Flexor hallucis longus (FHL) tendonopathy (or tendonitis) is an overuse injury in which repetitive plantarflexion and dorsiflexion (pointing and flexing) of the foot lead to inflammation of the FHL tendon. This tendon originates in the middle of the posterior fibula and runs down the back of the ankle along the bottom of the foot to insert at the joint between the great toe and the first metatarsal. The site of inflammation is typically in the back of the ankle at the point when the tendon runs behind the talus through a fibrosseous tunnel.
Dancer’s tendonitis is more common in female ballet dancers who spend a lot of time en pointe or demi pointe. FHL tendonitis may occur as a primary condition, or as a secondary condition of os trigonum impingement syndrome. Failure to properly treat inflammation can result in a nodule (obstruction of the fibrous tunnel the tendon runs through) or partial or complete tear of the tendon.
If FHL tendonitis is diagnosed, refrain from pointe work until the inflammation subsides. Also, take an inventory of the dancer’s technique–especially the alignment of the feet. Forcing turnout to the extreme causes the inner ridge of the foot to roll in, which can either lead to or exacerbate FHL tendonitis. Conservative treatments include anti-inflammatory drugs, ice and physical therapy. Surgery should be a last result when all other approaches fail. Recovery from FHL surgery can take over 3 months and permanently reduces the range of motion in the sagital plane (pointing and flexing).
The FHL is also used in taking off and landing from jumps. FHL inflammation can also be caused by repetitive jumping (especially if the dancer fails to press the heels into the floor), or spend long amounts of time in grand plié. FHL Tendonitis can also occur as a secondary condition in dancers with bunions.
FHL tendonitis is sometimes mistakenly diagnosed as posterior tibial tendonitis, as both are characterized by tenderness at the posteromedial ankle (soft area between the “ankle bone” and heel on the inside of the leg). A consequence of FHL tendonitis is functional hallux rigidus, in which the dancer is unable to complete a full demi pointe due to reduced dorsiflexion at the metatarsophalangeal (MTP) joint with knee extension and ankle doriflexion.
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