Causes
FHL tendinitis is so common in dancers that it is also referred to as “Dancer’s Tendinitis.” There are many factors that can be blamed for the increased incidence of this pathology in dancers, including:- Prolonged periods of weight-bearing and moving on the heads of the metatarsals with the great toe fully extended (on demi-pointe/rélevé)
- Excessive isometric contractions of the FHL muscle while stabilizing the foot (or balancing) on rélevé/demi-pointe or while “gripping the floor”
- Dancing in unsupportive or inflexible shoes, leading to compensatory (and excessive) muscle contractions
- Posterior ankle impingement, which can cause impingement or irritation of the FHL tendon as it enters the tarsal tunnel. Dancers have a higher incidence of posterior ankle impingement than is typically seen in the athletic population due to the excessive use of end-range plantar flexion, often coupled with weight bearing.
Related Conditions
There are many related conditions that may make it difficult to reach an accurate diagnosis of FHL tendinopathy. Many of these conditions might also be present with the FHL tendinopathy, as the conditions have similar etiologies. These pathologies include:- Posterior ankle impingement
- Steida’s process fracture
- Os trigonum syndrome
- Tarsal Tunnel Syndrome
- Tendinitis of the Flexor Digitorum Longus and/or Tibialis Posterior
- Achilles tendinitis
- Talus osteochondritis dessicans
- Plantar fasciitis
It is important to remember that an asymptomatic (and previously undiagnosed) os trigonum could be causing irritation and inflammation of the FHL tendon that resumes when the dancer-patient returns to dancing activities. Make sure you look for one (or another anatomic cause of posterior ankle impingement) when traditional conservative treatments and technique adjustments fail to produce long-lasting results.
Clinical Presentation
In the dancer-patient, FHL tendinopathy is often distinguished from all other pathologies by its symptoms. However, identifying the correct cause(s) of the injury, with an eye toward preventing recurrence, may be more difficult.Patients with FHL tendinopathy present with:
- Posteriomedial ankle pain
- Tenderness with palpation of the FHL tendon, especially just posterior to the medial malleolus
- Pain that increases with active or passive ankle or great toe dorsiflexion, with the most pain present with full great toe and ankle dorsiflexion
Occasionally, dancers will note pain radiating along the medial arch (in fact, sometimes, this is their only complaint). To determine that the pathology is caused by FHL tendon inflammation instead of plantar fasciitis or another condition, place the patient in a seated position, barefoot, with the foot resting on its lateral aspect (this positioning promotes patient relaxation and provides optimal visualization for you). Observe the medial plantar surface of the foot as you passively dorsiflex the great toe. This motion should cause the distal portion of the tendon to “pop out” of the plantar surface of the foot. This motion by itself may produce pain, but the telling sign is tenderness with palpation of the distal portion of the tendon in this position. The tendon will feel very thick and fibrous, especially compared to asymptomatic tendons elsewhere (remember to check to see if they’re having bilateral symptoms before you compare to the other foot!). This little evaluative test allows you for precise identification of the source of the pain, thus differentiating FHL-based plantar pain from plantar fasciitis or a stone bruise.
Complications
Undiagnosed, untreated, or improperly treated FHL tendinitis or other related conditions can lead to trigger toe. Additionally, with an untreated, unrelenting repetitive mechanism of injury, the FHL tendon may develop stenosing tenosynovitis or tendinosis. This may lead to nodule development (and trigger toe) or partial tendon tears at the level of the posterior tubercles of the talus or calcaneus.Treatment
Common treatments for tendinitis work well for FHL tendinitis: rest, ice, gentle and targeted stretching, stim (in the general region), ultrasound, soft tissue mobilization, tendon flossing to address or prevent entrapment. Admittedly, some of these treatment modalities are used purely to decrease symptoms, often simply to allow for a more effective manual treatment session.FHL tendinitis responds well to instrument-assisted soft tissue mobilization (IASTM) applied along the distal portion of the tendon, extending proximally to just proximal to the tarsal tunnel (just be sure to avoid neural involvement!). Targeting the tendon as it passes along the plantar surface of the foot is a little easier for you and more comfortable for your patient than attempting to isolate and treat the tendon just proximal to the tarsal tunnel. One trick to improve the efficacy of the IASTM treatment is to hold the great toe in a dorsiflexed position (in the same way as the evaluative test described above) while applying the treatment along the tendon on the plantar aspect of the foot. This makes the tendon more superficial and, therefore, easier to affect with the IASTM treatment. For early-stage treatments, the patient may only be able to tolerate a small amount of dorsiflexion. As the patient’s symptoms are reduced during rehabilitation, the amount of great toe dorsiflexion can be gradually increased session by session until the treatment is being performed with the great toe fully dorsiflexed. Ankle dorsiflexion can also be added to the patient’s positioning, if desired.
Any concurrent or complicating conditions, will obviously need to be diagnosed correctly and then treated accordingly. Many of these conditions, including excessive muscle tissue, auxillary FHL or FDL muscles, bony posterior ankle impingement, os trigonum syndrome, or a symptomatic Steida’s process (or fracture) will need to be treated surgically (most often through an excision), as conservative treatment will have only a palliative effect instead of a curative one.
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