Foot & Ankle International

Talar compression syndrome is a painful condition at the back of the ankle in which a protruding bone (either the posterior tubercle or an os trigonum) crowds the tissues, and causes them to be compressed when the foot is forcibly and repeatedly pointed, as in classical ballet. The condition is easy to diagnose, but care must be taken to distinguish it from a number of other painful conditions at the back of the ankle which are commonly seen in dancers. Some cases respond to rest and conservative treatment, but in many cases operating is necessary to remove the protruding bone, and this provides a good relief of pain.

A common ankle problem among dancers is impingement of the tibia on the talar neck. Two syndromes are described. One results in the development of exostoses on the anterior tibia and talus. The other results in plantar fascial sagging and chronic foot strain. The treatment and prognosis are presented along with representative cases.

The problems of flexor hallucis tendonitis and os trigonum syndrome in dancers are presented. The mechanism of injury, diagnosis, treatment, and rehabilitation are outlined. Pitfalls in diagnosis are discussed as well as prognosis for return to dance class and the stage. The best surgical access to the os trigonum is a lateral approach.

A posterior block of the ankle joint caused by an os trigonum, a large posterior tubercle of the talus, or prominence on the dorsum of the posterior part of the os calcis is described. The presenting symptoms are listed, the most important being Achilles tendonitis anterolateral ankle pain, recurrent calf strain, and pain under the plantar aspect of the foot. All these can be associated with difficulty in pointing the foot. Details are given of the operation and the after care.

The conditions occurring in the dancer's forefoot can be divided into five categories. The three categories presented in Part I of our study include those conditions occurring from poor training, those from chronic forefoot stresses, and those of static deformity. Five hundred dancers were observed for both symptomatic and asymptomatic forefoot conditions. It is most important that a young dancer have at least three years training before dancing en pointe. Many skeletal changes in a dancer's foot occur from use and should not be interpreted as injuries. Static forefoot deformities tend to appear in dancers at a younger age than the general population but seldom require corrective surgery.

Conditions in the dancer's forefoot can be divided into five categories. Part II of our study presents two categories: acute conditions of the forefoot and conditions which masquerade as forefoot problems. Five hundred dancers were studied. Of those, some had conditions including muscle spasm, soft tissue trauma, fractures, dislocations, and abscesses, and were treated accordingly. The general health of the dancer was an important factor in treatment as well as difficulty in diagnosing the injury. Prolonged periods of healing were expected but did not prevent the return to dance class and rehearsal. The highly motivated, goal-oriented dancer often did not complain of systemic disease or pain and this prevented diagnosis until triggering tendons or muscle paralysis made it obvious. Such a sequence gave rise to prolonged convalescence or termination of the dancer's career.

Ankle sprains are common in dancers. They result from working in the positions which allow increased risk of sprain on the lateral side of the ankle for many hours a day. One hundred ankle injuries were evaluated. The mechanisms of injury are presented, as well as a classification of these injuries. The recommended treatment and rehabilitation are discussed. Leg muscle strength must be restored before rehabilitation is considered complete.

Eleven patients who were treated for talonavicular arthrosis with a talonavicular arthrodesis between 1961 and 1979 at the Mayo Clinic have been reviewed. Follow-up from surgery ranged from 2.5 to 21 years with a mean of 9.5 years. Clinical, radiographic, and gait analyses were obtained. All patients had satisfactory pain relief, but all noted difficulty in ambulating on irregular ground. Three patients had roentgenographic evidence of arthrosis affecting other tarsal joints that had not been involved before arthrodesis. Gait analysis revealed decreased terminal stance-phase plantarflexion and pronounced reduction of subtalar motion. Talonavicular arthrodesis does give predictable union and patient satisfaction but results in limitation of subtalar motion and loss of stance-phase plantarflexion.

We have performed an ongoing retrospective and prospective multi-institutional review of 50 patients who underwent 53 lateral ligamentous reconstructive procedures of the ankle. The point grading system used for postoperative evaluation of our patients allowed for classification of functional activity. The grading system included evaluation of the patient's return to preinjury activities and athletics, degree of pain, degree of swelling, number of recurrent sprains, and any disability that the patient incurred secondary to the tendon transfer. Preoperative and postoperative stress radiographs were obtained to evaluate the talar tilt angle. Of our 53 lateral ankle ligamentous reconstructions, we consider 45 to be excellent, with the patients returning to full activity and athletics. Our results show no statistically significant difference in long-term function among the five ligamentous repairs employed in this series (Pearson Chi-square test; χ² = 2.30, df = 4, P = 0.68). No correlation could be made between the long-term clinical response of the various procedures and the postoperative talar tilt angle. We conclude that lateral ligamentous reconstructive repairs of the ankle are indicated, and that good or excellent clinical results, greater than 91 %, can be obtained with any of the five reconstructive procedures, performed correctly.