Now that I'm an adult (and a practicing physical therapist), I cringe whenever I remenisce about this incident. First of all, pointe isn't good for you.
{via Pointe Shoe Physics}
Pointe causes an abnormal distribution of forces through the feet, and therefore, through the entire body. Just as your car absorbs shock, your body does the same thing. Our heel bones are super thick for this reason. As you can see from this x-ray, the calcaneus (or heel bone) is nowhere near immediately load-bearing. It's an unnatural movement that puts your body in a very vulnerable position for injury.
My mom, though not a healthcare professional, was aware of this and was understandably hesitant about letting me start pointe. Most young ballerinas begin pointe training around twelve years of age. I was nine. My mom took me to a doctor and had me ask him what pointe could do to my body. He told me all kinds of scary things and showed me all kinds of crazy pictures of jacked up feet (that's the medical term, you know, "jacked up"). Armed with this new and terrifying knowledge, my mom then allowed me to make an informed decision about whether or not to take the next step in my dance career. In hindsight, this was absolutely brilliant parenting. Nonetheless, it had absolutely no impact on my decision whatsoever. And you know what? Even with what I know now, I would make that decision all over again if I had to because ballet is awesome.
What really makes me cringe about that horrible injury, isn't the fact that pointe that caused it. It's the fact that I never did anything about it. I don't think I ever even told my parents. Now that I know what I know, I should have gone to the emergency room because I had a Grade III ATFL tear.
{via Beantown Physio}
"ATFL" stands for anterior talofibular ligament, which connects the talus (a foot bone) to the fibula (a shin bone). Grade III means it's completely ruptured. If I had gone to a physician, they would have had me immobilize my foot to allow the ligament to heal in a functional position. If it had been a really bad Grade III, they may have even done surgery to reattach the ligament. Either way, I needed to avoid weightbearing to allow time for healing. Instead, I iced it and went to rehearsal the next week. Oh, I did wear an ACE wrap though, which I'm sure helped a lot (sarcasm).
Throughout the next few years, my left ankle was subject to frequent sprains. It happened occasionally at dance, and pretty much every time I was hiking. The fact that I grew up in South Florida and therefore lived in flip flops didn't help. Walking all over a college campus in a sundress and Rainbows may look cute, but it's not supportive footwear for an unstable ankle.
Even with all of these recurrent sprains, my ankle never really hurt. It wasn't until 2008 (a decade or so after the initial injury) that I started to experience pain. I was in graduate school at Emory studying physical therapy when I had the brilliant idea (again, sarcasm) to become a runner. We teach people how to walk again after a stroke; why couldn't a healthy person learn how to run? (The answer of course, is that my ankle was not healthy). I learned that I could run a 5K so I started training for a half marathon. (See?! Brilliant!) When I got to about seven miles as my base, I started to develop really bad shin splints. Shin splints typically present along the anterior aspect of both shins, but mine were only on the outside of one shin. I consider myself to have a pretty high threshold for pain (see above x-ray), but this got so bad that I decided to quit running. I was initially pretty bummed, but I got over it quickly. I wasn't a runner to begin with, so I didn't really miss it.
Then a few years later, I was visiting New Orleans with my husband and sister. After a few days of walking around on cobblestone streets, my shin splints returned. I understood that running could cause pain in an unstable ankle, but walking?! This was unacceptable. I was starting to become frustrated with my failing joint, but I chalked it up to wearing unsupportive shoes and vowed to wear something better than sandals during future vacations.
Last year, my pain became constant. I wasn't running, I wasn't walking on an uneven surface, there was no trigger. My ankle just hurt. The pain worsened over the next few months, which prompted me to invest in custom orthotics. Instead of wearing cute flats with my business casual physical therapist clothes, I now wear sneakers with these inserts every day. At least I have a job where I can pull that off, I suppose. This helped with the pain for a little while, but then it came back. This time, the pain was accompanied by a periodic audible pop. The pop became more frequent and the pain became more severe.
