Injuries: Morton’s Neuroma

A comment on my foot pain post reminded me that I had missed Morton’s Neuroma. How could I forget something so painful? Must have blocked it out.

A neuroma is technically a tumor. Morton’s Neuroma is NOT a tumor, but the name has been used for so long that it is here to stay. The true technical term is Morton’s metatarsalgia. This is a thickening of the sheath that surrounds the nerves that converge between the 3rd and 4th toes (usual place) or the 2nd and 3rd toes (less common). This thickening is caused by irritation caused by pressure or trauma. The pain associated is often described as burning and shooting and happens when the foot bears weight, meaning when you stand, walk, run…and dance.
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The picture above is from a website run by a podiatrist in Southern California: Dr. Daniel Bank. Clicking on that link takes you to his page on common foot problems.

In college, I dealt with this as well as sesamoiditis. When this pain hit me, I thought it was sesamoiditis again, so I self-treated this one by doing what my PT had done for the sesamoiditis: my PT made a pad from thick moleskin to cover the ball of my foot, but there was a hole cut in it over the area of the inflammation. This prevented me from putting weight on that area. We put a similar pad without the hole on my other foot so that my alignment was not affected. I wore dance shoes in all of my modern classes until it was healed. This healed, too.

Now, very often the cause of the Morton’s pain is attributed to shoes that are too tight or to tight high heels. The toes are squeezed together which irritates the nerves between the toes. This eventually causes a thickening of the sheath that surrounds the nerves which adds more pressure on the nerves…and now we have pain. Apparently this pain occurs mainly between the 3rd and 4th toes because 2 nerves converge here, but it can also happen between the 2nd and 3rd toes as well.

So what to do about those tight shoes in Irish dance? I am a proponent of the close-fitting dance shoe. In general, a loose shoe does not help the foot look its best. In ID, if the hard shoe in particular is loose it not only looks bad, but it can then offer NO support for the dancer in toe stands. Hmmm…back to that thought that someone needs to design the perfect ID hard shoe…

But there is perhaps another reason that MN happens. It occurred to me as I was thinking about this post that I dealt with MN when I was in college as a MODERN DANCER…I did not wear shoes. I had a suspicion. So, I went surfing the net to see what I could find…

“Pronation of the foot can cause the metatarsal heads to rotate slightly and pinch the nerve running between the metatarsal heads. This chronic pinching can make the nerve sheath enlarge. As it enlarges it than becomes more squeezed and increasingly troublesome.

Tight shoes, shoes with little room for the forefoot, pointy toeboxes can all make this problem more painful.

Walking barefoot may also be painful, since the foot may be functioning in an over-pronated position. “http://www.aapsm.org/neuroma.html

There it was! That nasty problem, OVER-PRONATION!!! It always comes back to mis-use of the leg and foot! Here is what over-pronation looks like:

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Why is this a problem? Some pronation happens when we walk, run, jump, etc, because it is part of the landing mechanism of the foot. Over-pronation because of weakness, incorrect alignment, and/or faulty movement technique weakens the structure of the foot by putting stress on the bones and soft tissues of the foot which will eventually cause pain not only in the foot but also the knees, hips and even the back.

So, what to do about MN? Making sure the toes are not squeezed by excessively tight shoes will help alleviate the pressure on the nerve. A pad as I described above might also help alleviate some pain. And if over-pronation is part of your problem, arch supports can help because they can prevent the arch from rolling in. Better yet, having orthotics made specially for you might be even better.

And then learn how to use your legs right. Most over-pronation in dancers is caused by not understanding how to rotate the leg in the hip socket. Dancers hear, “Turn your feet out” so that is what they do, turn their feet out. Yes, the knees and thighs follow, but turn-out happens more effectively and safely if the hips turn out first so that the thighs, knees and feet follow them! And if the hips are correctly rotating, then the leg stays in alignment which means the foot will most likely not over-pronate (there are always exceptions to the rule!).

