Ballet dancers are no strangers to foot and ankle injuries. One common yet often overlooked issue is a problem with the Flexor Hallucis Longus (FHL) tendon – the tendon that flexes your big toe. When this tendon becomes inflamed or restricted, dancers may experience “trigger toe” (also known as stenosing tenosynovitis of the FHL). This condition can cause pain, clicking, or even locking of the big toe, threatening a dancer’s ability to rise up on pointe. In this blog, we’ll explain why the FHL tendon is so important in ballet, how it can become injured or stenotic (tight and irritated), and what can be done to fix it.
Whether you’re a dancer, a dance parent, or an instructor in the Pittsburgh area, this guide will offer authoritative and reassuring insight, and remind you that if you’re ever in doubt about an injury, “When in Doubt, Check it Out.” We fix dancers and get them back to doing what they love!
Why the FHL Tendon Is Crucial for Dancers
The FHL tendon is sometimes called the “dancer’s tendon” because of its vital role in ballet. The FHL muscle originates deep in the calf, and its tendon runs behind the ankle, under the foot, and attaches to the tip of the big toe. Every time a dancer goes on relevé or pointe (rising onto the balls of the feet or toes), the FHL tendon is hard at work. Its primary job is to plantarflex the big toe and assist with pointing the ankle. This action stabilizes the foot, helping the dancer achieve beautiful lines and explosive jumps. In fact, the FHL has been nicknamed the “Achilles of the foot” for its powerful role in controlling the arch and big toe during movement.
Because of this, ballet dancers, especially those training en pointe for long hours, put a huge demand on the FHL tendon. It passes through a narrow fibro-osseous tunnel behind the ankle and under the ligaments, which makes it prone to friction and irritation. When everything is working well, the FHL glides smoothly as the dancer points and flexes the toe. But when the tendon or its sheath becomes inflamed, thickened, or develops a nodule, the movement can become painful and restricted – much like a rope snagging in a pulley.
What Is “Trigger Toe” (FHL Stenosing Tenosynovitis)?
Trigger toe is the term dancers often use for FHL stenosing tenosynovitis, essentially a tight, inflamed FHL tendon sheath that causes the big toe to catch or lock. Dancers might notice a clicking or popping sensation in the back of the ankle or foot when moving the big toe. Over time, the irritated tendon can become temporarily stuck, causing the dancer to manually straighten their big toe or experience it “release” with a sudden pop. Initially, this may be a mild annoyance without much discomfort. However, if unaddressed, the friction and inflammation can worsen: the tendon may fray, develop scar tissue or a thickened lump (nodule), and begin to adhere to the sheath instead of gliding smoothly. At this stage, a dancer will typically experience pain, often in the posteromedial ankle area (behind the inner ankle bone), which worsens when coming down from pointe or jumping and landing. They might also experience crepitus (a crackling sensation) and obvious triggering or locking of the great toe with motion.
Trigger toe is more than just an inconvenience. In severe cases, the FHL tendon can become so restricted that it risks a partial or complete tendon rupture if a dancer continues to force it through the tight tunnel. Think of it like a frayed wire being pulled taut – it can eventually snap. That’s why early evaluation and treatment are essential. Remember our motto: “When in doubt, check it out.” If a dancer’s big toe is catching or painful, it’s best to have it examined before a minor irritation turns into a major tear.
Signs and symptoms of FHL tendonitis/tenosynovitis in dancers include:
- Pain or tenderness behind the ankle (along the inside) that often worsens during relevé, pointe, or landing from jumps.
- Clicking or locking of the big toe, especially when going from a pointed position to flat, you may feel or even hear a snap as the toe “let’s go” (trigger toe).
- Stiffness or difficulty flexing the big toe: usually, dancers may feel they can’t put weight on the toe en pointe because it “gives out” or lacks strength when the tendon sticks.
- Swelling or fullness along the FHL tendon sheath (inner ankle or under the arch), sometimes accompanied by a crackling feeling (crepitus) when moving the toe.
- Reluctance to demi-plié or pain in plié position, because the FHL is stretched in plié, an inflamed tendon can hurt during deep bends.
