Getting Back to the Stage: A Dancer's Recovery

In December of 2013, while talking morning class at the New York City Ballet, I rolled my left ankle and sustained a minor sprain. It was a grade one sprain, the type of sprain that only sidelines a dancer for a week or so; in my case I only missed five days of work. This sort of occurrence is not out of line with the norm at a company such as New York City Ballet, but what made this occurrence significant is the history of ankle sprains my left ankle had endured over the years. Three times during my life as a dancer, I have sustained a third-degree sprain of my left ankle joint. Third-degree sprains are characterized by the total rupture of ligaments in one’s ankle joint; following a third-degree ankle sprain, there is severe pain and swelling of the ankle joint and it is not possible to walk on the foot/ankle. In most cases, surgery is required to repair the joint following a third-degree sprain, but I always chose to rehab in a more conservative manner. By choosing a prolonged immobilization period, ultimately taking more time, I was always able to avoid surgery. Each third-degree sprain occurrence resulted in a casting/non-weight bearing immobilization period of six to eight weeks, allowing the ligaments to scar over and tighten up as much as possible. Following the casting period, two to three months of physical therapy was required to strengthen the ankle joint, to return to dance.

Following this minor sprain in December, I returned to work with little to no concerns, since I had dealt with much worse sprains over the course of my career. At first everything seemed fine, but as the months passed I realized that my ankle was swollen and red all the time. As the level of chronic swelling increased, so did the discoloration and level of pain in my ankle.

 By the end of March, I was in constant pain and spent my evenings icing and elevating, in too much pain to do much else. By April, the range of motion in my ankle joint became increasingly limited. The limitation in movement of my ankle joint was effecting my ability to turn, jump, and to create appropriate ballet lines. At this point, I stopped jumping in classes and rehearsals, the only time I would jump was in performance. Problems didn’t stop with the loss of motion; by mid-April, my ankle joint would get caught in certain ranges of motion. For instance, I would be walking home from a show and my ankle would freeze up.  Moving the joint in any direction was excruciatingly painful, requiring me to sit down on the side walk until the ankle gave way to moving again. I was living in constant fear of my ankle joint locking during a performance.  During the first week of May, I had reached my breaking point, the pain was too much to push through and I spoke to work about cutting back on my performance schedule. New York City Ballet was agreeable to lessening my work load, while I sought answers to what was happening with my ankle joint.

In a consultation with the company’s Orthopedic Surgeon, Dr. Hamilton, it was decided that an MRI of the joint was necessary to get to the bottom of what was going on in my left ankle. Magnetic resonance imaging (MRI) is a medical imaging tool that is used by radiologists to form pictures of the inside of the body. The images produced by this machine show all sorts of anatomy, such as the bones, ligaments, muscles, fluid, etc. Using radio waves in tandem with magnetic fields, the machine can construct 3-D images of a joint, such as my ankle. Dr. Hamilton was the physician that had treated all three of my prior third degree sprains, so he was familiar the history of this specific ankle and knew that something severely wrong was taking place in my joint.

Part of being a dancer is having an extremely intimate relationship with the signals one’s body sends to their brain.  Part of this heightened awareness is knowing the anatomy of one’s body and what receptors are telling one based on their knowledge of the joint shapes, ligament structures, and muscular syntax. Part of having my ankle evaluated and understanding what was plaguing my ankle requires is an in-depth knowledge of the anatomy of the ankle joint.  Over the course of my career, I have had to study the ankle joint with every sprain, but with the deterioration of my ankle, I was tasked with further study of the joint. To understand the findings of my MRI, I needed to understand the following details about the ankle.