To learn about the hips and find a simple exercise to train the hips to turn out correctly, go here: Hips and Turning out

Click for more kinesiology info: Dance Kinesiology

To start educating yourself, try here.

Injuries: Foot Pain

(Please remember: Pain is your friend. It is signalling that there is a problem to be addressed. Do not ignore it. Seek professional advice.)

I woke up early with a post in my head…felt the need to write about feet. No, no…no foot fetish here. On the contrary…I actually have a very pronounced distaste for feet, toes in particular. Quickest way to get me off the couch is to touch me with your toes or, worse yet, put your feet in my lap for rubbing. AIN’T happening!!! Poke me with your toes and you might lose one.

But, feet are necessary, aren’t they? I have had my fair share of foot trouble, most of it when I was a modern dancer in college. Why? Because I did not understand hip rotation correctly which meant I was hyper-pronating my feet. There was also the added stress on my feet of dancing bare-foot…up until college I wore tight ballet shoes, jazz shoes or tennis shoes (pom-pon girl!). My poor feet were in shock when I took up modern dance in college!

Anyway, foot pain can be debilitating for a dancer for obvious reasons. There can of course be as many reasons for pain as there are dancers, but in my experience, a huge contributing factor to foot pain for so many dancers is hyper- or over-pronation.

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Sometimes over-pronation is simply caused by the fact that you have flat feet meaning the arch of your foot is very low or non-existent. If you were born with flat feet, this may not be painful for you. If flat feet are a new occurrence, it probably is. Either way, the sheer fact that the arch is collapsed allows the foot to over-pronate.

Over-pronation in dancers and athletes is usually caused by faulty biomechanics of the leg as a whole. Being evaluated by a doctor or sports therapist will help identify the problem so it can be addressed.

Here are some common foot problems.

1) Plantar Fasciitis: This is pain felt under the foot at the heel, in the arch, and/or all the places in between. The pain is caused initially by inflammation and swelling of the plantar fascia, and can worsen as tears and bone spurs develop.

“The plantar fascia is a ligament attached to the heel bone (calcaneus) that divides and fans out to attach at the base of the toes (metatarsals). Layers of muscles, tendons, nerves, and blood vessels run over the bottom of the foot. The plantar fascia covers these layers and acts as a bowstring on the bottom of the foot, helping the bones of the foot maintain the arch. A fat pad covers the plantar fascia beneath the heel bone; this pad cushions the heel as it takes the force of each footstep.”WebMD

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Plantar fasciitis can not only put you on the sidelines of dance, it can make the rest of your locomoting life miserable as well. See your doctor for diagnosis and help with the pain. Show your doctor what you do…if there are alignment issues, specifically with the leg and foot when turned out, get thee to a sports therapist or trainer so someone can help you learn to use your outward rotation correctly. More hip rotation info here: Hips & Turning Out

Treatment: R.I.C.E.R. This is rest (R), ice(I), compression(C), elevation(E), and getting that referral (R) for the necessary medical treatment. This is ALL so important. In my book, REST (meaning, NO DANCING!) is most important whether we like it or not. ICE alleviates pain as well as inflammation. COMPRESSION (ace bandage or taping) and ELEVATION (above the hip joint) both help to alleviate inflammation as fluids are directed out of the affected area. Anti-inflammatory over-the-counter medications like Ibuprofen (Tylenol is not an anti-inflammatory medication even though it is a pain killer) help this process as it alleviates the swelling as well as the pain. And then, to stop the pain train, REFER this problem to an expert: an orthopedic doctor, a sports medicine doctor, a sports therapist. There must be an analysis of any misalignment and pronation, and then professional direction for correction through re-training, strengthening, stretching, taping, adding orthotics if needed, etc.

2) Heel pain in children: This pain might be in the same place as plantar fasciitis, but can be caused by apophysitis instead of irritation of the fascia. Apophysitis is an irritation/swelling of bone growth plates that have not fused yet. Examples of apophysitis are calcaneal (heel, Sever’s Disease), tibial (shin, Osgood-Schlatter Disease), and iliac (hip).

