Keeping twin dancers on their toes

Dance-Twins-IIEighteen-year-old twins Sasha and Lise Ramsay are like two peas in a pod. They started dancing at 3, fell in love with ballet by age 6 and will both enter the ballet program at Brigham Young University in the fall. The girls are also mirror-image twins, which means some features, like cowlicks in the hair, are opposite each other.

When Sasha was diagnosed with os trigonum syndrome, a tiny extra bone behind her right heel, at 15, the family expected Lise to follow in her footsteps. And she did. True to mirror-image form, Lise’s os trigonum developed opposite her twin’s—in her left heel.

The syndrome makes dancing difficult, causing ankle pain and preventing the dancer’s toes from fully pointing. “Releves [balancing on the balls of my feet] and turning were really painful,” recalls Lise.

Budding ballerinas

Dance-twins_ISasha and Lise demonstrated their commitment to ballet at a young age. At a mere six years old, the duo ganged up on their mother to persuade her to let them transfer from a small local studio to a Boston Ballet satellite 18 months ahead of schedule.

“They found a passion at a young age,” says the twins’ mother Debbie Ramsay. They excelled. But at age 11, Sasha suffered a stress fracture (an overuse injury often related to repetitive movement) in her right ankle. Debbie brought Sasha to Lyle Micheli, MD, director of Boston Children’s Hospital’s Sports Medicine Division.

Micheli prescribed physical therapy with Michelina Cassella Kulak, PT. Debbie, highly aware of her daughters’ similarities, suspected Lise would develop the same issue and asked for injury prevention physical therapy. Cassella focused on helping the girls build pelvic stability, core strength and develop the strength and flexibility in their hips, knees, ankles and feet needed for classical ballet.

Sasha healed and continued to shine on and off stage. The girls transitioned to a new studio—The Brookline Ballet School, under the direction of Trinidad Vives and Parren Ballard—and began participating in competitions.

But by age 15, Sasha’s occasional ankle pain became constant. An MRI revealed a hook-shaped os trigonum that was shredding the tendon behind her ankle.

Micheli performed surgery in October 2011 to remove the os trigonum and a small cyst in Sasha’s heel. Sasha began physical therapy with Cassella and focused on re-learning ballet technique to prevent additional injuries.

Take two

Meanwhile, Lise started developing pain in her left foot. X-rays showed os trigonum in both feet. She managed the pain for nearly two years. Cassella worked with her to maintain and increase ankle range of motion, which is often restricted in dancers with os trigonum.

But sometimes the ankle pain caused by an os trigonum can became extremely intense and limit the dancer’s ability to dance at the desired level. During these flare-ups, the third member of the twin’s care team—Andrea Stracciolini, MD, director of Boston Children’s Dance Medicine Section—follows the dancer more closely and prescribes a steroid injection to calm the inflammation. A brief period of immobilization and directed physical therapy is next.

By July 2013, it became apparent that Lise would follow in Sasha’s surgical footsteps. Micheli recommended an operation to remove the os trigonum. The surgery was a bit simpler than her sister’s as Lise did not have a cyst, and her impingement had not shredded muscle or tendon.

Dance-twins-IV

Lise differed from her twin in another way too. “After my sister’s experience, I learned not to force my recovery too fast or too soon.”

Sasha had learned the same lesson, but only after pushing her recovery. “I’d have periods of no pain and would dance full out and overdo it. Eventually, I learned to listen to my body and let it heal,” says Sasha.

Both girls found that their recovery progressed as Micheli predicted; it took one full year to reach their pre-surgery performance levels. Since then, Lise and Sasha have flourished, nabbing solo and ensemble roles and performing in the Youth America Grand Prix, a prestigious annual ballet scholarship competition.

Leaping into the future

The next step is the ballet program at Brigham Young University, a demanding track that pairs a full academic load with four hours of dancing, six days a week. “Lise and Sasha will do well,” predicts Stracciolini. “They are smart dancers. They have learned how to listen to their bodies and not push through pain, and have adopted a routine strength and conditioning regime to keep them healthy.”

Debbie credits Boston Children’s dance medicine team with helping her girls reach their goals. “Dr. Micheli and Dr. Stracciolini speak the language of dance, which is a tremendous benefit for dancers. They understand the time, commitment and physiology of dance.” And after seven years of working with the twins, Cassella has become so attached to the family that she threatened to follow the girls to Brigham Young University.

Is your young dancer dealing with injury? If so, you may want to visit the website of our Dance Medicine Section to learn more or set up an appointment with one of our experts.