Introduction
- William G. Hamilton, MD, BSE, AAOS, AOA, FACS
- Marika Molnar, PT, LAc
- Nadia Sefcovic, DPT, COMT
- Marika Molnar, PT, LAc
Epidemiology
Flexor hallucis longus (FHL) tendinopathy (dancer’s tendinitis) is common in female ballet dancers who perform in toe shoes. It is rare in athletes.
- •
Age: early teens to early 40s
- •
Sex: females (male dancers rarely dance in toe shoes)
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Sport/Art: usually ballet, but occasionally in other dancers and athletes
- •
Position: maximum plantarflexion
Pathophysiology
Intrinsic Factors
- •
The FHL tendon is the “Achilles tendon of the foot” for the ballet dancer working on pointe.
- •
The tendon has its origin on the posterior fibula, crosses behind the ankle and passes through a fibroosseous tunnel on the medial side os calcis then exits into the arch of the foot.
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It can become strained and swollen within this tunnel, setting up a repetitive cycle: because it is swollen, it binds as it moves and the binding, in turn, causes swelling and irritation, etc.
- •
If the condition is chronic, the tendon can develop a fibrous knot that causes triggering of the great toe (“hallux saltans”) ( Figure 41-1 ).
FIGURE 41-1
A nodule on the FHL tendon causing triggering of the hallux.
- •
Splits and partial tears can develop in the tendon but these are infrequent ( Figure 41-2 ).
FIGURE 41-2
A serious tear of the FHL with shredding of the tendon.
- •
FHL tendinitis can be associated with posterior impingement on an os trigonum or trigonal process (“Stieda’s process”) ( Figure 41-3 ).
FIGURE 41-3
Posterior impingement on an os trigonum.
- •
At times, the differentiation between these two syndromes can be difficult, because they can exist separately or together.
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Posterior impingement does not cause FHL tendinitis. They are two separate syndromes that may coexist.
Extrinsic Factors
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Toe shoes and pointe work contribute to the injury, although it can be found in male ballet dancers and even modern dancers who usually dance barefooted.
- •
It is a common “overuse” injury in this group of performers.
- •
It is rare in athletes but can occasionally be seen in pronated runners along with the “jogger’s foot” (tendonitis at Henry’s knot).
- •
It can occur in athletes such as place kickers in American football.
- •
The author has removed the os trigonum of a place kicker of an NFL professional football team.
- •
Hard floors, fatigue, and poor technique (“rolling in,” or pronating) can contribute to this injury.
- •
It is frequently misdiagnosed as posterior tibial tendinitis, which is relatively common in athletes but rare in dancers.
Traumatic Factors
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This is rarely an acute injury. It is almost always caused by overuse.
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Forced plantarflexion in the presence of an os trigonum or trigonal process is usually the cause of posterior impingement.
- •
Posterior impingement can be associated with fractures of the posterior process (“Shepherd’s fracture”) ( Figure 41-4 ).
FIGURE 41-4
Fracture of the posterior process—“Shepherd’s fracture.”
Classic Pathological Findings
- •
FHL tendonosis results in chronic swelling and inflammation in the tendon as it enters or passes through the fibroosseous tunnel on the medial side of the os calcis.
- •
The swelling can cause ganglion-like cystic formation behind the ankle.
- •
Posterior impingement causes inflammation, fractures, cystic changes, and occasionally displacement of the os trigonum ( Figure 41-5 ).
FIGURE 41-5
Displacement of the os trigonum when the ankle is plantarflexed.
Clinical Presentation
History
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The pain is usually activity related and relieved by rest.
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FHL tendonitis presents as posterior medial ankle pain without a history of trauma.
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Posterior impingement usually causes posterior lateral pain and may have a definite onset. It is exacerbated by plantarflexion such as pushoff in running and relevé in ballet (going up in a toe raise).
- •
The symptoms are frequently mistaken for strains of the Achilles or posterior tibial tendons.
Physical Examination
Abnormal Findings
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Localized pain and swelling behind the ankle over the FHL tunnel medially or over the os trigonum posterior laterally, or both
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Increased pain with plantarflexion, especially when forced—the positive “plantarflexion sign.” It is only positive for posterior impingement, not for FHL tendonitis. This sign differentiates posterior impingement from all other causes of posterior ankle pain ( Figure 41-6 ).
FIGURE 41-6
The “plantarflexion sign” for posterior impingement.
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Pain in FHL tunnel with active and passive motion of the first MP joint
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Triggering of the Hallux may be present.
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Tenderness over the FHL tunnel behind and below the medial malleolus
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Range of motion of the ankle may be reduced because of pain.
Pertinent Normal Findings
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No ecchymosis
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No effusion within the ankle joint
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No pain with dorsiflexion
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No loss of subtalar motion
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The “drawer sign” for ankle ligament will be negative.