Treatment: Go to the doctor. More info here: FootPhysicians.com.

3) Achilles tendonitis: This is pain felt at the back of the heel and/or from the heel up the back of the ankle. The pain is caused by the inflammation and swelling of the irritated achilles tendon. This tendon attaches the 2 calf muscles, the gastrocnemius and the soleus, to the back of the calcaneus (the heel bone).

Tendonitis is, for the most part, an over-use syndrome. Implications for treatment? Stop using it!! Treatment: R.I.C.E.R. (see above)

In my experience with dancers, tendonitis can be the result of trying to point the foot using the ankle only. It is important to understand that a pointed foot is accomplished by movement in 3-4 areas, not just one. 1st you move your ankle, then the bones in the tarsus (the area in front of the ankle), then the metatarsals (the long foot bones), then lastly the phalanges (toes). Learning how to use and articulate the intrinsic muscles in your feet can help alleviate the pain of tendonitis because you are no longer trying to use only your ankle. Trying to get more point out of your foot by pulling hard on your heel bone is a common cause of this problem in dancers. For more info, see On your toes.

4) Big toe joint pain, Bunions: This was my bugaboo. Started within months of going to college and starting modern dance. What changed? I was not wearing shoes which meant that there was no outside help for my over-pronation. As my feet spread, no longer being contained by tight dance shoes or supported by the arch in my athletic shoes, my over-pronation became worse which put tremendous pressure on my big toe joints. Taping my arch up helped. Powerful anti-inflammatory drugs helped. Cortisone shots helped (though they also made the joints crunchy). But all I really needed was to learn how to rotate my hips correctly which happened as soon as I went to grad school. It was that simple.

Now, of course in my undergraduate journey, I was told that I had bunions. “Bunions are often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bony framework of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion’s ‘bump.'” Foot Physicians

One zealous doctor wanted to operate, to break my feet to straighten things out. Only problem was that I might not really dance again. I opted to deal with the pain a bit longer! So glad I did, because I did not have bunions, just faulty leg and foot mechanics.

If you are diagnosed with bunions, get thee to a sports doctor who specialises in runners to get help. The best would be a doc who specialises in dancers, but these are few and far between.

5) Sesamoiditis: This is pain caused again my inflammation and swelling, this time of the tendon that encases the sesamoid bones at the base of your big toe. These little bones develop in the tendon under the big toe to act as shock absorbers. I would imagine that sesamoiditis is fairly common in Irish dance because the technique requires jumping and landing on the ball of the foot.

Treatment: as soon as you feel any bruising on the ball of the foot, stop dancing and ice it! If you take care of it, it does not have to be a huge problem. But, obviously, if the pain continues or is severe, go to the doctor. When I had this, my PT made a pad from thick moleskin to cover the ball of my foot, but there was a hole cut in it over the area of the sesamoid inflammation. This prevented me from putting weight on that area. We put a similar pad without the hole on my other foot so that my alignment was not affected. I wore dance shoes in all of my modern classes until it was healed.

For more on the sesamoids, go here: Sesamoid injuries.

6) Ankle sprains, strains, and breaks of all kinds: Go to the doctor.

More: Foot and ankle information

Click for more kinesiology info: Dance Kinesiology

To start educating yourself, try here.

Injuries: Shin Splints

Photo Sharing and Video Hosting at Photobucket (From the Mayo Clinic.)

Shin splints are a drag. Plain and simple. Irish dance is all about being on the toes and jumping/hopping almost continually, all of which is just asking for shin splints. I wonder if there is a higher incidence of shin splints in ID since the technique requires that the heels never contact the floor?

As usual, there are many things that can contribute to a dancer getting shin splints, but along with the rehabilitation and treatment options, there is really only one cure when you get them…rest. No dancer wants to hear that, but it is a fact. And then once the pain is gone, besides starting activity again slowly and carefully, there are things that need to be evaluated and addressed so that the shin splints do not return, and that requires a professional. See an orthopedic doctor to make sure all is well…spill your guts about your shoes and the floors you dance on. And then head off to a sports therapist or trainer. Shin splints do not have to be a chronic problem.

