Medial Ankle Pain: Dancers Tendonitis
Updated: Oct 13
In our deep dive into medial ankle pain and Dancer's Tendonitis, we explore the anatomy, diagnosis, and comprehensive treatment strategies. Discover how a multimodal approach, combining Motion Specific Release (MSR) procedures with targeted exercises, can significantly boost recovery. This integrative method, blending conservative care with manual therapy, is designed to enhance long-term foot health and manage pain effectively.
Our article also includes video demonstrations, providing practical tips on stretching, strengthening, and balance exercises to support your healing journey.
Article Index:
Introduction
If you've heard a dancer mention pain on the inner ankle or foot, it might be due to an injury involving the flexor hallucis longus (FHL) muscle. Known as "Dancer's Tendonitis," this condition isn't just for dancers—runners, soccer players, and other athletes who perform repetitive, forceful movements like jumping are also at risk.
The Flexor Hallucis Longus
The flexor hallucis longus muscle (FHL), shown in red, is located beneath the calf muscles (gastrocnemius and soleus) and plays a crucial role in foot movement. Injuries to the FHL can be challenging to diagnose, as they are often misidentified or overlooked (Tao et al., 2019). There are two primary types of FHL injuries: inflammation (tendonitis) and tears in the tendon connecting the FHL muscle to the foot bones. Both conditions can cause significant discomfort and hinder an individual's ability to engage in physical activities (Myerson et al., 2016).
Special Considerations For Dancers
Dancers' FHL injuries often stem from the repetitive transition from plié (bending) to relevé (rising onto the toes), a motion that exerts a force up to 10 times their body weight. Dancers with FHL tendonitis may also feel pain when moving from demi-pointe (on the balls of the feet) to full pointe (fully extended vertical foot).
For dancers, limited plantar flexion (pointing the toes downward) can increase the risk of an FHL injury. Biomechanically, reduced plantar flexion prolongs foot pronation during the propulsion phase. The FHL tendon endures compression in relevé and overstretching in plié, often causing pain in the posterior medial ankle during plié movements.
Causes and Presentations
Repeated plantar flexion during dancing, running, or jumping can lead to FHL injuries. Damage to the FHL tendon may present as either tendinopathy—a degenerative condition without inflammation—or tendonitis, characterized by inflammation.
FHL inflammation typically occurs in one of three areas:
Along the inner ankle within the fibro-osseous tunnel.
At the "Knot of Henry," where the FHL tendon crosses the flexor digitorum longus (FDL) near the big toe.
Behind the big toe, near the sesamoid bone, which enhances mechanical force by distancing the tendon from the joint.
Anatomy and Biomechanics
The flexor hallucis longus (FHL) muscle, located deep within the calf, plays a key role in plantar-flexing the big toe and stabilizing the subtalar (talocalcaneal) joint. This joint, between the talus and calcaneus bones, enables heel inversion and eversion.
The FHL originates from the distal two-thirds of the fibula in the lower leg, crosses behind the tibia towards the medial ankle, and passes beneath the sustentaculum tali of the calcaneus.
The FHL continues its path beneath the sole of the foot, passing between the two parts of the flexor hallucis brevis muscle, and connects to the base of the big toe. As it moves through the inside of the ankle, it travels through the tarsal tunnel, a passageway formed by a thick ligament (flexor retinaculum), the heel bone (calcaneus), the ankle bone (talus), and a nearby muscle.
The tarsal tunnel also houses the flexor digitorum longus and tibialis posterior tendons, the tibial nerve, and the posterior tibial artery. If any of these structures become restricted or inflamed, it can lead to altered gait, nerve entrapment, or blood flow issues, all of which are signs of Tarsal Tunnel Syndrome. This condition can cause tingling, numbness, and pain in the foot and ankle, significantly affecting mobility and quality of life.
Big Toe Trigger Finger
In dancers, repetitive strain on the FHL tendon can lead to the formation of nodules, resulting in a condition known as Hallux Saltans, or "Big Toe Trigger Finger." Similar to trigger finger in the hand, the big toe "triggers" when the thickened tendon snaps through the fibro-osseous tunnel, causing a jerking motion.
If left untreated, Hallux Saltans can progress to Hallux Rigidus, a condition where the big toe becomes stiff and painful, severely limiting its range of motion. Hallux Rigidus, the second most common disorder of the big toe joint after bunions, can significantly impact a dancer's performance and daily activities, making early intervention crucial for maintaining mobility and foot health.