If you notice these symptoms in yourself or your dancer, don’t ignore them. Dancers are notoriously tough and often try to dance through pain, but early intervention can mean a simpler solution and a quicker return to dance.
Why Do FHL Tendon Problems Happen? (Technique Matters)
FHL tendinitis in dancers is usually an overuse injury with a strong link to technique and anatomy. In other words, it’s not typically a one-time traumatic injury, but the result of repetitive strain combined with certain risk factors. Here are some common reasons the FHL tendon can become irritated or injured in ballet dancers:
- Overuse and Repetitive Pointe Work:
- Spending hours en pointe or demi-pointe means the FHL is continuously sliding back and forth in its sheath under high tension. This repetitive maximal plantarflexion (downward pointing) of the ankle and big toe can lead to micro-trauma over time. Dancers often perform countless relevés, jumps, and footwork drills, sometimes on hard surfaces or without enough rest, which can overwhelm the tendon's ability to recover. Not surprisingly, FHL tendinopathy is especially common in ballet dancers who dance en pointe, since the tendon is responsible for pointing the big toe.
- Poor Technique (Forced Turnout and Misalignment):
- Dancers who force their turnout from the feet or ankles (instead of using the hips) put abnormal stress on the foot and ankle tendons. When the feet are turned out beyond one’s natural hip rotation, the knees and ankles may roll in and the FHL tendon’s path can become twisted or compressed. This often happens when hip rotator muscles (gluteus medius, gluteus maximus) are weak, the dancer tries to achieve a perfect 180° turnout by torquing from the lower leg. Poor alignment in jumps and landings (for example, not keeping the knees over toes in plié) can also concentrate forces on the FHL. Over time, “overuse or misuse of the FHL tendon due to poor technique can lead to pain, swelling and even catching – called trigger toe”. In short, technique flaws like pronation, rolling in, or sickling the foot can all contribute to FHL problems.
- Weak Supporting Muscles:
- This goes hand-in-hand with technique. A dancer with weak glutes, core, or foot intrinsic muscles may have instability that the poor FHL tries to compensate for. For example, weak turnout muscles in the hip force the dancer to use the lower leg to maintain turnout, straining the FHL and other structures. Similarly, inadequate calf or foot muscle strength can cause the FHL to be overworked during pointe work and jumps. Strengthening the glutes, deep rotators, calf, posterior tibialis, and foot muscles can improve alignment and offload the FHL tendon, reducing injury risk.
- Bad Landings and Jumps:
- Ballet (and other dance forms like jazz, contemporary, gymnastics, etc.) involves a lot of jumping and leaping. Improper landing technique, such as landing stiff-legged, with the foot in poor position, or not using a toe-ball-heel roll through, can jar the foot and ankle. A hard landing can acutely strain the FHL or cause it to slide abruptly, irritating the sheath. Repeated micro-injuries from jumps can accumulate into a chronic problem. Dancers should always focus on controlled, cushioned landings with proper alignment to protect their tendons.
- Anatomical Factors (Os Trigonum & Hallux Valgus):
- Sometimes, a dancer’s anatomy can predispose them to FHL issues. One common co-factor is an os trigonum, an extra bone at the back of the ankle that can pinch the FHL tendon during extreme plantarflexion. In fact, posterior ankle impingement (often due to a large Stieda’s process or os trigonum) and FHL tenosynovitis often go hand-in-hand in dancers. Another factor is hallux valgus (a bunion deformity of the big toe). When a dancer has a bunion, the big toe angles outward and the FHL tendon is pulled off its straight course, causing it to bowstring laterally out of alignment. This malalignment can increase friction in the toe joint and tendon sheath, contributing to tendinitis or triggering. Hallux valgus also often indicates a foot mechanics issue (like prolonged pronation) that can affect the FHL. Managing bunion pain, using toe spacers, or, in some cases, surgical correction might eventually be considered to reduce stress on the FHL tendon.
