Treating A Dancer With Posterior ‘Impingement’ Pain

This author details the treatment of a dancer who had a combination of right plantar heel pain and posterior heel pain deep in the right Achilles tendon.

A professional dancer presented with pain in the right plantar heel that she had for two weeks and right posterior heel pain deep in the Achilles tendon area that she had experienced for approximately four weeks.

   The plantar and posterior heel areas were both sore and achy in nature, and aggravated by increased activities and dancing in the morning and after prolonged sitting. The Achilles had been sore for a longer timeframe and at times the ankle felt “jammed” and “stiff with full relevé and plié positions.” The patient denied any ecchymosis, warmth or neurological type pain or symptoms. There was no swelling plantarly but slight fullness in the posterior heel area along the anterior border of the Achilles tendon.

   The patient was dancing everyday, typically in ballet slippers or barefoot, which aggravates both areas of pain. There was some previous and current lateral leg muscular soreness along both muscle bellies. She noted she had some relief of these issues with massages and strengthening exercises. A physical therapist had treated the patient at the dance studio with ultrasound, massage and various taping methods.

   The physical exam revealed pain with palpation at the medial plantar heel with no swelling, color or warmth. She had minimal pain with palpation along the distal course of the plantar fascia and along the abductor hallucis muscle belly. She had pain with palpation of the anterior border of the Achilles tendon, mainly distal to the watershed area. The patient also had pain with deep palpation along the superior lateral corner of the calcaneus and into the retrocalcaneal bursa area. She had minimal pain at the insertion of the Achilles. There was slight soreness along both peroneal muscle bellies but no pain along either tendon or at the peroneal tubercle. Muscle testing for extrinsic and intrinsic foot muscles revealed no crepitus, pain or weakness (eccentric or concentric), with an emphasis on flexor hallucis longus testing in three positions.

   X-rays revealed a slight irregularity to the superior corner of the calcaneus and os trigonum syndrome.

   The patient’s initial treatment was a corticosteroid injection into plantar heel. In order to address both pain locations, we employed a combination of strapping with a dancer’s pad, the use of heel cups with heeled shoes, stretching, ice, physical therapy modalities and massage to the lateral and medial extrinsic foot musculature. In regard to dance modification, we had the patient limit jumping and had her wear jazz shoes or dance gym shoes with padding/heel cups and/or tape.

How The Patient Had Progressed At The Follow-Up Visit

Due to the patient's work travel and performance schedule, the first follow-up was at 12 weeks. The patient had full plantar heel pain resolution due to exceptional adherence. The posterior heel/Achilles area was still painful to palpation with persistent minimal swelling in the retrocalcaneal bursa area. She felt much better in heeled shoes and any flat shoes or barefoot dancing were painful as the posterior heel pain was re-aggravated, even with various persistent treatments. In addition to repeating the aforementioned treatments, I gave the patient a Traumeel injection (Heel, Inc.) into the posterior heel/bursa/Achilles area.

   The use of diagnostic ultrasound revealed the following findings.
* A mild increase in caliber to the Achilles tendon, watershed area and distally posterior to the calcaneus
* A small focal deficit (4 mm x 4 mm x 2 mm) to the anterior fibers of the Achilles at the posterior superior corner of the calcaneus
* A prominent posterior superior border of the calcaneus with some impingement of the anterior fibers of the Achilles with dynamic evaluation.
* Hypertrophy of the retrocalcaneal bursa with increased fluid
* A slight extension of the peroneus brevis muscle belly distal to the inferior aspect of the lateral malleolus with significantly hypertrophy

   I discussed the findings of the Achilles tendon injury and bursa with the patient. We agreed to treat her conservatively with a series of prolotherapy type injections utilizing Traumeel. We started bimonthly injections in combination with deep tissue work, ultrasound, heat, heeled shoes and modified dancing with some form of heel padding. In addition to performing continued strengthening exercises, the patient also ensured proper warm up and cool down periods. Although this dancer has a “posterior” condition, she felt best with some slight heel height in her street shoes but excessive relevé and plié positions were uncomfortable.

What You Should Know About Treating Posterior ‘Impingement’ Ankle Pain

Posterior “impingement” ankle pain is common in dancers. The continual relevé and en pointe positions will continually stress the tissues behind the ankle due to the constant pinching in the region. When it comes to the diagnosis of ankle "impingement," there are many differentials to consider and rule out. These differential diagnoses include:

* Os trigonum syndrome
* Flexor hallucis longus tendonitis or interstitial tear
* Posterior capsule injury to ankle or posterior subtalar joint
* Achilles injury or tear
* Retrocalaneal bursitis
* Peroneal retinaculum injury
* Osteochrondral injury

   Conservative care is common when treating dancers so the practitioner must be creative and have many tools in the toolbox. Due to the fact that the calcaneus has been slightly irregular for probably some time with this patient, it was not appropriate to do any surgery on this professional dancer. I focused on repairing the Achilles tendon and reducing inflammation of the bursa via conservative needling or “prolotherapy” treatments.

Can Prolotherapy And Traumeel Have An Impact?

Prolotherapy has been present in the osteopathic literature for quite some time. It is a series of injections that one introduces into damaged tissues to stimulate the inflammatory cascade to induce reorganization of the disorganized collagen type III into proper type I collagen, creating the best linear mechanical strength for the tendon. The typical prolotherapy solution is a Dextrose solution. One can perform needling injections with other medications or solutions as well.

   Traumeel is listed in the Physicians Desk Reference and is a Food and Drug Administration (FDA) approved homeopathic medication. I have been utilizing this medication for approximately 20 years with great success for many foot and ankle conditions. Traumeel can induce the growth factors (TGF-beta) necessary for the regeneration of tissue.

   The typical technique is a bimonthly injection into the damaged tissues. One would complement this with other modalities and treatments as I discussed above. The bimonthly injection of Traumeel creates stability while still allowing mobility of the tendon, which is paramount to proper regeneration. These injections encourage the continual recruitment of fibroblasts to allow the tissues to go through more controlled inflammatory, proliferative and remodeling stages. Although these patients should ideally emphasize relative rest for the duration of the treatment protocol, this would be difficult for a professional dancer. This regimen affords the best outcomes with little to no downtime for the dancer's schedule with only minor compromises and alterations.

   Dr. Schoene is a triple board certified sports medicine podiatrist and a certified athletic trainer. She is a Fellow of the American Academy of Podiatric Sports Medicine and the American College of Foot and Ankle Surgeons.