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There is usually no peroneal tendon weakness.
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Examination of the posterior tibial tendon and Achilles tendon is normal.
Imaging
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Lateral radiographs taken in foot flat and in forced plantarflexion on in full toe raise will help diagnose posterior impingement but will not show FHL tendonitis.
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Sonography will reveal swelling of the FHL tendon.
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An MRI study will show the swollen FHL tendon and fluid within the sheath and tunnel surrounding it. This fluid may extend upward to the posterior ankle area and can be mistaken for joint fluid ( Figure 41-7 ).
FIGURE 41-7
An MRI study of acute FHL tendonitis showing fluid within the sheath extending upward behind the ankle.
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Imaging studies do not always pick up tears, partial tear, and rents in the tendon.
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Often a sonogram will show these better than an MRI.
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A bone scan will be negative for FHL tendonitis but positive for posterior impingement.
Differential Diagnosis
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An osteochondritis dissecans lesion of the posterior talar dome
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Early arthritis or degeneration of the posterior facet of the subtalar joint
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A fibrous middle facet tarsal coalition
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Posterior tibial or Achilles tendinitis or strain
Treatment
Nonoperative Management
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Relative rest—“don’t do what hurts” and antiinflammatory medications
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Physical therapy modalities such as phonophoresis, iontophoresis, and acupuncture
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Technique correction if this is a contributing factor
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If the symptoms warrant it, immobilization of the ankle and first metatarsophalangeal joint in a walking boot along with antiinflammatories
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If these fail, then a sonographic guided corticosteroid injection into the FHL sheath (but NOT into the tendon itself) or the os trigonum, if posterior impingement is present
Guidelines for Choosing Among Nonoperative Treatments
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It is important to know which of the three syndromes is present: FHL tendinitis, posterior impingement, or both. This can be difficult to determine.
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The diagnosis may require diagnostic injections of local anesthetics.
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Immobilization in a walking boot treats both conditions.
Surgical Indications
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Failure to respond to conservative therapy
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Symptoms severe enough to warrant surgical intervention
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Surgery should NOT be performed in the absence of discomfort simply to increase the plantarflexion in the ankle by removal of the os trigonum. The results will be disappointing in these cases.
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A diagnosed tear in, or rupture of, the FHL should be surgically decompressed and repaired.
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
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Posterior impingement can be treated by removal of the os trigonum or trigonal process either by a small posterolateral incision or by endoscopic excision.
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The open technique has a lower complication rate but a longer postop recovery.
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The author prefers the open technique for tenolysis and debridement or repair of the FHL because the posterior tibial nerve can be identified and protected with the medial approach and the os trigonum can also be removed at the same time.
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The author’s results have been better in professional ballet dancers than in amateurs.
Aspects of Clinical Decision Making When Surgery Is Indicated
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Which of the two syndromes is present, or are both present?
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Are you going to do this endoscopically or open?
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In the open technique, posterior impingement alone can be corrected through a lateral incision, but FHL tendonitis or a combination of FHL tendonitis and posterior impingement should be approached through a medial incision so that the posterior tibial nerve can be protected.
Evidence
Multiple-Choice Questions
- QUESTION 1.
The “plantarflexion sign” will be positive for
- A.
FHL tendonitis only.
- B.
posterior impingement only.
- C.
Both conditions
- D.
Neither condition
- A.
- QUESTION 2.
Posterior impingement
- A.
is only seen in dancers.
- B.
is mostly seen in dancers.
- C.
is never seen in athletes.
- D.
usually accompanies FHL tendonitis.
- A.
- QUESTION 3.
Posterior impingement can lead to FHL tendonitis.
- A.
True
- B.
False
- A.
- QUESTION 4.
A documented partial tear in the FHL is best approached
- A.
through a lateral incision.
- B.
through a medial incision.
- C.
endoscopically.
- D.
Any of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Abnormal Findings )
- QUESTION 2.
Correct answer: B (see Pathophysiology )
- QUESTION 3.
Correct answer: B (see Pathophysiology )
- QUESTION 4.
Correct answer: B (see Aspects of Clinical Decision Making)
Beyond Basic Rehabilitation: Return to Ballet after Treatment for Flexor Hallucis Longus Tendinopathy and Posterior Impingement
- William G. Hamilton, BSE, MD, AAOS, AOA, FACS
- Marika Molnar, PT, LAc
- Nadia Sefcovic, DPT, COMT
- Marika Molnar, PT, LAc
Introduction
Unlike any other sport, the rules of the game are never the same in dance.