Winter melted away in Atlanta, and I was excited to break out my spring wardrobe. The first day I wore strappy sandals and a cute skirt, I was in absolute agony. I finally decided to see an orthopedic surgeon. He tested the strength in my ankle muscles and he palpated the ligaments to make sure nothing was inflamed. Since this testing was negative, he dismissed me and advised a follow-up appointment for a cortisone shot "if the pain got bad enough." Now that we're several paragraphs into this story, do you think the pain was bad enough? I begged for an MRI, which he finally agreed to.
The MRI revealed intact ligaments and tendons. Everything actually looked pretty good except for a 0.8 x 0.4 x 0.8 cm cyst that had formed beneath my talus, one of the foot bones. Without orthotics, my feet pronate when I walk. This is pretty common, even among athletes. But with pronation, the talus shifts downward. So basically, I have a collection of fluid that keeps getting squished up against nerves and joints every time I take a step. No wonder it hurts so much to wear flip flops!
I took my MRI to a different orthopedic surgeon, who listened to me and who asked me a lot of good questions. He did a lot of manual testing on my foot and ankle, including some tests that provoked the pain and popping. Then, he expressed that while he was concerned about the cyst, he was more concerned about how it got there. "I know, I know," I rolled my eyes. "My feet pronate and bad foot mechanics can cause fluid build-up."
He disagreed. He said that if the culprit was pronation alone, I would have this issue on both ankles. His manual testing revealed that yes, my ligaments were intact, as the MRI had suggested. However, my ATFL (that anterior talofibular ligament on the front of my left ankle) was hanging on by a thread. It was intact, but it felt like it had been torn a long time ago. It healed, but it healed in a lengthened position because it was never properly treated. So that ligament is intact, but it's not functional. This has caused poor foot mechanics over time, which caused fluid to collect, and has subsequently caused me so much pain. With that brief examination, he both confirmed my greatest fears and explained his findings in a manner that I found comforting.
We decided on Plan A: to wear an ankle brace for 3-4 weeks in an attempt to get the ligament to tighten up. I follow up with the physician later this month, and if those tests are negative this time, he'll drain the cyst and hopefully I'll be feeling better in a day or two. If the splinting is unsuccessful, we go to Plan B: ATFL reconstruction. He'll have to put me under general anesthesia, detach the ligament, reattach it in a tighter and more functional position, and drain the cyst while he's in there. I'll have to be in a cast for six weeks, and then I'll probably have to have one of my coworkers rehab me for a few more weeks.
The moral of the story, kids (if you're still reading), is go to the doctor when something is wrong. Denial, avoidance, stubbornness will only cause you more problems in the long run. Even if you're reluctant to put your faith in modern medicine, try some homeopathic shit, see some kind of alternative practitioner, do whatever you want, but in addition to seeing a true medical doctor. Then, follow that physician's recommendations, even if they're inconvenient. If I had gone to a physician immediately after the initial injury, they would have had me immobilize and then I would have needed physical therapy. I would have been greatly annoyed and inconvenienced by this (especially since it would have meant missing dance), but not nearly as much as I am now.
Are any of you out there kicking yourself for not dealing with a medical issue sooner?
Throughout the next few years, my left ankle was subject to frequent sprains. It happened occasionally at dance, and pretty much every time I was hiking. The fact that I grew up in South Florida and therefore lived in flip flops didn't help. Walking all over a college campus in a sundress and Rainbows may look cute, but it's not supportive footwear for an unstable ankle.
Even with all of these recurrent sprains, my ankle never really hurt. It wasn't until 2008 (a decade or so after the initial injury) that I started to experience pain. I was in graduate school at Emory studying physical therapy when I had the brilliant idea (again, sarcasm) to become a runner. We teach people how to walk again after a stroke; why couldn't a healthy person learn how to run? (The answer of course, is that my ankle was not healthy). I learned that I could run a 5K so I started training for a half marathon. (See?! Brilliant!) When I got to about seven miles as my base, I started to develop really bad shin splints. Shin splints typically present along the anterior aspect of both shins, but mine were only on the outside of one shin. I consider myself to have a pretty high threshold for pain (see above x-ray), but this got so bad that I decided to quit running. I was initially pretty bummed, but I got over it quickly. I wasn't a runner to begin with, so I didn't really miss it.