The ankle joint is a synovial joint, meaning that it is engulfed by a membrane that forms a sac around the joint itself. This flexible membrane houses a secreted viscous fluid (a sticky/thick liquid) that lubricates the movement of the joint. The ankle joint connects the leg bones to the foot bones; the tibia and fibula of the leg meet the talus of the foot creating the point at which the ankle joint rotates around. The tibia and fibula of the leg are bound together by a group of thick ligaments called the tibiofibular ligaments. The securing of these two bones creates a bracket like socket that floats above the talus, which is coated in a glassy like cartilage called hyaline cartilage. This bracket like socket that makes up the upper portion of the ankle joint is called the mortise. The talus of the foot fits into the space provided by the mortise, creating the hinge for the ankle joint. The talus is wider at the front of the ankle (anterior) and thinner at the back of the ankle (posterior). Movement of the socket, the mortise rotating around the talus, is described by dorsiflexion and plantarflexion. When the ankle joint is in dorsiflexion, the anterior part of the talus (the wide part) is in the mortise; dorsiflexion is when one bends their knees and pliés and/or when one brings their toes and foot up towards their shin bone. Contrastingly, the ankle joint is in plantarflexion when the posterior (thin part) of the talus is in the mortise; plantarflexion is when the foot is pointed or when a dancer is on relevé.

The stability of the ankle movement is supported by a series of ligaments that create a suspension of the ankle joint. One set of such ligaments is attached to the medial malleolus of the ankle joint; the malleolus is the bony prominence on both sides of the ankle. The medial malleolus, referenced above, is formed by the lower end of the tibia; looking down at the human ankle, it is the bony prominence on the inner part of the ankle. The lateral malleolus is formed by the fibula and is the bony prominence on the outside of the ankle. The set of ligaments that attach to the medial malleolus is referred to as the deltoid ligament. The deltoid ligament is comprised of four separate ligaments, all four begin at the malleolus but attach to different bones: the talus, calcaneus, and navicular bones. The function of the deltoid ligament is to prevent the ankle from extreme eversion, where one’s foot rolls in too far. The lateral ligament, which attaches to the lateral malleolus, is really three individual ligaments: the anterior talofibular ligament, posterior talofibular ligament, the calcaneofibular ligament. The calcaneofibular ligament connects the lateral malleolus to the calcaneus, the posterior talofibular ligament attaches the lateral malleolus to the posterior aspect of the talus, and the anterior talofibular ligament spans between the lateral malleolus and the posterior part of the talus. The posterior talofibular ligaments prevent the ankle from inverting too much, such a motion could be explained by severe sickling of the foot. This is all quite complicated, this video should help!

The MRI results of my left ankle were compared to a prior study done in 2008, completed following one of my past ankle sprains. The MRI showed progressive signs of synovitis, compared to prior studies, meaning that the synovial membrane that encapsulates my ankle joint was inflamed and swollen. Progressive cartilage loss was reported, in relation to the past study. The images showed prominent anteromedial capsular traction spurs, which were enlarged since the study in 2008; anteromedial traction spurs are bone growths on both the talus and tibia surfaces, created by the collision of the two bones during traction.