- Other Sports and Activities:
- While ballet dancers are classic victims of FHL problems, they’re not alone. Athletes who do repetitive or forceful toe-pointing and push-off can also suffer from FHL tenosynovitis. This includes gymnasts, figure skaters, football players, runners, and soccer players, who all can spend a lot of time in plantarflexion or tip-toe positions. So, if you’re a gymnast or other athlete in the Pittsburgh area with unexplained inner ankle pain or toe catching, you could have a similar issue (“dancer’s tendonitis” isn’t just for dancers!).
Non-Surgical Treatment: Rest, Rehab and When to Check It Out
The good news is that not every FHL issue requires surgery. Conservative management is the first line of treatment for FHL tendonitis or mild trigger toe, and it is often successful if the condition is caught early. Key steps in non-surgical care include:
- Rest and Activity Modification:
- Relative rest is critical to calm down the inflammation. We may advise taking a break from pointe work, jumps, or even all dancing for a short period (a few days up to several weeks, depending on severity). This doesn’t mean the dancer has to be completely idle; cross-training and working on other aspects of fitness (such as floor barre, arms, and conditioning) can continue, but the goal is to avoid movements that provoke pain (such as repeated relevés). Often, a brief period of immobilization in a walking boot or ankle brace can help, especially if there’s significant pain or tendon catching. Ice (ice massage along the tendon) is useful for reducing acute inflammation, and some dancers find that gentle toe stretches (pain-free range) before class keep the tendon limber.
- Anti-inflammatories and Therapeutic Modalities:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain and swelling in the short term. However, if the issue is more of a tendon degeneration/tendinosis, NSAIDs are not a cure-all. Occasionally, a corticosteroid injection into the tendon sheath may be considered to shrink inflammation; however, in dancers, this is used cautiously, as steroids can weaken the tendon if overused. Other modalities like ultrasound therapy, laser, or acupuncture have been used anecdotally (some dancers report relief from acupuncture or deep friction massage). These can be adjuncts, but the cornerstone is rest and proper rehab exercise.
- Platelet-Rich Plasma (PRP) is a safer injection that can reduce pain, inflammation, and degeneration of the tendon. This is a much safer type of injection compared to cortisone for this condition. THIS CAN BE DONE AT P.O.W. under Ultrasound Guidance by Me. (Please refrain from NSAIDS for 10 to 14 days prior to the injection).
- Physical Therapy and Technique Rehabilitation:
- Perhaps the most important aspect of non-surgical treatment is addressing the biomechanical contributors to the FHL problem. Working with a dance-knowledgeable physical therapist can help correct technique errors and strengthen the right muscle groups. Therapy will likely focus on:
- Strengthening the hip rotators (gluteus medius/maximus, deep external rotators) so the dancer can achieve turnout from the hips instead of the foot.
- Improving core and leg alignment to take stress off the inner foot. This includes ensuring knees track over toes in plié and landing, and avoiding pronation or “rolling in.”
- Foot intrinsic and calf strengthening. For example, exercises for the small foot muscles, doming of the arch, calf raises with proper form, to support the arch and relieve strain on the FHL.
- Stretching and flexibility where needed, such as gentle big toe stretches and ankle mobility work, to ensure the FHL isn’t being irritated by a very tight calf or other restriction. (If an os trigonum or bone impingement is an issue, stretching may be limited since extreme pointe is the problem – in such cases, resting that motion is more important.)
- Gradual return to dance with an emphasis on flawless technique. The dancer might start with barre work and flat technique, then demi-pointe, and only return to full pointe work when they can do so without pain and with proper form. Often, a PT or physician will have the dancer demonstrate relevés or single-leg rises to test endurance – one measure is being able to do 20–25 single-leg relevés with good form, which is expected for full return to dance.
During this rehab phase, remember that communication and listening to your body are key. If the pain or triggering persists despite rest and therapy, it may be time to consider more advanced interventions. Never feel afraid to get a second evaluation, FHL issues can be tricky to resolve, and dancers often need specialist care (that’s where we come in!). When in doubt, check it out, a quick visit to a dance medicine specialist can determine if you’re on the right track or if you need a different approach.
