not that swollen. Then she pointed at the spot on the navicular tubercle (marked 'o' on the picture). She had a previous 'twist' of the same ankle several years earlier.

It sounded like a foot injury seen in my gymnasts, diving and dance sports athletes. She had mild pain when asked to flex and extend her ankle but she could not twist her foot outwards (eversion). She also had pain twisting her foot inwards (inversion) against the resistance of my palm. I palpated (felt with my fingers) the tibialis posterior tendon insertion on the navicular tubercle and she had severe tenderness.

Informed her that her tendon was strained but the deltoid ligament was spared. She needed to ice every 4 hourly (15 minutes/session), avoid high heeled shoes, possibly tape her ankle if she wanted to do more vigorous walking or running, have another look at her walking gait with her shoes, start some isometric exercises and progress to some theraband exercises. "I will see you after a week and expect the injury to heal within 3 to 4 weeks if you do your exercises"