Basically, the two bones meet at the bottom of a deep plié and had created bone growths over time. The MRI showed a shearing injury of the cartilage over the tibia plafond, which correlates to the bone spurs on the talus surface. Over time, the bone spur had encountered the cartilage surface on the head of the tibia and had scored away at the cartilage’s robustness. Because of this sheering, trauma and bone spur contact, the MRI showed presence of a bone marrow edema pattern. Bone marrow edema is the body’s protective reaction to bone injuries, in which excessive fluid accumulates in related structures of bone marrow. The edema substance is thick/murky and in my case filled the cavity in the front/medial side of my left ankle. The MRI also showed cartilaginous debris in the posterior lateral recess of the ankle joint; essentially the cartilage that had been sheered away accumulated in the back of my ankle. In addition to the cartilaginous debris, the MRI identified six separate loose bodies in the joint; these loose bodies were thought to be pieces of bone that broke off with ligaments during past ankle sprains. Since the sprains, the loose bodies bounced around in the joint, enlarging in size and wearing down some of the cartilage on the talar dome surface. Moving to the back of the left ankle joint, the MRI showed subchondral sclerosis on the calcaneal side of the posterior facet. Subchondral sclerosis is bone formation which occurs as the result of cartilage loss; in the case of the subchondral sclerosis, there was a growth of bone in the lateral recess of the joint, on the fibula. The bone growth is a result of repetitive contact between the calcaneus and the fibula during extreme plantarflexion. The MRI showed that the repeated trauma of this contact between the calcaneus and the fibula was contributing to moderate synovitis, inflammation of the synovial membrane, in the posterior talar process. More bone marrow edema was seen in the medial (inside) sidewall of the talus, where there were signs of a prior high-grade deltoid injury. Since there is no new trauma in this area, the edema was thought to be passing through from the front part of the ankle. The MRI also showed signs of residual hyper intensity and thickening and plastic deformation in both the calcaneofibular and anterior talofibular ligaments. Hyper intensity and thickening refers to unhealthy and damaged ligaments and the plastic deformation refers to ligament that is so overstretched/damaged that they won’t support the load they are intended to carry. Ligaments that are in the plastic phase take about two to three years to remodel and heal on their own; in many cases, ligaments in the plastic phase will not heal adequately on their own. Within the poor remodeling of the anterior and posterior tibiofibular ligaments, there was an ununited fibular avulsion fragment; this is a bone fragment that resulted from ligament tearing away from the bone and taking bone with it, the bone fragment had healed into the ligament structure. Within the MRI’s findings, it was noted that none of the ligament damage was acute, meaning that there is no evidence that the damage in the joint was new, all damage was resulting from years of deterioration. Lastly, the MRI showed a stress fracture in the midshaft of the of the third metatarsal and bony proliferation around the flexor halluces longus. Stress fractures are small cracks in a bone caused by overuse and repeated stress on the bone; often stress fractures are the result of bone not being able to rebuild itself as quickly as it is being broken down. The bony proliferation around the flexor hallucis was attributed to signs of tendinosis extending down to the knot of Henry, the area in which the flexor hallucis longus tendon and flexor digitorum longus tendon cross over, around the navicular bone.

Having received what Dr. Hamilton referred to as “one of the longest” MRI reports he had ever read, he referred me to an old student of his Dr. Martin O’Malley. Dr. O’Malley is the Associate Attending Orthopedic Surgeon and Fellowship Director of the Foot and Ankle Service at the Hospital for Special Surgery. Dr. Hamilton referred to him as, “the best guy with an ankle scope around!” Dr. O’Malley is the go to guy for ankle surgery for the NFL, NHL, Major League Basketball, and the NBA; his office was kind enough to open space for me the same day for an appointment.  My consultation with O’Malley was unlike most doctors’ appointments. Dr. O had read the MRI report before coming into examine me and after taking a glance at my ankle exclaimed that “dancers are the most intense of athletes he has ever seen.” He claimed that none of his other sports patients would ever let an injury get this bad before seeking treatment. Essentially, my appointment went something like this. Dr. O asked me what I was doing one week from the day of my appointment and naively I responded by rattling off the ballets I was supposed to perform that given night. The doctor grabbed a set of crutches before responding and told me that he was opening room on his surgical schedule, one week from that day, to operate on my ankle. As he handed me the crutches, he instructed me to put no further weight through the joint until after surgery. At this time, Dr. O gave a brief description of surgical procedure but established with me that I would have to sign off on an open-ended procedure because it was impossible to know exactly what needed to be done in the joint until I was under anesthesia and he had a chance to evaluate the joint from within.

For my surgery, Dr. O’Malley had an epidural for pain management and I was put under general anesthesia. Three portholes were made in my ankle, two in the front (anteromedial and anterolateral) and one in the back of the ankle, the posterior outflow. One of the portholes in the front of the ankle has a camera inserted for visual, the other has a tool entry and the back porthole is used both for tools and for suction of items out of the joint. The first step of the surgery was to evaluate the ligament laxity in the joint and this was done with a scope and ankle manipulation. Next, Dr. O used a 3.5-millimeter shaver to shave down the synovium, which is the thickened and inflamed growth of the synovial membrane. Next, they identified the large loose body in the back of the back of the ankle joint; the size of this circular loose body required the use of a fragment grasper and a bone shaver to break the piece in two. Removal of this piece took fifteen minutes. Following the removal, another smaller bone fragment was identified in the posterior recess of the joint and was removed.