Surgical Options: Posterior Endoscopy vs. Open FHL Sheath Release
When conservative measures fail to fully resolve a significant FHL stenosing tenosynovitis (especially if the toe is locking or a nodule is present), surgery may be recommended. The goal of surgery is to release the constriction around the FHL tendon and remove any inflamed or scar tissue (tenosynovectomy) so that the tendon can glide freely again. There are two main surgical approaches to address this in dancers:
- Posterior Ankle Endoscopy (Arthroscopic FHL Release and Tenosynovectomy): This is a minimally invasive technique where I make two tiny incisions (portals) in the back of the ankle and use a small camera (arthroscope) and instruments to access the FHL tendon. Through the scope, I can shave away inflamed tissue, release the tight tendon sheath (retinaculum), and even remove bony impingements like an os trigonum if present. The advantages of an endoscopic (arthroscopic) approach are well documented: it is less invasive and produces less scar tissue than an open surgery, and the magnified camera view allows precise work with minimal disruption of surrounding tissues. For athletes and dancers, this often translates to a faster recovery and earlier return to activity. In fact, studies on hindfoot endoscopy for FHL tenosynovitis in athletes show excellent outcomes, significant pain relief, high satisfaction, and return to sports at the same level in just a couple of months. It also has a low complication rate (infection, nerve injury, etc. are rare). Posterior ankle arthroscopy is particularly useful if a co-existing os trigonum syndrome is present, as the surgeon can address both the bone and tendon in one procedure. In my practice, I favor the endoscopic approach for dancers due to these benefits. Dancers are usually eager to return to performing, and an efficient recovery is crucial!
- Open FHL Sheath Release (Open Posteromedial Approach): In some cases, a traditional open surgery may be indicated or preferred; especially when a significant tendon tear is present. This involves a small incision (often 3 to 5 cm) along the inner back of the ankle. Through this incision, I can directly visualize the FHL tendon and its surrounding sheath. I then cut open the tight fibro-osseous tunnel (sheath) and remove any thickened synovium or adhesions (a tenosynovectomy). If the tendon has any tears or fraying, a repair or debridement can be done at the same time.
Open surgery provides direct, wide exposure, which can be beneficial when the anatomy is unusual or when addressing a large nodule or tendon tear. The trade-off is a larger incision and potentially more scar tissue or a slightly longer healing process. However, even an open FHL release is typically a relatively small surgery, often done as an outpatient procedure with a few weeks of protected weight-bearing after. In my experienced hands, open FHL tenosynovectomy also has excellent outcomes, with studies reporting dancers returning to full activity with significant pain improvement and very high satisfaction rates. One large series of dancers treated with isolated open FHL tenolysis/tenosynovectomy showed over 90% good-to-excellent outcomes, meaning that the vast majority returned to their pre-injury level of dance.
Which approach is right depends on the individual dancer and specifics of the case. At our Pittsburgh dance medicine clinic, we have expertise in both endoscopic and open techniques. We will consider factors like the severity of the stenosis, presence of bony impingements, and how quickly the dancer needs to return. Often, minimally invasive endoscopy is a great first choice, but if there’s any reason to go open (or if we need to, for example, repair a ruptured tendon), we are fully equipped to do so. The goal in either case is the same: free up the FHL tendon so it glides without pain or catching.
Getting Back on Your Toes: Recovery and Prevention
After a successful treatment, whether nonoperative or surgical, the focus shifts to recovery and preventing recurrence. Dancers are passionate about their art, so our priority is getting you safely back on your toes as soon as possible, but also as strong as possible.
Recovery time will vary depending on the treatment. With conservative rehab, a mild FHL tendinitis might calm down enough to return to dance in a matter of a few weeks, whereas a more stubborn case could require a few months of rest and therapy. If you undergo surgery, the timelines are still quite encouraging: many dancers are back to full dancing around 8-12 weeks after a posterior ankle arthroscopy for FHL/Os trigonum issues. Some may take a bit longer for full pointe work. It’s essential to listen to your body and your surgeon’s guidance. Initially, after surgery, there may be a brief period of immobilization (a splint or boot for a week or two), but motion is started early to avoid stiffness. Physical therapy typically begins within the first 2-3 weeks post-operatively, focusing on restoring range of motion, followed by strengthening, and finally, dance-specific functional training. By 3-4 months post-op, most dancers are not only pain-free but also have their full ankle and toe motion back, and can jump and relevé without issues. Keep in mind that there might be some lingering mild stiffness or swelling for a few more months, which is normal as the body continues to heal. However, this typically doesn’t prevent you from performing as usual.
