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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”