With the joint space cleared out of the debris, Dr. O could evaluate the dome of the talus for cartilage damage. After inspection, chondral wear of the articular cartilage in the midpoint of the talar dome was identified. To address this issue, a hole was drilled into my iliac crest and sixty milliliters or bone marrow was harvested; the sixty milliliters was spun down to 4ml of my own stem cells. The surface of the talus was drilled into for blood supply, a process which is called micro fracturing, and some of the spun down marrow was adhered to the newly fractured talus surface. The next step in the operation was performing an ostectomy of the distal tibia for the removal of the anterior spurs; by taking great care to not damage the talar surface, a miniature saw was used to shave down the bone spurs in a medial to lateral movement. Following the reduction of the bone spurs, a full synovectomy of the posterior lateral part of the ankle joint was performed; a synovectomy is the surgical removal of the synovium, the membrane that lines the ankle joint. Having removed all the inflammatory tissue and edema patterns from the posterior lateral part of the joint, a full inspection of the flexor hallucis longus was performed. All damaged tissue was removed from the sheath of the tendon, the tube-like casing that directs and tracks the tendon.  An aggressive exploration of the sheath showed no loose bodies in the FHL’s path. Having fully cleared out the joint of debris, inflammatory tissue, and bony proliferations, some bone marrow aspirate was placed on the worn-down cartilage surface of the tibia and the three portholes were closed.

Now, Dr. O moved to address the ligament laxity of the joint; a lateral incision was made over the fibula and was carried down through the skin and subcutaneous tissues to expose the peroneal muscle and anterior talofibular ligament. The anterior talofibular ligament and calcaneofibular ligament were identified and appeared to be thickened; thickened means that they both suffered from severe tendinopathy. K-wires, which are anchoring fixations used in orthopedic repairs, were secured to holes drilled in my fibula. Fiber wires, a product that has an elasticity that was created to mimic ligaments, were attached to the K-wires and secured to part of the anterior talofibular ligament and part of the calcaneofibular ligament. Essentially, these fiber wires are synthetic reinforcements of my

natural ligaments. The left ankle was placed in slight eversion and the wires were tightened and secured. Following the tightening of the wires, both the anterior talofibular ligament and calcaneofibular ligament were cut and shortened to lengths that corresponded to the wires. Having successfully repaired the laxity of the ankle joint, the remaining bone marrow aspirate was placed in the joint and the incision was closed using stitches. This video of a full brostrom procedure is a great visual of the ligament tightening procedure I had done!

Immediately following the surgical procedure, I was sent home in a posterior ankle splint and bandages.  I was instructed to be non-weight bearing and to keep the ankle elevated for as much of the day as I possibly could.  Immobilization and no weight bearing was essential following my procedure to let the ligament repairs heal but also to avoid disruption of the stem cells that they placed onto the joint, for the repair of the articular cartilage.  Sleep was especially important during this phase and not surprisingly, I slept for most the week following my operation, only walking up to eat and take pain killers.  After two weeks, I was reevaluated, stitches were removed and my ankle was casted at a ninety-degree angle.  I remained in the cast, non-weight bearing with elevation requirements for four more weeks.  Upon removal of the cast, I was given a boot, which provides similar immobilization and support to a cast but is removable for physical therapy purposes.

