I must also disagree with Dr. Forman, and
respectfully suggest he review the JAPMA article
I just previously cited (Primary Avascular
Necrosis of the Halluces in a Ballet Dancer).
The dancer in that case study sickled, a
pronating fault which eccentrically loads the
medial forefoot column when dancers vault to en
pointe position. She also possessed
an "Egyptian" foot type (excessively long
hallux), the least efficient foot type for en
pointe dancers.
Collectively, we postulated those were the two
primary factors responsible for the eccentric
hallux loading that caused enough compression
force to create the avascular necrosis observed
in each hallux. A review of the Tc scan of that
dancer in that case clearly demonstrates disto-
medial tracer uptake in each distal phalanx,
totally commensurate with that eccentric
forefoot loading.
What ultimately allowed this dancer to return to
en pointe was: 1)sufficient rest from en pointe
dance to allow the halluces to complete their re-
vascularization phase, and 2) the fabrication of
a Whitney Mold to off load the halluces. A
Whitney Mold is a polyurethane-impregnated
neoprene appliance form fitted within the ballet
shoe. This forefoot "orthotic" successfully off-
loaded both halluces in our dancer and I doubt,
given her sickling fault and foot type, that she
would have been able to return to en pointe
dance without it.
I vividly recall the case because it was so
interesting, never previously reported in the
literature while the mold was such a pain in the
neck to fabricate; but, it ultimately worked. To
my knowledge, it was first described in the
podiatric literature by Dr. Alan Whitney.
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
