The differential diagnosis includes Achilles, peroneal and flexor hallucis tendinitis. However, for these conditions, the symptoms are rarely aggravated by plantarflexion. You can reproduce the pain of posterior impingement via forced plantarflexion. When it comes to treatment, you should emphasize a flexibility program, with attention to stretching, and an antiinflammatory medication. If symptoms become disabling, surgical excision of the bony mass is indicated. Top Treatment Tips For Tendinitis Although tendinitis can be an acute condition, the frequency of recurrence and the nature of dance tend to make chronic tendinitis a common occurrence in dancers. You will frequently see Achilles tendon problems that are associated with muscle weakness of the feet, lower leg and thigh musculature. Tight-fitting pointe
shoes or shoe ribbons that cut into the tendon may also cause Achilles tendon problems. When the gastrocnemius and soleus muscles are tight, dancers have difficulty with plié
and often have poor weight distribution, resulting in faulty technique. Treatment includes contrast baths and NSAID medication. During the initial acute phase, employing a small heel lift in street shoes can be effective. However, the cornerstone of rehabilitation and prevention of re-injury is a structured stretching program the dancer or patient performs in conjunction with eccentric and concentric progressive resistant exercises. Flexor hallucis longus (FHL) tendinitis may manifest as posterior medial ankle pain, arch pain or great toe discomfort. The dancer typically experiences posteromedial ankle pain with a “clicking” or locking sensation of the great toe when he or she points the foot or when going from the fully pointed position to a more dorsiflexed position. Sometimes, an audible pop occurs with this maneuver. During the physical examination, you will note tenderness over the posteromedial aspect of the ankle in the zone between the retomalleolar region and the sustentaculum. Passive motion of the great toe and ankle may induce symptoms of tendinitis when palpating along the FHL. Be advised, however, that this does not often induce the popping unless the patient actively contracts the FHL tendon with the foot pointed and the toes plantarflexed. Distinguishing between a posterior impingement and the FHL tendinitis is challenging because the two structures are in close proximity and these conditions may co-exist (see “Detecting Posterior Pain Syndromes Of The Ankle In Dancers” above). When conservative treatment is indicated for these patients, emphasize relative rest and avoidance of the offending positions. A course of NSAIDs and physical therapy with phonophoresis or iontophoresis is warranted. For resistant cases, you may employ a boot brace or a steroid injection. On some occasions, FHL tendinitis may be recurrent and disabling. In these cases, operative tenolysis may be indicated, but one should only consider this option after at least a year of conservative therapy in the young dancer or six months in a professional. Dr. Caselli (pictured) is Vice President of the greater New York Regional Chapter of the American College of Sports Medicine and is a professor in the Dept. of Orthopedic Sciences at the New York College of Podiatric Medicine.
References 1. Hamilton WG: Ballet. In Reider B (ed.), Sports Medicine, The School-Age Athlete, 2nd Ed, WB Saunders Company, Philadelphia, 1996. 2. Hardaker WT: Foot and ankle injuries in classical ballet dancers. Orthop Clin North Am, 20:4, 1989. 3. Schon LC: Decision-making for the athlete: the leg, ankle, and foot in sports. In Myerson MS (ed), Foot and Ankle Disorders, WB Saunders Company, Philadelphia, 2000. 4. Stone DA, Kamenski R, Shaw J, Nachazel KMJ, Conti SF, Fu FH: Dance. In Fu FH, Stone DA (eds), Sports Injuries, 2nd Ed, Lippincott Williams & Wilkins, Philadelphia, 2001. 5. Vincent LM: The Dancer’s Book of Health, Sheed Andrews and McMeel, Inc., Kansas City, 1978.