The day I had the cast removed was the first day of my physical therapy program. On day one of physical therapy, the ankle was evaluated to make sure there were no signs of infections and that the wounds were healing well. Until the scars are fully formed, there is not much manual therapy that can be performed on the ankle because there is a risk of pulling the wound apart and enlarging the scar/increasing the time until the wound is fully healed. The first days of P.T. were spent doing lymphatic draining exercises, designed to wake up the lymphatic system, which was dormant in my ankle following immobilization. The lymphatic system is part of the circulatory system and it helps to clear fluid from the extremities, bringing it back towards the heart. It is this system that ultimately reduces the fluid that comprises the inflammatory fluid in the ankle joint, following the surgery. My lymphatic exercises were to lift the ankle joint above heart level for thirty seconds and then return it to the ground for a minute. I would repeat this process for a half hour, four to five times a day. The repetition of this change in elevation is designed to exchange fluids in the way that the lymphatic system would if it was operating properly. By exchanging fluids within the body, through the force of gravity, the lymphatic system gets the message that fluids are being exchanged and it itself is jumpstarted. Within two weeks of doing these exercises, my lymphatic system kicked in and the inflammation and colorization of the joint started to normalize. While the joint was still swollen, it was not as warm to the touch and as red in appearance; a healthy joint is cooler to the touch and has a pigmentation that resembles the skin on the rest of the leg.

When the scars had healed enough to begin moving the joint, I added ankle flexing and isometrics to my exercise lists. I was instructed to flex my ankle joint without the use of my toes, initiating the movement from my shin muscles. Ankle flexes are done in a pain free range of motion and were used to get the ankle joint moving again. At first, the ankle joint was extremely stiff and it was as if the joint was glued together. The scar tissue in the joint and post-surgical inflammation makes the joint feel fused together. These ankle flexes led to multiple painful, sometimes nauseating cracks, which ultimately gave way to increased movement. Isometrics exercises of the ankle are characterized by strength training movements, in which muscle length does not change during the muscular contraction; specifically, my ankle isometrics were done in static positions, pushing against a wall. The purpose of these exercises was to engage the muscles that move my ankle, to wake them up and help to reconnect the brain and muscle synapses. Making the movements static allows the body to rebuild strength and muscular awareness without straining and/or damaging any surgical repairs that are not yet ready to be loaded. It is unbelievable how hard it is to rebuild the body’s ability to engage

Atrophied Calf

certain muscles after long periods of immobilization; when the body has completely atrophied, it is as if one never had muscles, yet alone knew how to use them. Isometric training allowed me to feel confident to put my best efforts behind getting muscles to fire because ultimately, I was not afraid of the strain on my ligaments that would be caused by the muscle contractions.

As I built strength with isometrics and ankle flexes, I progressed to doming of the feet and toe lifts. These exercises had dual purposes: (1) they rebuild strength in the intrinsic muscles of the foot (the small muscles in the foot that are essential for balance) and (2) they helped to pump blood through the joint and foot, helping to push inflammatory fluid out of the joint. Doming is a movement that challenges the core muscles of the foot, one starts with their foot flat on the floor. This movement is performed seated, with your feet about hip-width apart. Keeping one’s tips of their toes on the floor, one lifts the balls of their feet to make a dome shape underneath their foot. The toes should stay long and straight, for if the toes curl under the feet, one is not getting an intrinsic muscle contraction. Each dome is held for six or so seconds and then the foot is relaxed; at first performing one or two doming exercises was near impossible, but I worked up to doing sets of ten domes, eight times a day. Toe lifts are done seated as well and are essentially the anti-dome. Keeping one’s whole foot on the floor, one lifts their toes towards the ceiling, shifting their weight back into the heal and ball of the foot. Eventually, I progressed to doing as many of these exercises as I could in a day; doing toe raises whenever my ankle was elevated proved to be very helpful in pumping swelling out of my joint.  This video of intrinsic foot exercises gives you a good idea of the exercises I did to rehabilitate!

At this time in P.T., the use of modalities became essential to my healing process.  Electric muscle stimulation, less commonly known as neuromuscular electrical stimulation (NMES) was used to rehabilitate and strengthen muscles that were dormant during the immobilization period.  Electrical muscle stimulation uses electric currents to elicit muscle contractions in patients.  My calf muscle

would be connected to electrodes and varying programs of electrical pulses were used to rebuild my calf muscle, before I was even able to contract the muscles myself postoperatively.  The calf muscle works as a pump for the whole ankle joint and the muscle contractions that were induced by the electric muscle stimulation proved valuable for pumping swelling out of the joint.  The other modality used in my rehabilitation was the use of low-level lasers.  Diodes with laser lights were put directly on the ankle joint and supplied my joint with non-thermal photons of light; by transmitting light waves in the near infrared ranges, light can penetrate deep into the body.  Light that is transmitted into the body has an anti-inflammatory effect and immunosuppressive response.  The use of lasers coaxed my body into increasing blood flow to the region, which aids in the supplying oxygen to all the cells that were rebuilding the tissues, collagen, and bone in the joint.

