In "Medial Ankle Pain Uncovered: Understanding Tendonitis Beyond Dance," we explore the intricate anatomy, precise diagnosis, and tailored treatments, including Motion Specific Release (MSR) techniques. Moreover, we enhance understanding with video demonstrations, highlighting both therapeutic interventions and essential exercises.
Article Index:
Introduction
Examination & Diagnosis
Treatment
Exercise
Conclusion & References
Introduction
If you are acquainted with a dancer, you might have heard them mention experiencing pain on the inner side of their ankle or at the base of their foot. This discomfort is frequently linked to an injury involving the flexor hallucis longus (FHL) muscle (Smith et al., 2018). Although this injury is referred to as "Dancer's Tendonitis," it's crucial to note that it isn't exclusive to dancers. Runners, soccer players, and other athletes engaging in repetitive, forceful movements like jumping are also prone to this injury (Orishimo et al., 2013).
The Flexor Hallucis Longus
The flexor hallucis longus muscle (FHL), depicted in red, is situated beneath your calf muscles (gastrocnemius and soleus) and plays a crucial role in foot movement. Injuries to the FHL can be somewhat challenging to identify, as they are frequently misdiagnosed or not considered at all (Tao et al., 2019). Two primary forms of FHL injury exist: inflammation (tendonitis) or a tear in the tendon that connects the FHL muscle to the bones in the foot. Both of these conditions can lead to discomfort and impede an individual's ability to engage in physical activities (Myerson et al., 2016).
Special Considerations For Dancers
Injuries to the FHL in dancers are often a result of the repeated movements involved in transitioning from a plié position (a French term meaning "to bend") to a relevé position (a ballet term meaning "raised," referring to when a dancer rises up on their toes). This motion generates a force equivalent to 10 times the dancer's body weight. Ballet dancers suffering from FHL tendonitis might also experience pain when shifting from demi-pointe to full pointe. Demi-pointe refers to the position where a dancer is on the balls of their feet, also known as half-point, while full point (en pointe) describes a completely extended vertical foot.
For dancers, any movement that diminishes plantar flexion (the action of pointing the toes downward) could potentially lead to an FHL injury. From a biomechanical perspective, a decrease in plantar flexion can cause the foot to remain in a pronated position for an extended period during the Propulsion Phase, when pushing off.
In dancers, the FHL tendon often experiences compression when executing a relevé position and is overstretched during a plié position. As a result, the dancer may feel pain in the posterior medial ankle region while performing the plié.
Causes and Presentations
The continuous action of pushing off with your foot (plantar flexion) during activities like dancing, running, or any sport involving jumping can lead to FHL injuries.
Damage to the FHL tendon and muscle can manifest in various ways, sometimes involving inflammation. If the tendon is injured without inflammation, it is called "tendinopathy." Tendinopathy refers to a degenerative lesion within the tendon that does not impact the tendon sheath surrounding it.
In contrast, when FHL inflammation (tendonitis) occurs in the foot, it typically appears in one of these three locations:
Along the inner side of the ankle (in the fibro-osseous tunnel along the posteromedial ankle).
At the "Knot of Henry" – an area just behind the big toe (first metatarsal) where the flexor digitorum longus (FDL) muscle crosses the flexor hallucis longus (FHL) tendon.
Just behind the big toe near the sesamoid bone. A sesamoid bone enhances mechanical force by keeping a tendon away from the joint's center.
Anatomy and Biomechanics
Let's examine the flexor hallucis longus (FHL) muscle and its connection to nearby structures. The FHL muscle assists in pointing your big toe (plantar-flexing your big toe) and contributes to stabilizing the subtalar joint (talocalcaneal joint).
The subtalar joint is situated between the talus and calcaneus bones in your ankle. This joint enables the heel to move towards the medial plane (inversion) as well as towards the lateral plane (eversion).
About the FHL:
The flexor hallucis longus (FHL) muscle is found deep beneath your calf muscles, specifically as the outermost muscle of the deep compartment.