Diagnosis and Imaging
When treating musculoskeletal conditions, it's essential to perform comprehensive orthopedic, neurological, and vascular assessments, along with imaging studies. While X-rays may not directly diagnose FHL injuries, they are valuable for ruling out fractures that could affect the tendon. A detailed patient history and physical examination are also critical for making an accurate diagnosis.
Ankle and Foot Examination
This video demonstrates orthopedic tests to assess common ankle and foot conditions often seen in dancers, including Ankle Sprains, Cuboid Syndrome, Talar Dome Lesions, Achilles Tendon Tendinopathy, and more. These tests are crucial for diagnosing issues like Dancer's Tendonitis and other related injuries.
Lower Limb Neuro Examination
The lower limb neurological examination assesses the motor and sensory neurons supplying the lower limbs, helping detect any nervous system impairments. It's a key tool for both screening and further investigation.
Peripheral Vascular Examination
A peripheral vascular examination is essential for identifying signs of vascular pathology. Early detection and treatment of peripheral vascular disease (PVD) can help prevent cardiovascular and cerebrovascular complications. This video covers common procedures we use in daily clinical practice.
Imaging
Diagnosing Dancer's Tendonitis often involves multiple imaging techniques. X-rays can rule out bony abnormalities or joint issues around the ankle. Ultrasound provides real-time images of the flexor hallucis longus (FHL) tendon, revealing inflammation, thickening, or tears. Although MRI offers a detailed view of both bone and soft tissue, it is usually unnecessary and costly.
Conservative Care for Dancer's Tendonitis
Initial Treatment:
Ice massages to reduce inflammation.
Heat application later to improve circulation.
Activity reduction and modifications to promote healing.
Supportive Measures:
Short-term use of crutches or a walker boot.
Taping the foot and ankle for added support.
Therapeutic Interventions:
Soft-tissue therapy and joint mobilization for both local structures and the larger kinetic chain.
Carefully selected exercises to enhance strength, flexibility, and balance.
Long-Term Recovery:
Patient compliance with the exercise regimen is key to success.
Gradual return to activities.
Anti-inflammatory recommendations, including nutritional, dietary, and pharmaceutical advice from a medical doctor.
Multidisciplinary Approach:
Collaborate with a multidisciplinary team and incorporate concurrent treatments for optimal results.
Article Index
Motion Specific Release (MSR)
The following three videos demonstrate manual protocols for releasing the FHL, as well as addressing related muscle and joint restrictions in the foot and ankle. Our Fascial Expansion video also integrates fascial research with acupuncture points, providing a comprehensive approach to treatment.
4 Point Dorsi Flexion Protocol - Motion Specific Release
Dorsiflexion involves bringing the toes closer to the shin at the ankle joint. The shin muscles are crucial in clearing the foot from the ground during the Swing Phase of your stride (concentric contraction) and absorbing impact shock during running.
MSR - 7 Point Ankle & Foot Mobilization
Improving joint mobility is essential for effectively treating Dancer's Tendonitis and the entire kinetic chain. Myofascial treatments are significantly less effective without addressing joint mobility restrictions. Joint mobilization helps reverse adverse physiological changes by promoting movement between capsular fibers, ensuring a comprehensive approach to recovery.
Facial Expansion: MSR Foot Pain Protocol
Treating Dancer's Tendonitis with fascial expansions offers a holistic approach that combines modern fascia research with principles from acupuncture and traditional Chinese medicine.
This method aligns fascial lines with key acupuncture points like ST44, LV3, LV2, K3, and B60. It effectively reduces pain, enhances tissue mobility, manages scar tissue, and restores proper function and alignment, helping to prevent further complications.
Exercises for Dancer's Tendonitis
This program focuses on stretching, strengthening, and balance to support recovery from Dancer's Tendonitis. Always consult a healthcare professional before beginning and stop if you feel pain.
Stretching Exercises (Daily)
Calf Stretch: Stand facing a wall, one foot forward, one back. Keep your back leg straight, heel on the ground, and bend your front knee. Hold for 20-30 seconds; repeat 3 times per leg.
Plantar Fascia Stretch: While seated, cross your affected foot over the opposite knee. Gently pull your big toe toward your shin. Hold for 20-30 seconds; repeat 3 times.
Strengthening Exercises (Every Other Day)
Toe Curls: Sit with feet flat. Curl your toes, pressing them into the floor, then release. Perform 3 sets of 10 reps.