At the three-month post operation point in time, I was cleared by Dr. O’Malley to put weight through my left foot once again. That day, I went straight from my appointment to physical therapy, where I began the process of learning to stand and walk again. The first time one puts their foot on the ground and puts weight through the foot, following a prolonged period of immobilization, it feels like one

has thousands of needles poking at the surface of the skin. In addition to this nervous system overload, one’s fat pads on the bottom of their feet, which cushion the metatarsals and heel bone, are depleted. At first, it is painful to stand on one’s two feet! For the first week, I was tasked with just standing stationary for minute periods at a time. My proprioceptive (balance awareness) capabilities were extremely rudimentary and by standing, I not only improved these proprioceptive sensors but I encouraged my body to restore robustness to my fat pads. Since my ligaments were essentially cut and shortened in surgery, the sensations that are translated in my brain to messages about where my weight and balance lies had to be completely rebuilt. Standing still allowed me to take stock in this new feeling and build an understanding of where my tibia and fibula now rested in relation to my talus. After necessary fat pad rebuilding took place and I felt comfortable putting weight through one leg, I started practicing standing on one leg. At first I needed the help of my physical therapist to hold on to me, but eventually I worked up to standing on one leg for periods of time on my own. At first I worked up to standing for thirty seconds, then I was tasked with standing for a minute, then a minute with my eyes closed. Proper form for single leg balancing is to avoid any contact between the foot that is off the floor and one’s standing leg; this form, coupled with a slightly bent knee forces one to use only the proprioceptive receptors in their ankle to stay in balance. Adding the challenge of closing one’s eyes removes the proprioceptive capabilities of eyesight, leaving one with purely their ankle’s receptors keeping them straight up and down.

Around the time that I started balance exercises, I was instructed to walk without the aid of crutches for the first time.  My foot was still safe in the walking boot, provided by Dr. O’Malley, but it was freeing to be able to walk around the city once again. The act of walking helped me to strengthen my core muscles, hip stabilizers, and hamstrings. Following a few weeks of walking, now in the four-month post operation period, my physical therapy team began the process of teaching me to walk again. All the core strengthening, hamstring rebuilding, stabilizer bolstering, etc. training was done to prepare me for this task and moment. My physical therapy team approached teaching me to walk again by discussing the mechanics of walking with me. Having an in-depth knowledge of how the foot strikes the ground, transfers weight, and pushes off allowed me to approach the task in an

analytical way. Walking is a complex movement, not only does a foot/ankle move through space, but one’s head, shoulders, spine, hips, and arms must move in tandem to keep the human body balanced, while propelling oneself through space. It is the feet and legs that initiate the movement of a walk; the stride of a walk begins with the leading foot in an extended position and it is in this position that the feet are their furthest apart. As the heel of the leading foot strikes the ground, the heel touches the ground first followed by the outside of the foot. While being retaught to walk, I was taught to think of my heel hitting the floor, followed by my fifth metatarsal, then the pinky toe; each subsequent toe, ending with the big toe, hit the ground individually. As all toes are firmly on the floor, the weight of the body is transferred into the leading foot. The weight of the body should be evenly distributed between the toes as the knee bends over the foot, lining up with the second and third metatarsals.  The shock of the body’s weight transfer is caught by this knee bending motion. The position in which the knee is bent and the back foot is coming off the floor is called the recoil position it is in this position that the body is at its lowest proximity to the ground, during the walking motion. As the back-foot travels forward, the knee of the leading foot straightens out and the body is lifted once again. This position where the foot travels from the back to the frond is called the passing position; the free foot passes directly under the body, passing the supporting leg. As the passing foot passes the supporting leg, the weight of the weight-bearing leg shifts into the ball of the foot and the heel lifts off the ground. I was taught to focus on the weight transferring to the first and second metatarsals (the big toe and the second toe) as the foot pushed off. This placement was coordinating with a pendulum like motion to the free foot, which moved forward to strike the floor with the heel. This is the motion of half of a walk, two or more steps make up the act of walking.

