What is it?

The flexor hallucis longus tendon originates from the calf muscle and courses along the instep of the ankle and foot, assisting with flexion of the big toe. Irritation of this tendon can occur with repeatedly pushing off the foot and toes, which is commonly seen in ballet dancers. Runners can be affected as well. This injury can be further worsened with everting or rolling out the foot, often in young dancers who have improper form when performing the ”turnout” maneuver.

Symptoms

The main symptoms are pain and swelling over the posterior (back) part of the ankle. In some cases, a clicking or grating sensation can be felt by the dancer in this area, especially in the en pointe position. Other diagnoses to consider include posterior ankle impingement, posterior tibial tendonopathy, and osteochondritis of the talus bone in the ankle.

The exam will reveal tenderness behind the inside ankle bone and pain upon resisted flexion of the great toe. X-rays are not necessary to make the diagnosis, but they may be ordered to exclude other conditions, especially in persistent cases. Ultrasound can help establish the diagnosis by visualizing the inflammation around the tendon.

Treatment

Treatment is conservative and involves ice, rest, and NSAIDs (e.g., ibuprofen or naproxen). Physical therapy is helpful to work on ankle stability. In rare cases, immobilization for several weeks in a weight-bearing cast or walking boot may be required. Surgery may be indicated in persistent cases where chronic inflammation can lead to the formation of tendon nodules.

Return to Play

Return to activity or sport is as symptoms tolerate. In cases where surgery is required, the dancer may be out for up to 12 weeks. Prevention includes reducing turnout of the hip, avoiding hard surfaces, strengthening the body’s core (i.e. abdominal, back, and pelvic muscles), and using firm, properly fitted shoes.

AMSSM Member Authors
Jason Brucker, MD and Craig Young, MD

References
Quirk R. Common foot and ankle injuries in dance. Orthop Clin North Am. 1994 Jan;25(1):123-33.
Pagenstert GI, Victor V, Hintermann B. Tendon injuries of the foot and ankle in athletes. Clin Ortho Trauma. 2004; 52(1):11-21.
Simpson M, Howard T. Tendinopathies of the foot and ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-1114.