I found this great definition at HealthCareClinic.org: “Splints (Periostitis) – The term shin splints is a common misnomer in sports medicine. It does not imply a specific diagnosis, rather it is the symptom of pain over the front of the tibia bone. The pain from shin splints can be due to either problems of the muscles, the bone, or the attachment of the muscle to the bone. Therefore, ‘shin splints’ is simply the name given to pain over the front of the lower leg.”

The more common technical phrase for shin splints is “medial tibial stress syndrome.” Other problems such as posterior compartment syndrome and stress fractures can also cause shin pain.

Shin splints are very often caused by an overload on the tendons and connective tissues that attach the muscles of the lower leg to the shin bone, the tibia, causing inflammation and pain. For dancers, this overload can be caused by jumping back into vigorous exercise after there has been a lay off and dancing as if one is still in peak form. It can be caused by dancing on concrete floors. It can be caused by bad posture that contributes to leg misalignment. It can be caused by medially rotated hip joints, knock-knees, flat feet, feet with really high arches, and loose ligaments in the foot and ankle that allow hyper-pronation. It can be caused by not rotating from the hip sockets as this encourages hyper-pronation. It can be caused by tight calf muscles and an imbalance of the relative strength between the muscles of the lower leg. In this same vein, a rapidly growing dancer in peak form might develop some symptoms because of the difference in growth rates of the bones and muscles…bones grow first, muscles catch up.

In my experience as a dancer and teacher, I have found that one huge contributor to shin splints is over- or hyper-pronation of the foot. Pronation happens when you roll your foot inward, dropping your arch closer to the floor. Hyper-pronation is very common in dancers who force their turn-out from their knees and ankles. Forced turn-out results in habitual hyper-pronation which sets a dancer up for shin splints (as well as big toe joint pain, bunions, fallen arches/plantar fascia pain, knee problems, etc, etc, etc). Landing from jumps does involve some pronation as it is part of the landing mechanism of the foot, but over-pronation, loose ligaments, flat feet, or even arches that are too high all mess with the landing mechanism (the sequence of events in the foot) which puts tremendous strain on the lower leg muscles and all the connective tissues which then pull on the tibia. And once again, because we women have wider hips, the angles of the applied forces used to jump and land are more acute which exacerbates the problem…translation, women and girls are more prone to shin splints just as they are to knee and hip problems.

Obviously, the sheer pain of shin splints can and will stop a dancer in her tracks. So, taking care of them is paramount. But there are those who want to be brave, who want to dance through the pain. Please don’t. Stress fractures can result if shin splints do not heal and the underlying causes are not addressed, and then you are on to a whole new set of problems that take even longer to heal. The Mayo Clinic advises that you should “[c]onsult your doctor if rest, ice and over-the-counter pain relievers don’t ease your shin pain. Seek prompt medical care if:

*Severe pain in your shin follows a fall or accident
*Your shin is hot and inflamed
*Swelling in your shin seems to be getting worse
*Shin pain persists during rest

So, how do we prevent shin splints?

1) If you are coming back after a break, start slowly. We like to go at it gang busters as if we never stopped, and your body will oblige you because of the sheer excitement of being back in class. But you will pay by being very sore and by perhaps setting the shin splint train in motion.

2) Make sure there is an adequate calcium intake, especially for growing children and girls going through puberty. I am a firm believer in calcium supplements (unless there are kidney issues).

3) Warm up well and correctly, add more strengthening exercises for the lower leg such as slow releves (click here for more info) and this one with a partner:

Sitting on the floor with your legs straight out in front of you, pull your toes back so they are pointing up to the ceiling.Photo Sharing and Video Hosting at Photobucket

Partner, put your hands on the top of the feet and try to make the feet move to a pointed position while your sitting partner resists you. You are pulling your hands towards you while your partner’s feet are pulling against your hands, pulling towards them. Photo Sharing and Video Hosting at Photobucket

This helps strengthen the muscles at the front of the leg. Do this 10 times, holding for a count of 10, and then relax in between. (My wimpy model, Maggie, started whining that this was hard…guess we should be doing these regularly.)

