Interesting facts & figures about stress fractures! 🦴📈
Cool snippets of info that will help you understand and manage bone stress injuries just a little bit better, without all the reading... 🤓📖
(Refs at the end if you *do* fancy a read)
Thread 🧵 1/10 Bone can be loaded more frequently than muscle/tendon. It’s ready to go again after 4-6 hours. Short sessions of high intensity loading stimulates the bone for increased stiffness…

I’ve often wondered if I’ve missed hip, pelvic, or femoral shaft BSIs in my patients, but a review of the literature suggests my theory that dancers don’t get more proximal BSIs, is probably correct (not including pars defects, just lower limb & pelvic)!

A thread 🦴🩰 🧵 1/6 So why the difference in locations? 🤔

Here are my theories (backed up with a bit of reading - see the post for refs). I’d love to get a discussion going around this, so please feel free to comment 🙏🏻💬

2/6

Lateral ankle pain FULL case study 🦶🏼

Initial Ax & Mx = 1 hr ⏰
(Please ignore spelling mistakes in the autogenerated captions)!
#Sural #Tinels #Eversion

Thanks to this patient who gave documented consent to use these videos for educational purposes 🙏🏻

THREAD 🧵
1/8 This patient described around a year of right lateral ankle pain with slow onset. He reported a very significant ankle sprain (when I asked about it - ALWAYS ask about previous ankle trauma). But he couldn't remember which side…

2/8

Tango specific conditioning/rehab 💃🏼

Thread 1/7 🧵

🪗 Single leg balance and control
🏋🏼‍♀️ Y balance with the heel lifted 🪗 Pivots (forward ochos)
🏋🏼‍♀️ Rotating disc

2/7

Ankle sprain rehabilitation…
Reducing visual dependence 🎢
Balance is controlled by these systems:
Visual 👀
Vestibular 👂🏼
Proprioceptive 🦶🏼
Thread 🧵 inspired by @angiejphysio
1/6 When I teach the balance section during my foot and ankle courses, I ask which system is being trained during foam cushion/bosu ball single leg standing. Almost 100% of the time people answer
'proprioception’🦶🏼
2/6

A thread on anxiety, coping and injuries in dance… 🧵🧠🩰
1/9 This study found that
biopsychosocial factors were more important in injuries than strength, flexibility or balance…
And highlighted the importance of biopsychosocial assessment in addition to physical screening 🧠🍀

2/9 pubmed.ncbi.nlm.nih.gov/28599018/

Flexor Hallucis Longus pain (FHL) Pain… 🦶🏼

Consent to share ✅
Interesting case of bilateral foot pain which seems to be driven by FHL and tibialis posterior (possibly a knot of Henry issue as well)… 🤔

Working with @DrJN_SportsMed on this case 🤓

Thread 🧵

1/6 Most cases of FHL pain seem to be driven by ‘overuse’ of the extrinsic (FHL) over the intrinsic (flexor hallucis brevis (FHB)). On testing, these patients claw their toes when asked to flex them against resistance. In this case, it’s the exact opposite - see video… 🎬🦶🏼

2/6

Sesamoiditis or FHB tendinopathy? 🤔

Mini thread & case study 🧵 1/5

The sesamoids live within the FHB’s distal tendons & articulate with the head of the 1st metatarsal, acting as a fulcrum to increase the leverage of FHB/FHL. But is all ‘sesamoid’ pain actually the sesamoids? Certain cases of sesamoiditis seem to manifest more as FHB tendinopathy. The pain presents proximally to the sesamoids & is irritated by FHB activation (see pic below of 1st toe flexion), or passive toe extension rather, than pressure through the met head e.g. calf raises 2/5

So you want to be a dance physio? 🩰

🧵1/12 Get to know the terminology, lifestyle & culture. Many dance physios have a background in performing, but not all. However, knowing the difference between ‘fosse walks’ & a grande jeté en tournant will help you understand/manage dance injuries & importantly gain performers’ trust

Complex lateral ankle sprain ⚠️
Mini thread 🧵
Watch the left foot carefully… 👉🏼🦶🏼🦶🏼

🔹Grade 2 lateral ankle sprain
🔹Bifurcate ligament sprain
🔹5th MT avulsion fracture
🔹Calc compression fracture

Consent ✅ 1/5 Anterior Draw Test was positive, suggesting damage to the ATFL fibres, but Talar Tilt test (CFL) was normal = Grade 2 lateral ankle sprain. There’s still no consensus on the best classification system 👇🏼

2/5

pubmed.ncbi.nlm.nih.gov/32495041/

Consent ✅
PTTD Thread 🧵
Posterior Tibialis Tendon Dysfunction

75 yr old M. Keen golfer and very fit.
3-4 months of left medial foot pain.
Agg: Barefoot. Ease: Rest/insoles.
History of standing on broken bottle in river age 13 - lacerated plantar aspect of left foot 🦶🏼

1/7 Reduced inversion of L calcaneus noticeable with heel raise - suggesting poorly functioning tib. post. It improved as we practised it. Swelling/redness posterior to medial malleolus and down into navicular. Very tender navicular tuberosity and very weak/painful resisted IV.

