Young Dancer Returns to Stage Pain-Free Following Successful Physical Therapy

In the well-known song “Dem Bones,” listeners are reminded about the interconnectedness of the human body: 

Well, your toe bone's connected to your foot bone
Your foot bone's connected to your heel bone
Your heel bone's connected to your ankle bone
Your ankle bone's connected to your leg bone

Muscles and tendons are never mentioned in the lyrics, but just like bones, they’re all connected. Just ask Emma Shively, 11, who came to the Dance Clinic at Cincinnati Children’s complaining of two years of ankle pain, only to discover that overutilization of specific foot muscles were to blame.  

“I didn't know your toes have muscles. I didn't know the outside of your leg could hurt because of your toes. I didn't know that your toes are connected to everything on your leg,” said Emma. “But that’s why it was hurting. When I learned that, I was like, mind blown.”

Her mother, Erika, was also surprised and grateful at how quickly things unfolded during their initial visit. The problem was immediately diagnosed after Aly Filipa, PT, and Paul Gubanich, MD, conducted a simple toe test and assessed Emma’s dance technique.

“[Aly] literally put her finger under Emma's big toe, and she said 'push against my finger.' And [Emma's] toes curled. She was weaker and she felt the pain. And Aly knew instantly what it was,” said Erika. “With the amount of pain that [Emma] was having, it was shocking how quickly we were able to target it and treat it.”   

The Dance Clinic is a unique care model that incorporates a multidisciplinary approach that includes athletic trainers, sports medicine physician, and physical therapist to meet the unique needs of the dancer. This integrated team approach enhances efficacy and communication in establishing the plan of care, thus eliminating redundancy. 

Using an integrated model of care, Emma was able to be screened for more serious conditions and immediately begin a treatment pathway to address her own personal goals and needs.

Tailoring Emma’s Physical Therapy to Her Specific Needs

As a physical therapist and a former dancer herself, Aly understood Emma’s concerns about experiencing an injury with an upcoming performance ahead. She also brought specific knowledge about proper dancing techniques, common training errors and what cues can be given to correct identified faults.

Emma loves to dance, but during physical therapy her jumps and lifts were modified so she could focus on improving her foot intrinsic strength.

In addition, Aly recognized Emma’s strong desire to maintain some level of dancing during treatment, describing it as “the psychosocial relationship with dance, and the importance of keeping the dancer moving.”  

This continuity was very important to Emma, who had been selected as a performer in the upcoming Nutcracker ballet. She was excited about her first opportunity to dance inside Cincinnati’s famed Music Hall.

Aly and Emma worked together on dance-specific techniques in order to decrease unnecessary stress on her over utilized flexor hallucis longus (FHL)—a powerful, extrinsic calf muscle used to move the big toe and ankle.

“We worked on getting the small muscles (“foot core”) in her foot stronger so her flexor hallucis longus, a foot extrinsic muscle, didn’t have to work as hard during ballet performance and class,” said Aly. 

Jumps, lifts and other acrobatic moves were initially withheld as Emma modified her dance participation and focused primarily on improving her foot strength. Specifically, her physical therapy routine included tension bands of varying thickness so she could practice dance-specific movements without over utilizing her FHL. This meant Emma had to retrain herself how to keep her toes relaxed and elongated during her dance movements.

“I had one [band] from every level. I had a yellow band, a green, a blue and a black. It was like building muscle basically,” said Emma. 

According to Aly, flexor hallucis tendonitis is one of the most common injuries suffered in a dancer’s foot.  

“The tendon originates at the great toe, courses through the arch of the foot, and runs up the lateral side of the calf,” she said. “It is often missed, but is easily identified if the great toe flexor muscle is tested. This is what we did with Emma, and how her ankle pain was identified.”

Dancing Pain-Free, Performing at Music Hall

Regular physical therapy sessions and exercises at home helped decrease Emma’s pain, and after two months she returned to full strength.  

“It was very beneficial to have someone who had that dance expertise and knowledge,” said Erika. 

Emma agrees. “Aly gave me all these exercises to work on straightening my toes to where, once I learned how to do that, it didn't hurt as much anymore.”  

The number one goal of therapy, said Aly, is to meet the patient’s self-identified end goal of rehabilitation.

“We try our best to make sure that everyone’s treatment is tailored to what is important for them to get back to,” she said. “In treating dancers, it is commonly to get back to dance without pain.” 

Continued therapy worked for Emma, and with the pain gone, she was able to dance in the Nutcracker, playing several different roles, including Clara's Double, Party Boy and Delivery Kid.

“Performing at Music Hall was really cool. I was really nervous opening night,” said Emma. “Then once I go on, I forget about everything and I just dance.”

(Published July 2023)