To prevent FHL problems from coming back, we emphasize the same factors we talked about in causes:
- Continue to work on your technique and alignment. Even after your pain-free, keep those turnout muscles strong and be mindful of not forcing turnout or sickling your foot. Incorporate the corrections and exercises you learned in rehab into your regular cross-training.
- Maintain strength and flexibility in the calves, feet, and hips. Things like TheraBand exercises for the toes, calf raises, and core workouts should be part of a dancer’s routine. Strong glutes and core will protect your feet.
- Take care of any underlying foot issues. If you have a tendency for hallux valgus (bunions), for example, use spacers or proper fitting pointe shoes to minimize pressure. If you have a bony impingement like an os trigonum, be cautious with extreme ranges and address pain early if it flares up.
- Listen to your body and don’t push through serious pain. It’s normal for dancers to have aches, but sharp pain or consistent locking/catching is a red flag. Catching a flare-up early might just mean a few days of rest and therapy rather than another full-blown injury.
- Work with knowledgeable professionals (physios, dance teachers, etc.) to ensure your training load is appropriate. Avoid sudden spikes in activity, and give yourself adequate rest between intensive rehearsals or shows. Good nutrition and recovery practices (like icing after long dance days, proper warm-ups and cool-downs) also help your tendons stay healthy.
Our goal is not just to heal the tendon one time, but to set you up so that you stay injury-free and keep dancing for years to come.
We Fix Dancers: Expert FHL Tendon Care in Pittsburgh
Dealing with a tricky injury like FHL tenosynovitis can be scary for a dancer (and for a dance mom or dad!). You might worry: “Will I ever dance again without pain? Will I lose my pointe?” As an orthopaedic surgeon and dance medicine specialist, I want to assure you that these injuries are treatable, and most dancers make a full return to performance. In fact, treating dancers is a passion of ours – our motto is “We Fix Dancers!” We understand the unique demands of ballet and dance, and we’re committed to providing expert, compassionate care to get you back on stage.
If you or your child is experiencing big toe pain, clicking, or any foot/ankle issue that just doesn’t feel right, don’t hesitate to reach out. When in doubt, check it out – a professional evaluation can ease your worries and put you on the right path to recovery. Sometimes what seems like a minor annoyance can be addressed quickly before it becomes a bigger problem. And if it is something that needs intervention, you can trust that you’re in good hands with a team that has helped many dancers overcome FHL injuries.
Call 412-525-7692 to schedule an appointment with our dance medicine specialist (we’re conveniently located in the Pittsburgh metro area), or request an appointment online. We’ll diagnose the issue, answer all your questions, and guide you through treatment – whether that’s refining your technique, physical therapy, or the latest minimally invasive surgical options. Our priority is to get you back on your toes, pain-free and confident. Don’t let “trigger toe” or any foot pain linger and threaten your passion. With the right care, you’ll be back to dancing at full strength – and maybe even better than before, with stronger technique and awareness.
Remember, your health and performance go hand in hand. Flexor Hallucis Longus injuries may be common in dancers, but with prompt care and expert treatment, they don’t have to keep you off the stage. When it comes to dance injuries in the Pittsburgh area, we have the experience and dedication to fix the issue and get you flying high again. Keep dancing smart, take care of your feet, and we’ll be here whenever you need us. Ballet dreams are built on strong foundations – let’s keep your foundation (from hip to toe) healthy and ready to perform!
When in doubt, check it out – we fix dancers!
(If you’re experiencing any symptoms of FHL tendon issues or other dance injuries, call us at 412-525-7692 or book an appointment. We’re here to help you dance without pain.)