The flexor hallucis longus originates on the lateral lower leg (distal 2/3 of the fibula). From there, it runs at an oblique angle (crossing the posterior surface of the tibia) towards the medial ankle (posterior surface of the talus) and passes beneath a section of the heel bone (sustentaculum tali of the calcaneus).
The FHL continues to travel beneath the sole of the foot (between the two heads of the flexor hallucis brevis) and connects to the base of the big toe (base of the distal phalanx of the hallux).
As the FHL moves through the medial ankle, it also traverses a structure called the tarsal tunnel. This tunnel is formed by a thick ligament, two ankle bones, and a muscle (flexor retinaculum, calcaneus, talus, and the abductor muscle).
Besides the FHL, two other tendons (flexor digitorum longus and tibialis posterior), the tibial nerve, and the posterior tibial artery also traverse the tarsal tunnel. Restrictions or inflammation affecting any of these structures can lead to alterations in gait patterns, nerve entrapment, or vascular dysfunction, which are characteristic of Tarsal Tunnel Syndrome.
Big Toe Trigger Finger
When the FHL tendon develops nodules, a condition called Hallux Saltans can arise. Hallux Saltans is akin to trigger finger in the hand but occurs in the big toe instead. The triggering of the toe happens when the nodular thickening of the tendon snaps through the fibro-osseous tunnel, causing a jerking motion similar to a trigger finger.
If Hallux Saltans is left untreated, it can contribute to the development of another condition called Hallux Rigidus, which means "stiff great toe." Hallux Rigidus is the second most common disorder affecting the big toe joint (first MTP joint), with the most common injury being a bunion, also known as Hallux Valgus.
Diagnosis and Imaging
In addressing all musculoskeletal conditions, it is crucial to conduct a comprehensive set of orthopedic, neurological, and vascular tests in addition to imaging. X-rays, although not definitive for diagnosing FHL injuries, are helpful in ruling out fractures that could impinge the FHL tendon. A thorough patient history and complete physical examination are often essential for accurately diagnosing this condition.
In some cases, when imaging is necessary to assess tissue damage, MRI imaging is the preferred option. However, ultrasound imaging can also be effective and more cost-efficient. The subsequent videos demonstrate procedures commonly employed in examining an Achilles injury.
Effective Ankle and Foot Examination
This video uses orthopaedic test to evaluate for some of the most common ankle and foot conditions we see in clinical practice. These conditions include: Ankle Sprains (inversion sprain), Cuboid Syndrome, Talar Dome Lesions, 5th Metatarsal Fracture, Syndesmosis damage, Achilles Tendon Tendinopathy, Morton's Neuroma, 2nd Metatarsal Stress Fracture, Plantar Fasciitis, and Bunions.
Lower Limb Neuro Examination
The lower limb neurological examination is part of the over all neurological examination process, and is used to assess the motor and sensory neurons which supply the lower limbs. This assessment helps to detect any impairment of the nervous system. It is used both as a screening and an investigative tool.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is a valuable tool used for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video we go over some of the common procedures we perform in daily clinical practice.
Imaging
In diagnosing Dancer's Tendonitis, a combination of imaging modalities can be employed. Initially, an X-ray might be taken to rule out any bony abnormalities or joint issues around the ankle. However, for soft tissue assessment, an ultrasound is particularly beneficial as it provides real-time images of the flexor hallucis longus (FHL) tendon, allowing for visualization of inflammation, thickening, or tears. For a more detailed examination, an MRI remains the gold standard, offering a comprehensive view of both bone and soft tissue structures, ensuring a thorough understanding of the injury's extent.
Treatment
In the majority of cases, Dancer's Tendonitis (which includes partial FHL tears, tendinosis, or other inflammatory conditions) responds positively to Conservative Care. This non-surgical approach focuses on soft tissues and joints and is frequently the most effective treatment for resolving such injuries. Manual therapy, combined with a functional exercise program, is particularly potent and successful in achieving full recovery. A typical conservative care timeline for complete healing spans at least four to six weeks, with a full return to activities only possible once pain symptoms have completely subsided.
