"Dancer's Tendinitis"

Some injuries are so commonly seen in dancers – especially when compared to their incidence in non-dancers – that they earn a dance-specific nickname: Dancer’s Fracture, Dancer’s Tendinitis, Dancer’s Hip.

Dancer’s Tendinitis refers to Flexor Hallucis Longus tendinopathy (That’s quite a mouthful! No wonder it’s referred to as dancer’s tendinitis!).  The Flexor Hallucis Longus (FHL) muscle is located in the lower leg and its tendon runs down into the foot, attaching to the bottom of the big toe. As the name implies, it is responsible for flexing (pointing) the big toe. Tendinopathy simply means “an injury or disease related to a tendon,” making it a good term to use when discussing tendon-related conditions without worrying about what specific aspect of the tendon is injured (the actual tendon vs. the sheath of connective tissue surrounding it) or for how long it’s been injured (tendinitis vs. tendinosis – acute vs. chronic).

Causes

Tendon injuries are typically caused by repetitive microtrauma from overuse, and FHL tendinopathy is no different. Microtrauma occurs to a tendon when the tendon is pulled taut by body positioning and its associated muscle contracts.

The FHL tendon runs through the tarsal tunnel, located in the posteromedial ankle (the back of the ankle, on the “inside” part of the ankle – the part that faces the other ankle). It basically curves around the medial malleolus (the bumpy part of your bone that sticks out on the inside side of your ankle) before running along the medial longitudinal arch of the foot (the part of the foot that you’re referring to when you discuss foot arches).

The course of the tendon means that the FHL tendon experiences microtrauma any time the FHL muscle is used with the ankle dorsiflexed and/or the big toe extended (especially when weight-bearing). This means that dancing on demi-pointe/rélevé and performing rélevés over and over place a great deal of stress on the FHL tendon.

Recognizing FHL Tendinopathy

The mechanical stresses that can lead to FHL tendinopathy also cause other injuries in the foot, ankle, and lower leg, including plantar fasciitis, Achilles tendinitis, and tendinitis of other muscles in the region (tibialis posterior, flexor digitorum longus).

The easiest way to differentiate FHL tendinopathy from similar conditions is to carefully examine the symptoms, including their location.

The signs and symptoms most characteristic of FHL tendinopathy are:

• pain in the arch of the foot, located on the medial (big toe) side of the foot
• increased pain with active and passive toe extension
• pain or a feeling of tightness in the back of the ankle, just above the heel and behind the medial malleolus

When you bend your big toe back (extension), the FHL tendon will pop out from the rest of your arch. When the tendon is inflamed, it will be more prominent than usual, tender to the touch, and thicker and courser than usual.

Advanced-stage FHL tendinopathies will also cause trigger toe, wherein the big toe will become “stuck” in a curled or flexed position due to nodules on the tendon preventing normal gliding motions of the tendon through the tarsal tunnel.

Self-Treatment

Treatment for FHL tendinopathy is very similar to the treatment for plantar fasciitis, but the focus of the treatment is on a slightly different part the body:

• Tennis ball or racquet ball massage (place the ball on the ground and roll your foot over the ball, focusing on the medial arch)
• Frozen water bottle roll (same technique as the tennis/racquet ball, but with the effects of cold therapy)
• Ice massage; after a few minutes of massage, use your hand to gently pull your big toe back (to make the tendon pop out) and hold it there while continuing your treatment
• Brief, targeted cross-friction massage on the tendon as it passes through the foot (only if your pain allows this). Start with the foot and big toe in a neutral position and gradually progress to doing cross-friction over the tendon with the big toe extended (pulled back). Remember to start and finish your treatment with a light massage.

One of the best ways to treat any overuse injury is to reduce or stop the aggravating factors that are perpetuating the problem. How much you have to reduce or eliminate depends on the severity of your symptoms and how long you’ve been dealing with the inflammation. For FHL tendinopathy, this means:

• wearing appropriate, supportive shoes whenever possible (for dancers, this means any time you’re not dancing), especially during workouts
• wearing orthotics, if necessary
• reducing or temporarily eliminating cross-training workouts that are especially taxing on the FHL muscle and tendon by forcing the big toe into end-range extension (bending it back all the way). The biggest offenders would be plyometric jumping workouts, sprinting, running stairs, and running hills (especially sprinting up hills on concrete). After you’ve healed, you can gradually start to work these workouts back into your routine (in good, supportive footwear).

When to go to the doctor

Seek a medical professional’s guidance and expertise if:

• Your pain is localized under the joint between your big toe and your foot (the joint is in the ball of the foot) – this may indicate an injury to the joint itself (“turf toe”) or a sesamoid injury, including fracture
• You develop trigger toe (your big toe gets “stuck” in flexion)
• You have pain in the posteromedial aspect of your ankle (back-middle, between your Achilles and your ankle joint) that gets worse when you point your foot and is significantly worse with bearing weight while standing on demi-pointe or pointe.
• You feel a nodule in the back of your ankle
• You begin to notice a decrease in your ability to point your foot, especially after an ankle sprain or other acute ankle injury
• You have excessive pain that interferes with your daily life (you can’t walk without a limp)
• Rest and/or other treatments do not reduce your symptoms
• You would like custom orthotics (as opposed to over the counter or semi-custom orthotics available at drug stores and specialty shoe stores)