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Dancers are required to perform their art at the extremes of range, making return to activity challenging. Extreme plantar flexion (PF) of the ankle/foot complex is necessary so that the dancer can balance on the tips of the toes as well as be able to fully dorsiflex the hallux while in plantar flexion at the ankle in order to balance or push off from there. Ankle dorsiflexion (DF) is essential for landing from big jumps, lunging, preparation for all turns, etc.
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The dancer must also regain strength and proprioception of the ankle/foot complex in these extreme ranges of motion. Acceleration, deceleration, and isometric holds are required.
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The dancer must be able to maintain strength, stability, and flexibility at the lumbopelvic and hip joints and the entire lower extremity in order to meet the demands of the choreography. For example ballet dancers must have adequate neuromuscular control in hip external rotation (i.e., turnout).
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Dynamic strength and alignment control will be important as the dancer returns to the studio. The dancer must be able to move with varying speeds, in various body positions, in all planes of movement and in all directions.
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Special attention must be paid to the type of shoe the dancer must wear in order to return to dance (i,e., pointe shoes, ballet slippers, jazz/character shoes, barefoot, etc.). Dancing barefoot or in ballet slippers usually requires more hallux dorsiflexion than other forms of footwear.
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Posterior ankle impingement (PAI) is caused by compression of the tissues between the posterior tibia, talus, and calcaneus, which occurs in extreme ranges of ankle plantar flexion that dancers require to achieve en pointe and demi-pointe positions.
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Osseous or soft-tissue can be impinged in PAI. Causes of osseous impingement include an os trigum, Stieda’s process, or anatomical variations in the posterior aspects of the tibia or calcaneous. Soft tissue impingement causes can include various structures including: the capsule or synovium of the subtalar or talocrural joints; ligaments such as the posterior talofibular ligament, the posterior intermalleolar ligament, or the posterior tibiotalar ligament; or tendons such as the flexor hallucis longus (FHL) as it passes from the fibula, crossing the posterior talus, and running through the fibroosseous tunnel.
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Repetitive plantar flexion required of dancers can also cause FHL tendinopathy. Dancers can develop irritation and swelling of the tendon or the tendon’s sheath. This irritation to the tendon and sheath causes pain and limited motion as the musculotendinous unit hypertrophies. The dancer will have resultant tendon and muscular weakness secondary to pain and disuse of the muscle. As this becomes a chronic condition the tendon can develop adhesions, calcifications, and nodules at the musculotendinous junction as part of the degenerative process.
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Flexor hallucis longus injury is very common in dancers, both male and female. Most dance movements require the use of the FHL as the foot and ankle go through plantar and dorsiflexion thousands of times per day. When the foot is in plantarflexion, the FHL functions as a stabilizer and eccentrically it restrains dorsiflexion at the first metatarsophalangeal joint as well as eccentrically controlling calcaneal eversion. As the dancer is landing a jump or in grand plié, the FHL is stretched between the posterior talar tubercles and the sustentaculum tali.
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Flexor halluces longus tendinopathy and posterior ankle impingement are separate injuries, but often they occur in combination.
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Posterior impingement pain is usually posterolateral to the ankle joint; pain, tenderness or swelling posterior to the medial malleolus is experienced with FHL tendinopathies. The dancer also can experience triggering of the toe or crepitus of the FHL tendon, which can be palpated at the tendon sheath when the dancer moves their hallux.
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Although posterior impingement and FHL tendinosis are seen in both genders, these injuries seem to be more problematic for females and pointe dancers. Female dancers who are on the professional track will usually have their os trigonum removed as it interferes with their ability to go up onto pointe. Once the surgical site is healed the rehabilitation follows the same course as outlined if it was a simple bony removal.
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A common precursor to posterior ankle impingement is ankle instability resulting from an ankle sprain. If a lateral ankle sprain precedes these injuries it usually takes longer to rehabilitate owing to laxity in the ligaments, which then allows for excessive anterior displacement of the talus. This excessive motion will need to be controlled to provide more boney stability. Often when there is boney instability and ligamentous laxity, this will lead to muscle overactivity that can lead to tendinopathies. Stability of the ankle as well as proprioception must be addressed in the dancer’s rehabilitation in addition to addressing the stability role of the FHL in the medial longitudinal arch and great toe.
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Generally if these injuries are treated appropriately with a conservative physical therapy program including sufficient relative rest and appropriate exercises, all usually return to dance.
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If conservative therapy does not return the dancer to full function, surgical repair of tendon or removal of extra bone or scar tissue in the posterior ankle may be necessary; the dancer can usually return to full participation once all rehabilitation criteria have been met.
Phase I (Weeks 1 to 2): Advanced Strength and Conditioning Programs
Periodization
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Linear
| PHASE I (Weeks 1 to 2) | PHASE II (Weeks 3 to 7) | PHASE III (Weeks 7 to 12) |
|---|---|---|
|
|
|
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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