The most difficult aspect of walking for me was allowing my shoulders, hips, and spine to move normally; I was so concerned with the motion of my ankle and foot, guarding against any possible misstep, that I would forget about the movement of the rest of my body.  Breaking down how the shoulders, hips, and spine function in the walking motion helped me to recreate a normal walking gait. My P.T. team taught me about how the hips are the center of the body’s gravity; understanding that the body’s ability to balance begins with the placement of the hips was essential in my efforts to walk again. During the walking motion, the P.T.s taught me to focus on the hips as two separate motions and parts: the left hip and the right hip. For instance, if the right leg is extended forward, the hip rotates along the axis of the spine and puts the right hip forward. As the left leg swings through from the back to the front, the left hip meets the right hip in neutral and then travels forward, essentially the left hip rotates along the spine. As the hips rotate around the spine, the shoulders do as well. The shoulders have a mirroring motion to the hips; if the left hip is forward, the right shoulder is front as well. As the hips meet in neutral, so do the shoulders. Essentially, it is the counter balance and opposition created by the hips and shoulders, around the spine, that keeps the body in balance as the legs and feet propel the body forward through space. It took me many weeks before walking felt normal; for the first two weeks, I had to think critically about this motion and all the mechanics that went into walking, to maintain balance and successfully walk. Like many things, with practice, walking became easier and eventually an intuitive motion that needs no extra thought.

After five months of rehabilitation and the return to walking and pedestrian life, I was at the point where I could begin the process of becoming a dancer again. With my P.T. team, I worked through the basics of a barre, retraining my muscles and joints as if for the first time. The primary difference of retraining at this point, following the ankle reconstruction, was training is less extreme positions (smaller degrees of turnout, lower leg extensions, etc.), to work on alignment and strength. Practicing ballet alone will not recondition the body to be an elite athlete; thus, cross training was a huge part of my rehabilitative process.  A strict cardio regimen of biking and swimming were implemented by my P.T. team.  I preferred my two swimming sessions a week to my daily thirty-minute bike rides. 

Biking was essential not only for my stamina but was instrumental in rebuilding my calf strength to absorb the shock of landing jumps.  Swimming was beneficial for the full body workout it provided; swimming was the closest feeling to the challenges of dancing with the full body.  In addition to swimming and biking, my cross-training regimen included pilates, gyrotonics, and weight training.  Returning to the stage required not only that I be able to use my foot again to dance but I needed to recondition my body to lift women and partner again.

One of the last major challenges of returning to the stage was learning to jump again. The male dancer repertoire is heavily based in the act of jumping and one must be able to control the eccentric and concentric phases of jumping when enormously fatigued. Jumping was reintroduced on the pilates reformer, with the utilization of a jumping board. This equipment allowed for my body to go through the jumping motion, while lying horizontal to the floor, with “gravity” created by a set of springs. At first, jumping was done with two feet, landing back on two feet with one spring.  Basically, the spring provided enough “gravity” to pull me back down towards the spring board but with no added weight; using one spring allowed for a prolonged period of push off and landing, in which form could be assessed by my P.T. and my body has time to make corrective adjustments. Over the course of a week, springs were added to my regiment to increase the speed of the jumping motion and the force with which I was working against. Two legged jumps were progressed to jumps that took from two legs but landed back on one foot. This allowed for me to build the confidence to land on one foot and to rebuild the strength necessary to land back on one foot. Single leg jumps followed, taking off and landing on one foot. Once I had the strength and coordination back to the jumping motion, my repetitions were increased and I worked up to jumping for five minutes at a time.  Jumping for five minutes was essential to rebuilding my endurance, which was necessary for me to complete a male variation once again.

