Pointing Hurts! Tale of an Os Trigonum

Today’s post came from an email from a concerned mother who’s daughter was diagnosed with an os trigonum in both ankles.  She writes…

My daughter is 14 and very serious about her dancing.  She has heel pain and has worked with a PT for the past year and rested a  good part of last year.  After x-rays and consulting with a few doctors her conditioned was diagnosed.  As you may know, there is a small bone at the back of the heel that sticks out a bit and hyperflexion of the foot can irritate the tendons and ligaments, as I understand it, around the bone.  In my daugheter’s case the small bone has not fused, but is attached.  She often has pain when she points her feet.
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She is on pointe twice a week, but the medical people do not think the pointe work aggravates the condition.  It occurs in 10-15% of dancers and soccer players.
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Everyone seems in agreement on the diagnosis and the surgeons want to operate to remove the small bone, but my husband and I are concerned about Grace’s age, the risk of surgery and the extent of the recovery.   One surgeon quoted a journal article describing that 84% of surgery patients had positive outcomes. On the other hand, Grace often feels that she has tried everything and wants to condition resolved and to dance pain free.
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Do you have any suggestions or information that might help us in this situation?
Thanks, Susan
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Dear Susan, I’m so sorry to hear about your daughter’s ankle problem.  I am quite familiar with os trigonum’s as dancers are a common group that have challenges with them.  There are many people, I’m sure, who have them and don’t know it because they don’t work in the extreme ranges of motion that dancers do.
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I would disagree with your doctors that pointe work is not influencing her ankle pain.  The reason why she has pain when pointing is she’s closing the back of the ankle joint Picture-1when she does that – put her on pointe with the extra weight into the joint and it often makes it worse.   The diagram on the right shows how an os trigonum is like a nut in a nutcracker when the ankle closes.  That is why they feel pain while pointing or being on pointe, and why non dancers may not have pain from this extra bone.
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My suggestion wuold be to take her off pointe work at this time, and increase her anti-inflammatory efforts such as placing her feet in a bucket of ice water after dancing. (I know… doesn’t sound very pleasant)  The challenge with letting an os trigonum continue to irritate the tissue is the tissue in the posterior ankle area can become thickened and fibrotic – which isn’t good for anybody’s ankle.
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I’m assuming they tried putting her on an anti-inflammatory treatment program which probably only worked to decrease discomfort, but not alleviate it.  That, along with continuing to work in non painful ways is usually the first phase of treatment.  Certainly the work with a physical therapist who will make sure your daughter is working the ankle muscles correctly, to have correct alignment when pointing the foot as well as on pointe is all helpful.  I applaud you for trying all things non surgical before consenting to surgery.
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What I can tell you is that the dancers that I know of with os trigonums and chose to have the surgery are very happy dancers.  They fully returned to dancing and were so happy to pointe their feet and/or do pointe work without pain.  The downtime from this surgery is much less than many other invasive surgeries.  There are cases of professional ballet dancers being back to dancing within 3 months.  I have known others that were even faster.  I know she isn’t my daughter,  (I am mom to 3) but this is one surgery where I am more confident about better chances for a positive outcome.  Of course, there are risks to any surgery – but it sounds like your daughter is committed to dancing, and I do know that if it hasn’t gotten better with the more conservative measures you are taking now, that it probably won’t get better on its own. As a parent I would get her to the orthopedic surgeon that works with the athletes – and of course – has done their fair share of this specific surgery.
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I hope my email has helped in some small way.  It is so hard to make choices like this as a parent!
I’d like to request from my blog readers that if you have any experience with os trigonums please tell us about your experience by writing in the comments below.  We can learn from each other!
Warm regards,
Deborah
“Education is the key to injury prevention”
13 replies
  1. George Ou
    George Ou says:

    I’ve always had problems with “trigger toe”, and occasionally some inflamed heels where the Achilles tendon attaches especially on heavy rehearsal days. With the recent cold weather, being my leanest in 10 years which means less natural insulation, and being in best shape in last 10 years, my heel tendons are really acting up. Just doing the tendu with a very pointed foot and ankle has always caused pain on occasion but it’s really bad when I’m cold. Makes me wonder if I have a mild os trigonum condition.

    Now the funny thing that I realized is that I can go to the gym and be warm in 10 minutes and sprinting full speed on the basketball court with zero pain. I also noticed that if I break a sweat before barre, I have virtually zero pain anywhere including my problem trigger toe and Achilles tendon area. From what I understand, we literally have lubrication chemicals in our joints when we break a sweat.

    In the past, I tried to “warm up” like all dancers do which is to do basic barre exercises e.g., tendus and releves. But the “warm up” was inflaming my ankles and once it was irritated, it stayed problematic for the remaining day for the rest of class and rehearsal, and that just makes the problem worse. Icing at night helped, but this was really giving me concerns. I’m 39 years old now hanging with the 20 year old so this something that is very alarming for me because I fear age-related deterioration.

    So it struck me like a stick and I asked myself why I was “warming up” my cold problematic joints with barre exercises. I’d been programmed to do this at a dancer but it was causing me pain. Being in better shape which makes it difficult to break a sweat and having less insulating fat was exacerbating the problem which was frustrating since I thought I shouldn’t be having these problems being in the best shape in a long time. Then I thought back to my gym experience, so I started doing some heavy resistance exercises to break a sweat before barre, and voila no more pain or inflammation from the barre or the rest of the day.