Even after pain relief, it is advisable to gradually resume activities. For dancers, this could mean initially excluding point work, jumps, or grand plies (a grand plié involves a full knee bend) from their routines.
Conservative Care for Dancer's Tendonitis
Ice massages can be helpful during the initial stage to reduce inflammation, followed by heat application to enhance circulatory function.
A reduction in activity is usually necessary, with some modifications to all activities to encourage healing.
Supports, such as crutches or a walker boot, may sometimes be beneficial in the short term.
Taping of the foot and ankle can provide additional support.
Soft-tissue therapy and joint mobilization are crucial for rapid, long-term recovery. This involves considering and treating both Local Tensegrities (local structures) and Global Tensegrities (structures within the larger kinetic chain).
Implement carefully selected exercises that promote strength, flexibility, and balance development. Keep in mind that the patient's compliance with exercise protocols will dictate their success in resolving this condition.
Ensure a gradual return to activities.
Follow appropriate anti-inflammatory recommendations, which may include nutritional, dietary, and potential pharmaceutical advice from a medical doctor. Collaborating with a multidisciplinary team and using concurrent treatments is often recommended.
Article Index
Motion Specific Release (MSR)
The following three videos demonstrate the type of manual protocols we would use to release the FHL, but all related muscles and joint restrictions in the foot and ankle. These procedures are Motion Specific Release procedures developed by Dr. Abelson.
MSR Calf Muscle + Tom, Dick, and Harry Release
This video is about releasing both your superficial calf muscles (gastrocnemius and soleus) and the deeper muscles Tom, Dick, and Harry (TDH). Tom, Dick, and Harry stands for: T=Tibialis posterior, D=Flexor digitorum longus, an=posterior tibial artery and tibial nerve, and H=Flexor hallucis longus.
4 Point Dorsi Flexion Protocol - Motion Specific Release
Dorsiflexion is the movement at the ankle joint where the toes are brought closer to the shin. The muscles of the shins help your foot to clear the ground during the Swing Phase (concentric contraction) of your stride, and absorb much of the impact shock during running.
MSR - 7 Point Ankle & Foot Mobilization
Improving joint mobility is critical if you are going to effectively address the body's full kinetic chain. In fact, we greatly reduce the effectiveness of any myofascial treatment if we don’t also address the restrictions in joint mobility. The objective of joint mobilization is to reverse adverse physiological changes by promoting movement between capsular fibers.
Treatment Frequency Recommendations
The treatment strategy is crafted to adapt to the patient's evolving response to manual therapy for Dancer's Tendonitis. Continuous communication between the patient and therapist is essential to adjust treatment. Manual therapy, when combined with exercises, has been highly effective in managing Dancer's Tendonitis, leading most patients to substantial relief and recovery. Adherence to treatments and at-home exercises is key for optimal results.
Initial Treatment Phase:
Objective: Reduce acute inflammation and pain, improve local blood flow, and initiate the healing process.
Frequency: 2-3 times a week.
Response Assessment:
After two weeks of initial treatment.
Positive Response:
Frequency: Reduce sessions to once a week, and review weekly.
Persistent Symptoms:
Frequency Maintain sessions at 2-3 times a week, review each week.
Cessation of Treatment:
Complete resolution of symptoms: If the patient has no pain, discomfort, or any functional limitations related to Dancer's Tendonitis, and these results are consistent over several sessions.
Lack of progress: If after an extended period (e.g., 6-8 weeks), the patient sees no improvement or even worsening of symptoms despite different treatment strategies.
When to Make an Appropriate Referral:
Diagnostic ambiguity: If the therapist is uncertain about the diagnosis or feels there's an underlying condition not within their scope.
Complex presentations: If the patient presents with symptoms suggesting a more complex condition, like a systemic disease or neurologic issues.