Jumps progressed to the floor, using the real forces of my own body weight and gravity. The next step my P.T. team took with me was rebuilding my ability to rebound from jumps. With an extreme focus on alignment, meaning that my foot landed in a neutral position with sixty percent of my weight in the heel of my foot and forty percent of my weight in the ball of my foot, I would jump and rebound into a second jump. To increase the challenge of rebounding, my P.T. team had me take off from elevated surfaces; jumping from elevated surfaces mimicked the landing of a large jump, requiring me to rebound from increased forces of a landing like I would experience with a higher jump. Once I mastered the double leg rebound, I repeated the process of rebound training with single leg jumps. Landing with my weight in an acceptable sixty/forty distribution proved difficult with single leg jumps. My P.T. team concluded that I still lacked glute strength on my surgery side, the left side of my body, so I was given single leg bridging exercises to supplement my program. Within a week, I could control single leg rebounding jumps, landing in an acceptable sixty/forty weight distribution.

The last set of exercises I was given to help me retrain jumping was single leg jumps in a square. My P.T. team made a box on the floor with painter’s tape and instructed me to jump consecutively on a single leg, hitting all four corners of the box on the floor. This helped me to retrain changing directions with landings and takeoffs. Much of ballet choreography requires dancers to be able to change direction on the drop of a dime; landing in one trajectory and taking off in another is very common. To increase the difficulty of the exercise, my P.T. would call out which corner I was supposed to land on next, while landing form the preceding jump. Imagine a complex game of Simon, in which one must jump to the next highlighted corner. This exercise challenged the mechanics of my jumping as well as my mental ability to adapt on the spot. This skill is essential when dancing in the corps of a ballet; often one’s directions and spacing are continually recalculated to stay in each formation and/or line. If the formation changes due to other dancer’s spacing, one must recalculate mid-jump and correct the spacing with their next step; often corrections such as these require steps to be performed in minutely different directions and in varying size, due to the human errors within a group trying to move as one.

The most challenging part of returning to performance, following an injury period such as this one, is reestablishing one’s place in their professional ballet company. I remember feeling so excited to return to work after the uphill battle of my nine-month recovery and I was excited to explode back on the scene. Having established a day to return to work, I was disheartened to see that I was not cast in my roles, roles that I had been dancing for years. The roles that I was scheduled to perform were roles that I had previously done in my first couple years with the company. Essentially, I had to rebuild my reputation from scratch, as if I was new to the company. Even though my P.T. team, doctors, and myself has assured the company that I was back in tip top shape, nothing was taken at face value. The artistic staff outspokenly needed to see proof that I was worthy of the casting that I had come to expect. The process of reestablishing myself at work took almost two years and prolonged my feelings of being injured and “less than.” Overcoming the challenges of my injury were ultimately about proving to myself that I could dance again and that I could enjoy being a dancer again with the challenges it had thrown my way. Waiting for validation from the artistic staff at New York City Ballet was not a healthy way to gauge my progress of ultimately overcoming what could have been a career ending injury.

Back to Performance

The lessons I learned while rehabilitating from my ankle reconstruction have been lessons that I carry through to my everyday practice of ballet. I have taken it upon myself to learn more about the human anatomy and the function of each of the joints, muscular systems, nervous systems, etc. within my body. The way that I listen to pain in my body and care for my body has totally changed. Before my ankle surgery I felt invisible and now I have gained a respect for my body, for I only have one! The cross-training that I used to get back in dancer shape has become a part of my body maintenance regiment; having multiple techniques and approaches to condition my body, outside of ballet itself, has proved to be important for my levels of pain and longevity. Most importantly though, I have learned the value of perseverance and inner strength to overcome the curveballs that life throws one. The human experience is one that is fraught with many challenges but the human body and mind is infinite in its ability to cope and persevere. Above all, I have learned that validation and measuring of one’s success must be done on a personal level, for if one waits for the validation of others, one may wait forever to feel fulfilled and happy.

The most important thing to know as a member of the rosin box community is that perseverance is everything!