Pediatric flexor hallucis longus tendinitis (Dancer’s Tendinitis)

What is pediatric flexor hallucis longus (FHL) tendinitis?

Flexor hallucis longus (FHL) tendinitis is an overuse injury that occurs when there’s irritation in the band of FHL tissue (tendon) that connects to the big toe (great toe). This irritation causes the tendon to swell, leading to tendinitis.

The FHL tendon and calf muscle work together to point and flex the feet and big toes. They also stabilize the ankles when a ballet dancer goes up on their tiptoes (“en pointe”) or a runner or swimmer pushes off from their feet. Doing these movements repeatedly can cause painful swelling in the tendon and the sheath that surrounds it. Our dance medicine and sports medicine specialists help athletes recover from this sports injury.

What are the signs and symptoms of pediatric dancer’s tendinitis?

• Grating or clicking sensation in the ankle

• Musculoskeletal pain in the ankle, heel or middle of the foot that worsens when walking, pointing the toes downward or pushing off from the feet

• Tenderness and mild swelling in the back of the ankle

How is pediatric flexor hallucis longus tendinitis (Dancer’s Tendinitis) diagnosed?

Other conditions like Achilles tendinitis, ankle sprains and stress fractures can cause similar symptoms. Our specialists tap their extensive expertise in dance and sports medicine to provide the correct diagnosis and develop the most effective treatment plan.

In addition to a physical exam and symptom evaluation, our team uses advanced diagnostic tests, such as:

• X-rays of the ankle while a dancer is in ballet shoes and en pointe (on their toes).

• Ultrasound or MRI to check for FHL tendon inflammation and stress fractures.

What causes pediatric flexor hallucis longus tendinitis (Dancer’s Tendinitis)?

Repeatedly pushing off from the toes (overuse) leads to FHL tendinitis. But a small number of youths have a condition called os trigonum syndrome that makes them more prone to FHL tendinitis. Os trigonum syndrome occurs when the os trigonum (a small extra bone in the back of the ankle) pinches or catches between the ankle and heel bones (an ankle impingement).

In most teens, this extra bone fuses with the back of the talus bone during puberty. In rare instances, this bone fusion doesn’t happen. Most people don’t know they have this extra ankle bone because it rarely causes problems.

However, young dancers and other athletes with an os trigonum who repetitively point their toes or push from their feet can develop os trigonum syndrome or “nutcracker injury.” During repetitive movements, the posterior ankle and upper heel bones trap the extra bone between them. This causes a pinching (nutcracker) effect on the bone. In rare instances, an os trigonum develops a stress fracture. The FHL tendon can also become inflamed if the tendon presses against the os trigonum bone, causing friction that leads to tendinitis.

How is pediatric flexor hallucis longus tendinitis (Dancer’s Tendinitis) treated?

We offer a full suite of treatments for dancers and athletes experiencing FHL tendinitis.

Nonsurgical treatments for FHL tendinitis

FHL tendinitis treatments include:

• Icing the injured area

• Immobilizing the ankle with a walking boot or cast

• Limiting activities until symptoms improve

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Therapeutic ultrasound

• Ultrasound-guided corticosteroid injections

Specialized rehabilitation programs

Physical therapy is key to recovery and preventing a reinjury. Depending on an athlete’s activity, they may participate in physical therapy through one or more of these programs:

• Dance Sports Medicine Program

• Bridge training via the Sports Performance powered by EXOS program

• Running Program

• Sports rehabilitation

Advanced orthopedic surgeries to repair torn tendons

If nonsurgical treatments don’t ease FHL tendinitis symptoms caused by os trigonum syndrome, our orthopedic surgeons perform arthroscopic surgery to remove the extra bone. Our team performs this procedure through small incisions using a thin, lighted tube and a camera (arthroscope). This minimally invasive approach promotes a faster recovery with less pain and scarring.