    We’re talking maybe 50 push-ups, 30 pull-ups, squat jumps, sprints, etc which sounds crazy before barre exercise, but the idea of using other muscles/joints that I don’t use at barre to warm-up makes logical sense. I even tried this tactic before a show and it worked. I was able to do full size ballet jumps without the benefit of a ballet warm-up, and this is crucial since we never have the luxury of a full barre right before performing difficult dances. Doing some tendus and releves to warm-up simply wasn’t working for a performance, but non-ballet exercises were doing the job of breaking a sweat and lubricating my joints.

    Reply
    • deborah
      deborah says:

      George, thanks for the post! Your tale of warming up is such a powerful one! Warming up – should be exactly as you described, literally warming up the body, muscles and joints so they have better lubrication!

      Reply
  2. George Ou
    George Ou says:

    It seemed completely counter intuitive to the ballet dancer. I’m essentially doing big jumps (though not with ballet form and with athletic shoes that hug my Achilles better) before barre, which seems like the reverse of the standard ballet class. Who does jumps before barre? That’s blasphemy and why I never considered it in the past until the pain and inflammation forced me to take desperate measures.

    Tendus and releves hurt on my cold body, but lifting 400 lbs with the calves and Achilles tendons on a cold body doesn’t hurt and neither does sprinting or other heavy weight exercises. More importantly, the tendus don’t hurt after the heavy exercises that induced some slight perspiration.

    Reply
  3. Alexis
    Alexis says:

    I was diagnosed with Os Trigonum Syndrome almost six months ago. After three doctors, casting, boots, and cortisone injections, I was told I had two options: hope for my condition to get better or get surgery. I had surgery Friday, and I will say it was not as bad as I thought. Being that I am only 17 and it was my first surgery, I can say that I was extremely nervous and trying my best to avoid the surgery. My parents had similar concerns and all were addressed pre-op. Your daughter would be given the option to get a nerve block done which will numb the leg after her surgery. Combined with the pain pills, and lots of rest, the surgery should not be bad. The recovery time is not terribly long, and the relief of the constant pain in your ankle is immediate. I strongly suggest surgery if all options thus far have failed. The surgery has very few complications and will be worthwhile. Good luck with your decision!

    Reply
    • Catalina
      Catalina says:

      Hi Alexis,

      I came across this website while doing my research on os trigonum, and I noticed that you mentioned receiving cortisone injections. I am just wondering how painful were those injections? I am getting them in a week, and I’d like to mentally prepare myself for it. I’ve been looking everywhere on the Internet to find out how painful the shot is. Thank you.

      Catalina

      Reply
      • deborah
        deborah says:

        Hi Catalina,
        Hopefully Alexis will respond, but typically they will first use a numbing agent before giving the injection so discomfort is minimized.

        Reply
  4. kylie gilbert
    kylie gilbert says:

    my name is kylie gilbert i had found out that i had an os trigonum so the dr. removed it 4 months ago……it still really hurts what can i do? all the dr said is to take a anti-flammitory pill…….. what should i do? and is there anything i can do to get rid of this scar? its ugly

    thanks,
    kylie gilbert

    Reply
    • deborah
      deborah says:

      Hi Kylie, I would suggest that you find a good physical therapist to help you work through your ankle and foot correctly as you return to dance. The scar will probably not go away although it will fade in time. Some dancers like putting vitamin E or MSM cream on scars to help them fade faster. Good luck!

      Reply
  5. Daniel B.
    Daniel B. says:

    Hi all,

    My name is Daniel, and similar to some individuals on this post, I have been diagnosed with Os Trigonum Syndrome a couple months ago. I am a male teenager who rarely is ‘pointing my feet downward.’ Instead, I was a camp counselor and was constantly walking/putting pressure on my feet. After weeks of this agonizing pain, I finally went to see a podiatrist who took x-rays and pointed to the os trigonum bone present in both of my feet/ankles. Since then, I have been receiving steroid injections in my feet, physical therapy/electrical stimulation, heel-pushers/orthotics, and consulting opinions of various medical professionals.
    NOTHING IS WORKING! This is two + months post-diagnosis and I’m scheduled to see an orthopedic surgeon very soon. Surgery is what I want and need to get my pain away. What do y’all think?
    Bye-bye bones!

    Reply
    • deborah
      deborah says:

      You’ve done all the nonsurgical options and I would totally understand wanting to get the surgery. It has helped many dancers who were in similar situations such as yours – and I would suggest that they do what you did. First try everything you can to address the problem non-surgically, and then look at your surgical options.

      Good luck! Deborah

      Reply
  6. emerson
    emerson says:

    I went to the podiatrist today and got x-rays on both feet and I have os trigonum in both of my ankles. But the podiatrist I’m seeing isn’t convinced that the bone is causing the pain because on the x-ray you could really only see the outline of the bone and it was rather small, but still there. I only have pain when pointing my feet. My ankles will pop in an uncomfortable way back there by my heel and Achilles tendon every time I Pointe my foot. I have the range of motion to get over my box while dancing en pointe but I’m usually unable to get all the way on my box with out it being very very painful. If it’s not the is trigonum causing these symptoms as the podiatrist believes then what else could be causing this?!?

    Reply

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