2/7

Consent ✅

‘And my bunion is better’ is often what dancers say after rehab for a different foot/ankle issue that has indirectly addressed their hallux valgus. This dancer’s primary concern was bilateral HV… Worse at end of day.

3 exercises for hallux valgus 🦶🏼
A thread 🧵

1/4 Warm up:

A combination of Piano Toes (flexion) + ‘Paper’ from ‘Rock Paper Scissors’ (abduction). To spread the toes it helps to do it with your hands at the same time. This was a first attempt - It takes practise. About 10-15 reps x 2 of each to wake up the feet!

2/4

Foot & Ankle Case Study 🦶🏼
Shared with consent ✅

What initial exercises would you give a patient who was reporting ‘weak ankles’ and most importantly, why?

Thread…🧵🪡
1/8 Female dancer in 8 shows a week. Ankles feel ‘tired’ & ‘achy’ by end of day. No specific pain. Requested exercises to help 🙌🏼

Hx of ankle sprains
Very mobile ST joints
Poor functional endurance IV/EV
⬇️ balance: hip airplane
SLHR: 11 - VERY low
Overuses FDL for SLHR: clawing
2/8

Balance Assessment in Dancers 🩰
Mini thread 🧵
Are tests specific enough and are they validated to be part of a return to dance criteria? 🤔

🔸Pirouette test 🌀
🔸Hip airplane 🛩
🔸Force plates 💪🏼
🔸SEBT (+ variations) ☮️
🔸Single leg stand 🦩

1/4 Pirouette & hip airplane are the most specific, but quite subjective in how they’re scored. SEBT & SLS are overly static. Force plates are unavailable at most dance facilities and don’t replicate a dance environment eg noise-free/no dynamic movement 🤔
2/4
pubmed.ncbi.nlm.nih.gov/34517937/

Summary Thread 🧵

FUELLING FOR PERFORMANCE
🌽🩰🌮⛹🏿‍♂️🍗🤽🏼‍♀️🍔🚴🏼🥑🧗🏽

The collective minds of #medtwitter helped me compile this list of resources for Pts. I’ve aimed it primarily at dancers 💃 but there’s lots of crossover with other sports 🎿🏄🏻‍♂️

Thank you to all who replied 🙏🏻

1/7 Blogs and Websites:

Nutrition for Dancers 🩰
dancenutrition.com/nutrition-for-…

What & When to Eat Before a Workout 🏋🏽‍♂️ by @AnitaBean
anitabean.co.uk/what-and-when-…

Fact sheets and recipes found via the top left-hand menu 📋 (and lots more)!
sportsdietitians.com.au
2/7

Metatarsalgia Treatment:
A (Non-Exhaustive) Overview Thread 🧵

🔸Off loading
🔸Simple analgesia
🔸Physiotherapy
🔸Lifestyle changes
🔸Onwards referral
1/10

Link to diagnosis thread below 👇🏼

https://twitter.com/lizbayleyphysio/status/1493845121875513346?s=21

Off Loading:
Rest/activity modification
No barefoot walking/No heels 👠
Possible air cast boot for Freiburg’s or stress #

Rocker bottom shoes ⬇️ pressure through MT heads. ‘Hoka’ are a more fashionable option 😎

General:
Go for flat, wide box, roomy shoes with stiff sole👟
2/10

Metatarsalgia 🧵🦶🏼
…is not a diagnosis ☝🏼

Specific locations help to differentiate:

🔹Arthritis/Arthropathy
🔹Gout
🔹Frieburg’s
🔹Sesamoid injury
🔹Bursitis
🔹Morton’s neuroma
🔹Plantar plate
🔹Stress fracture
🔹Overload/synovitis

1/11 Arthritis, particularly OA most frequently affects the 1st MTPJ. It’s quite common in dancers, secondary to hallux valgus. Inflammatory conditions may cause a number of MTPJs to flare up - see also ‘synovitis’ - 10/11 in this thread…
2/11

MRI/POCUS of LL injuries in ballet dancers Bauman (2015)
pubmed.ncbi.nlm.nih.gov/26788031/
I still need a bit (lot) of help reading scans, so this paper was useful 📝
This 🧵will skim the surface of when best to use each imaging modality & discuss common Ballet injuries + their scans:
1/16 US = fast & accessible - great for assessing superficial tissues or areas like the F&A🦶🏼
MRI = better for global evaluation of structures & deeper tissues eg articular cartilage/bone. While MRI is a static image, US can provide real-time visualisation of structures in motion
2/16

When to consider plantaris in your diagnosis and how it changes Mx…

Mini 🧵
Summary from resources 👇🏼👇🏼

🏃🏽‍♂️@tomgoom
running-physio.com/plantaris/

🦶🏼@Seth0Neill & @davidphysioedge
spoti.fi/3ndFMUj

📖 @BJSM_BMJ via @function2fitnes
bjsm.bmj.com/content/51/10/…
1/4 Clinical presentation:

🔹Pain medial mid-portion AT
🔹Worse with DF e.g. uphill running
🔹Worse with pronation
(⬆️ forces on medial AT)
🔹Poor response to rehab
(3/12 progressive loading)

2/4