Happy New Year!
Ms GR is a 36 year old female who has been a dancer since she was a small girl. She studied ballet and wanted to be a professional dancer until her late teen years, and gradually changed into other forms of dance, including modern jazz and hip-hop. As she has matured, gotten married and has had children, she has progressed to competitive ballroom dancing, rehearsing several nights a week with her partner/husband and entering events and competitions on many weekends. Since having her second child, she has noticed a change in the structure of her feet, she is developing bunions on both feet, with painful callus formation on the bottom of the foot behind the big toe, behind the second and on the inside of the big toe. In the past few months the condition has worsened, she is now experiencing some swelling under the ball of the foot near the big toe, and after a particularly long dance session she formed a water blister in the same area. She is worried the problem will prevent her from participating in a big New Year’s Eve competition in approximately two months' time. A friend of hers recommended she have some orthotics made, so she arrived today to the clinic with a shopping bag full of various shoes and a request for orthotic devices to help her dance.
The patient is 5’4” in height and weighs 115 pounds. She is a housewife who homeschools her children. She reports being in perfect health, denies any medical conditions, prescription medications, food or drug allergies. She does not smoke and has an occasional glass of wine with dinner.
Examination of her lower extremities is unremarkable with the exception of the chief complaint. Her circulatory, neurological and dermatological systems are within normal limits with the exception of the above mentioned calluses and blisters. She presents with a mild Hallux Abductovalgus deformity on both feet, with slight medial dorsal contracture of the second toe bilateral. There is noted enlargement in the plantar of the feet in the sesamoid area with some tenderness elicited upon forced dorsiflexion of the hallux and pain to palpation of the Tibial sesamoids. She is noted to have a reducible plantarflexed first ray bilateral, but is otherwise biomechanically unremarkable. Her gait pattern is also mildly overpronated during the propulsive phase with mild abductory twist and flexion contracture of the lesser digits.
Weight bearing x-rays of both feet reveal a neutral foot type, with a relatively short first metatarsal compared to second metatarsal, mild Hallux Abucto-Interphalangeus, and an enlarged bipartite Tibial sesamoid. Her collection of shoes includes various types of dance shoes, ballet flats, Capezios, jazz oxfords, dance sneakers, ballroom pumps and sandals.
Discussion:
Our challenge in this case is decreasing the reactive ground force under the first ray, controlling the pronatory forces during propulsion, and offloading a hypertrophied sesamoid bone. Ballroom dancing is an athletic endeavor performed in a dress shoe environment, often a variety of different types of shoe, slipper, or even barefoot. The pattern of callusing and the evidence of early crossover deformity of the second toe indicates instability in the forefoot during propulsion, while the blistering indicates friction and shearing forces at play. Most experienced dancers are well accustomed to foot issues and many have created self treatment remedies using lamb’s wool, moleskin or duct tape. Fortunately in this case, the complaints are limited to the forefoot area and orthotic corrections can be focused entirely on redistributing the ground reactive force under the forefoot to achieve our treatment goals. It is decided to focus on an orthotic device for the ballroom pumps the patient will be wearing on New Year’s Eve, which has an enclosed heel, 3 inch in height to best pair with her husband’s height.
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