Then a few years later, I was visiting New Orleans with my husband and sister. After a few days of walking around on cobblestone streets, my shin splints returned. I understood that running could cause pain in an unstable ankle, but walking?! This was unacceptable. I was starting to become frustrated with my failing joint, but I chalked it up to wearing unsupportive shoes and vowed to wear something better than sandals during future vacations.
Last year, my pain became constant. I wasn't running, I wasn't walking on an uneven surface, there was no trigger. My ankle just hurt. The pain worsened over the next few months, which prompted me to invest in custom orthotics. Instead of wearing cute flats with my business casual physical therapist clothes, I now wear sneakers with these inserts every day. At least I have a job where I can pull that off, I suppose. This helped with the pain for a little while, but then it came back. This time, the pain was accompanied by a periodic audible pop. The pop became more frequent and the pain became more severe.
Winter melted away in Atlanta, and I was excited to break out my spring wardrobe. The first day I wore strappy sandals and a cute skirt, I was in absolute agony. I finally decided to see an orthopedic surgeon. He tested the strength in my ankle muscles and he palpated the ligaments to make sure nothing was inflamed. Since this testing was negative, he dismissed me and advised a follow-up appointment for a cortisone shot "if the pain got bad enough." Now that we're several paragraphs into this story, do you think the pain was bad enough? I begged for an MRI, which he finally agreed to.
The MRI revealed intact ligaments and tendons. Everything actually looked pretty good except for a 0.8 x 0.4 x 0.8 cm cyst that had formed beneath my talus, one of the foot bones. Without orthotics, my feet pronate when I walk. This is pretty common, even among athletes. But with pronation, the talus shifts downward. So basically, I have a collection of fluid that keeps getting squished up against nerves and joints every time I take a step. No wonder it hurts so much to wear flip flops!
I took my MRI to a different orthopedic surgeon, who listened to me and who asked me a lot of good questions. He did a lot of manual testing on my foot and ankle, including some tests that provoked the pain and popping. Then, he expressed that while he was concerned about the cyst, he was more concerned about how it got there. "I know, I know," I rolled my eyes. "My feet pronate and bad foot mechanics can cause fluid build-up."
He disagreed. He said that if the culprit was pronation alone, I would have this issue on both ankles. His manual testing revealed that yes, my ligaments were intact, as the MRI had suggested. However, my ATFL (that anterior talofibular ligament on the front of my left ankle) was hanging on by a thread. It was intact, but it felt like it had been torn a long time ago. It healed, but it healed in a lengthened position because it was never properly treated. So that ligament is intact, but it's not functional. This has caused poor foot mechanics over time, which caused fluid to collect, and has subsequently caused me so much pain. With that brief examination, he both confirmed my greatest fears and explained his findings in a manner that I found comforting.
We decided on Plan A: to wear an ankle brace for 3-4 weeks in an attempt to get the ligament to tighten up. I follow up with the physician later this month, and if those tests are negative this time, he'll drain the cyst and hopefully I'll be feeling better in a day or two. If the splinting is unsuccessful, we go to Plan B: ATFL reconstruction. He'll have to put me under general anesthesia, detach the ligament, reattach it in a tighter and more functional position, and drain the cyst while he's in there. I'll have to be in a cast for six weeks, and then I'll probably have to have one of my coworkers rehab me for a few more weeks.
The moral of the story, kids (if you're still reading), is go to the doctor when something is wrong. Denial, avoidance, stubbornness will only cause you more problems in the long run. Even if you're reluctant to put your faith in modern medicine, try some homeopathic shit, see some kind of alternative practitioner, do whatever you want, but in addition to seeing a true medical doctor. Then, follow that physician's recommendations, even if they're inconvenient. If I had gone to a physician immediately after the initial injury, they would have had me immobilize and then I would have needed physical therapy. I would have been greatly annoyed and inconvenienced by this (especially since it would have meant missing dance), but not nearly as much as I am now.
Are any of you out there kicking yourself for not dealing with a medical issue sooner?
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