Towel Scrunches: Use your toes to scrunch a towel toward you on the floor. Do 3 sets of 10 reps.
Heel Raises: Stand with feet hip-width apart, holding a wall or chair. Raise your heels onto tiptoes, then lower. Perform 3 sets of 10 reps.
Balance & Proprioceptive Exercises (Every Other Day)
Single-Leg Balance: Stand on one leg, other leg bent. Hold for 30 seconds; repeat 3 times per leg.
Wobble Board: Stand on a wobble board for 30 seconds, progressing to one leg as balance improves. Do 3 sets of 30 seconds.
Toe Taps: Stand on one leg, tapping the opposite foot in front, to the side, and behind. Perform 10 taps in each direction; repeat 3 sets per leg.
References
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Hamilton WG. Posterior ankle pain in dancers. Clin Sports Med. 2008;27:263–277.
Hodgkins CW, Kennedy JG, O’Loughlin PF. Tendon injuries in dance. Clin Sports Med. 2008;27:279–288.
Luk P, Thordarson D, Charlton T. Evaluation and management of posterior ankle pain in dancers. J Dance Med Sci. 2013;17(79):79–83.
Russell JA, McEwan IM, Koutedakis Y, Wyon MA. Clinical anatomy and biomechanics of the ankle in dance. J Dance Med Sci. 2008;12(3):75–82.
Sammarco GJ, Cooper PS. Flexor hallucis longus tendon injury in dancers and non-dancers. Foot Ankle Int. 1998;19(6):356–362.
Clanton, T. O., & Haytmanek, C. T. (2014). Hallux and sesamoid injuries in the athlete. In S. W. Micheli, L. J., Kennedy, J. G., O'Laighin, G., & D'Addona, G. (2016). Flexor Hallucis Longus Tendonopathy in Dancers. Operative Techniques in Sports Medicine, 24(1), 76-81.
Fox, A., Wykes, P., & Szypryt, E. (2011). Flexor hallucis longus tendinopathy: diagnosis and management. Foot and Ankle Surgery, 17(4), 268-272.
Hamilton, W. G. (2012). Flexor hallucis longus dysfunction in dancers. Foot and Ankle Clinics, 17(2), 297-306.
Kennedy, J. G., Hodgkins, C. W., Colombier, M., Guyette, T. M., & Brage, M. (2008). Hallux Rigidus: Etiology, Biomechanics, and Nonoperative Treatment. Foot and Ankle Clinics, 13(1), 1-8.
Kadel, N. (2006). Foot and ankle problems in dancers. Physical Medicine and Rehabilitation Clinics of North America, 17(4), 813-826.
Russell, J. A., Kruse, D. W., Koutedakis, Y., McEwan, I. M., & Wyon, M. (2010). Pathoanatomy of posterior ankle impingement in ballet dancers. Clinical Anatomy, 23(6), 613-621.
Liederbach, M., Dilgen, F. E., & Rose, D. J. (2008). Incidence of anterior cruciate ligament injuries among elite ballet and modern dancers: a 5-year prospective study. The American Journal of Sports Medicine, 36(9), 1779-1788.
Neville, C., & Flemister, A. S. (2015). Posterior ankle impingement in dancers and athletes. Foot and Ankle Clinics, 20(2), 349-364.
Peace, K. A., Hillier, J. C., Hulme, A., & Healy, J. C. (2004). MRI features of posterior ankle impingement syndrome in ballet dancers: a review of 25 cases. Clinical Radiology, 59(11), 1025-1033.
Solomon, R., Brown, T., Gerbino, P. G., & Micheli, L. J. (1999). The young dancer. Clinics in Sports Medicine, 18(3), 667-682.
Thacker, S. B., Gilchrist, J., Stroup, D. F., & Kimsey, C. D. (2002). The prevention of ankle sprains in sports: a systematic review of the literature. The American Journal of Sports Medicine, 30(6), 918-926.
Wapner, K. L., & Taras, J. S. (1995). Hallux rigidus: demographics, etiology, and radiographic assessment. Foot and Ankle International, 16(10), 612-618.
Michelson, J. D., & Dunn, L. (2005). Ankle injuries in dancers. Journal of Dance Medicine & Science, 9(3), 85-92.
Shah, S. (2012). The role of foot and ankle injury in dancers. The Journal of Dance Medicine & Science, 16(2), 51-56.
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DR. BRIAN ABELSON, DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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