Persistent symptoms: If symptoms do not improve despite consistent treatment, suggesting that another specialty's intervention is required.
Transition to Maintenance Care:
Objective: To ensure the gains from therapy are maintained and to prevent the recurrence of symptoms.
Criteria: A consistent reduction in symptoms, restoration of foot biomechanics, and the patient's ability to engage in regular activities without pain.
Frequency: Once every 2-4 weeks, then gradually lengthening the interval between sessions as long as the patient remains symptom-free.
Logic: While the patient has improved, the body might still have vulnerabilities. Regular check-ins allow the practitioner to catch and address any minor issues before they become significant problems.
The recommendations provided are based on a combination of best practices, logical deduction, and the understanding of Dancer's Tendonitis typical clinical course. They serve as a guideline and can be adjusted based on individual presentations and the practitioner's clinical judgment.
Exercises
The following exercises are designed to help anyone with dancers tendonitis by focusing on stretching, strengthening, and balance proprioceptive exercises. Always consult with a healthcare professional before starting any exercise program, and stop immediately if you experience pain or discomfort.
Stretching Exercises
Calf Stretch: Stand facing a wall with one foot forward and the other foot behind. Place your hands on the wall for support. Keep your back leg straight and your heel on the ground while bending your front knee. Hold the stretch for 20-30 seconds and repeat 3 times on each leg.
Plantar Fascia Stretch: While seated, place the affected foot over the opposite knee. Gently pull your big toe toward your shin and hold for 20-30 seconds. Repeat 3 times.
Strengthening Exercises
Toe Curls: Sit in a chair with your feet flat on the ground. Slowly curl your toes, pressing them into the floor, and then release. Perform 3 sets of 10 repetitions.
Towel Scrunches: Place a towel on the floor and use your toes to scrunch the towel toward you. Repeat for 3 sets of 10 repetitions.
Heel Raises: Stand with your feet hip-width apart, holding onto a wall or chair for support. Slowly raise your heels off the ground, coming onto your tiptoes, and then lower back down. Perform 3 sets of 10 repetitions.
Balance Proprioceptive Exercises
Single-Leg Balance: Stand on one leg, with the other leg bent at the knee. Hold onto a wall or chair for support if needed. Hold the position for 30 seconds and then switch legs. Repeat 3 times on each leg.
Wobble Board Exercises: Stand on a wobble board with both feet, maintaining balance for 30 seconds. Progress to standing on one leg as your balance improves. Perform 3 sets of 30-second holds.
Toe Taps: While standing on one leg, tap the toes of the opposite foot in front of you, then to the side, and finally behind you. Keep your weight on the supporting leg and maintain balance throughout the exercise. Perform 10 taps in each direction, then switch legs. Complete 3 sets for each leg.
Incorporate these exercises into your routine to help alleviate symptoms of Dancer's Tendonitis and improve overall foot and ankle strength, flexibility, and balance. Remember to always consult with a healthcare professional to ensure these exercises are appropriate for your specific situation.
Conclusion
In conclusion, Dancer's Tendonitis is a condition that affects not only dancers but also other athletes who engage in repetitive, propulsive activities like running and jumping. This injury, involving the flexor hallucis longus (FHL) muscle and tendon, can cause pain and discomfort in the medial ankle and the bottom of the foot. Early detection and intervention are essential in managing this condition effectively.
Conservative Care, including ice and heat therapy, activity modifications, manual therapy, and supportive measures, has proven to be a successful approach in treating Dancer's Tendonitis. Incorporating stretching, strengthening, and balance proprioceptive exercises into a rehabilitation program can further aid recovery and help prevent future injuries.
It is important to work with healthcare professionals and follow their recommendations to ensure a safe and gradual return to activities. By understanding the nature of Dancer's Tendonitis, individuals can take appropriate measures to manage and overcome this injury, allowing them to continue pursuing their athletic passions with confidence and resilience.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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