4) STRETCH!!! Go here for pics of the 3 most effective stretches. I always did these with my students before class gently, and then again at the end, though we did the stretch for the front of the leg differently than it shows in the link. The third stretch in the series that stretches the front of the lower leg is a great one. And I like the fact that it is shown being done while sitting. This puts you totally in charge of the stretch. Just make sure your foot is aligned correctly with your lower leg…see pic #3 below.

That same lower front leg stretch can be done GENTLY with your partner after the exercise I illustrated above.

First, for both of you, identify the straight point position.

#1 – This is an inverted/sickled pointed position. This is incorrect.
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When you are stretching make sure the foot is not sickled as in #1 above and as it is in this pic below.
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#2 – This is an everted/winged position. While this can be a desirable position (in ballet in particular), I feel it trains the foot to habituate a hyper-pronated position. To me, this is incorrect.
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No matter your feeling on winging, when you are stretching make sure the foot is not everted as in #2 above and as it is in this pic below.
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#3- This is a wonderfully aligned foot. Good point, nice straight line down the shin through the foot.
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That is the position in which I GENTLY stretch the foot through its point. Notice in the pic below that I am using two hands. I grasp the foot and gently pull it towards me as I slowly stretch the foot out and then down. Do not simply press down as that will compress the ankle and heel. You will know you are doing it correctly when your dancer sighs and says, “Oh Mama, that feels so good…aahhh.”
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They will feel a nice gentle stretch above and below where I am indicating here on Maggie’s shin.
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5) If you do pronate, you should consider arch supports. you can buy them at the drugstore, but I personally would talk to a professional about getting orthotics that are built just for you. It is SO worth the time and expense to safeguard your dancing body.

Something to think about if your pronate your feet is that if your shoes are stretched out they are offering no real support for your feet, even if you do have arch supports. Loose shoes and dancing should not go together.

6) If you do dance on concrete floors, please get some thick insoles for your shoes, soft and hard alike. I personally love the gel insoles. More padding in the shoe means more safety for the dancer.

Ok. So…you have been the model of responsible dancer health, but you have been hit with shin pain. It is the first night after your first class after a long vacation. Or you have been growing. Or you have been working on a new floor. Or you are working harder on your turn-out. Or you are just plain working as hard as you can for the coming Oireachtas. Damn. Now what?

R.I.C.E.R. This is rest (R), ice(I), compression(C), elevation(E), and getting that referral (R) for the necessary medical treatment. This is ALL so important. In my book, REST (meaning, NO DANCING!) is most important whether we like it or not. ICE alleviates pain as well as inflammation. COMPRESSION (ace bandage or taping) and ELEVATION (above the hip joint) both help to alleviate inflammation as fluids are directed out of the affected area. Anti-inflammatory over-the-counter medications like Ibuprofen (Tylenol is not an anti-inflammatory medication even though it is a pain killer) help this process as it alleviates the swelling as well as the pain. And then, to stop the shin splints train, REFER this problem to an expert: an orthopedic doctor, a sports medicine doctor, a sports therapist. There must be an analysis of any misalignment and pronation, and then professional direction for correction through strengthening, stretching, taping, and adding orthotics if needed. If dancing is important to you, take shin pain seriously.

More resources: I have to say here that the best information I found came from sports or running sites. The dance sites, except for Harkness, were incomplete, derivative, and frustratingly crunchy-granola. Please feel free to send more links to me.

Wikipedia: Shin Splints – excellent, though very technical, explanation of the causes of shin splints, how misalignment of the foot causes the muscles to work in an imbalanced way which puts excess stress on the tissue connecting to the tibia.

Harkness

The Stretching Handbook

The Runner’s Web

Google it…there is so much on the web it makes my head spin.

Click for more kinesiology info: Dance Kinesiology
To start educating yourself, try here.